Pent-up demand for care among dual-eligible victims of elder financial exploitation in Maine.

Elder financial exploitation (EFE), the misuse of a vulnerable adult's property or resources for personal gain, is a form of elder abuse. This study addresses whether dual-eligible EFE victims were experiencing pent-up demand for health services alleviated through investigation by Adult Protective Services (APS). A quasi-experimental design addressed health service utilization and costs for 131 dual-eligible Maine APS clients over age 60 with substantiated allegations of EFE relative to comparable non-APS controls. APS case files spanning 2007-2012 were linked to 2006-2014 Medicare and Medicaid claims data. Service utilization and costs were analyzed 1 year prior, during, and 2 years after the initial APS investigation. Difference in differences logistic regression and generalized linear models addressed the likelihood of incurring costs and expenditure levels relative to matched controls, respectively. Victims of EFE had higher overall odds of using inpatient and long-term services and supports (LTSS) and higher odds of using LTSS post-investigation than controls. Higher overall levels of outpatient and prescriptions expenditures and higher inpatient expenditures during the APS event year contributed toward APS clients incurring $1,142 higher PMPM total costs than controls. Victims of EFE were experiencing significant pent-up demand for health services post-APS involvement.

Time-Varying Effects of Parental Alcoholism on Depression.

INTRODUCTION: Children of alcoholic parents are at increased risk for lifetime depression. However, little is known about how this risk may change in magnitude across age, especially in mid-adulthood and beyond. METHODS: We used a nationally representative sample (N = 36,057) of US adults from the National Epidemiologic Survey on Alcohol and Related Conditions, wave III. After adjusting for demographic characteristics, we examined the relationship between parental alcoholism and outcomes of 1) major depressive disorder, Diagnostic and Statistical Manual of Mental Disorders-5th edition (DSM-5) and 2) DSM-5 persistent depressive disorder. To examine continuous moderation of this relationship across participants' age, we used time-varying effect models. RESULTS: Parental alcoholism was associated in general with a higher risk for both major depressive disorder (odds ratio [OR], 1.98, 95% confidence interval [CI], 1.85-2.11; P < .001) and persistent depressive disorder (OR, 2.28, 95% CI, 2.04-2.55; P < .001). The association between parental alcoholism and major depressive disorder was stable and positive across age, but the association with persistent depressive disorder significantly declined among older adults; respondents older than 73 years old were not at increased risk for persistent depressive disorder. CONCLUSIONS: Findings from this study show that the risk of parental alcoholism on depression is significant and stable among individuals of a wide age range, with the exception of a decline in persistent depressive risk among older adults. These findings highlight the importance of screening for depression among adults with parental alcoholism.

How effective is health coaching in reducing health services expenditures?

BACKGROUND: Health coaching interventions aim to identify high-risk enrollees and encourage them to play a more proactive role in improving their health, improve their ability to navigate the health care system, and reduce costs. OBJECTIVES: Evaluate the effect of health coaching on inpatient, emergency room, outpatient, and prescription drug expenditures. RESEARCH DESIGN: Quasiexperimental pre-post design. Health coaching participants were identified over the 2-year time period 2009-2010. Propensity scores facilitated matching eligible participants and nonparticipating controls on a one-to-one basis using nearest kernel techniques. Difference in differences logistic and generalized linear models addressed the impact of health coaching on the probability of incurring costs and levels of inpatient, emergency room, outpatient, and prescription drug expenditures, respectively. MEASURES: Administrative claims data were used to analyze health services expenditures preparticipation and post health coaching participation time periods. RESULTS: Of the 6940 health coaching participants, 1161 participated for at least 4 weeks and had a minimum of 6 months of claims data preparticipation and postparticipation. Although the probability of incurring costs and expenditure levels for emergency room services were not affected, the probability of incurring inpatient expenditures and levels of outpatient and total costs for health coaching participants fell significantly from preparticipation to postparticipation relative to controls. Estimated outpatient and total cost savings were $286 and $412 per person per month, respectively. CONCLUSIONS: Health coaching led to significant reductions in outpatient and total expenditures for high-risk plan enrollees. Future studies analyzing both health outcomes and claims data are needed to assess the cost-effectiveness of health coaching in specific populations.

Federal telehealth policy changes during the COVID-19 public health emergency: Associations with telemental health use among rural and urban Medicare beneficiaries.

PURPOSE: The COVID-19 public health emergency (PHE) led to increased mental health (MH) concerns among Medicare beneficiaries while inhibiting their access to MH services (MHS). To help address these problems, the federal government introduced temporary flexibilities permitting broader telehealth use in Medicare. This study compared rural versus urban patterns of change in telemental health (TMH) use among adult MHS users in fee-for-service Medicare from 2019 to 2020, when PHE-related telehealth expansions were enacted. METHODS: In this cross-sectional investigation based on 2019-2020 Medicare claims data, we used chi-square tests, t-tests and adjusted logistic regression to explore how year (pre-PHE vs. PHE), rurality, and beneficiary characteristics were related to TMH use. FINDINGS: From 2019 to 2020, the proportion of MHS users who used TMH rose from 4.8% to 51.9% among rural residents (p < 0.0001) and from 1.1% to 61.3% (p < 0.0001) among urban residents. Across study years, adjusted odds of TMH use grew more than 18-fold for rural MHS users (OR = 18.10, p < 0.001) and nearly 120-fold for their urban counterparts (OR = 119.75, p < 0.001). Among rural MHS users in 2020, adjusted odds of TMH use diminished with increasing age. CONCLUSIONS: TMH mitigated PHE-related barriers to MHS access for rural and urban beneficiaries, but urban residents benefited disproportionately. Among rural beneficiaries, older age was related to lower TMH use. To avoid reinforcing existing MHS access disparities, policies must address factors limiting TMH use among rural beneficiaries, especially those over 75 and those from historically underserved communities.

Rural-Urban Differences in Workers' Access to Paid Sick Leave.

Paid sick leave (PSL) is associated with health care access and health outcomes. The COVID-19 pandemic highlighted the importance of PSL as a public health strategy, yet PSL is not guaranteed in the United States. Rural workers may have more limited PSL, but research on rural PSL has been limited. We estimated unadjusted and adjusted PSL prevalence among rural versus urban workers and identified characteristics of rural workers with lower PSL access using the 2014-2017 Medical Expenditure Panel Survey. We found rural workers had lower access to PSL than urban workers, even after adjusting for worker and employment characteristics. Paid sick leave access was lowest among rural workers who were Hispanic, lacked employer-sponsored insurance, and reported poorer health status. Lower rural access to PSL poses a threat to the health and health care access of rural workers and has implications for the COVID-19 public health emergency and beyond.

Cost-effectiveness of open versus endovascular repair of abdominal aortic aneurysm in the OVER trial.

OBJECTIVE: This study was conducted to determine the costs and comparative cost-effectiveness of two methods of abdominal aortic aneurysm (AAA) repair in the Open Versus Endovascular Repair (OVER) Veterans Affairs (VA) Cooperative Study, a multicenter randomized trial of 881 patients. METHODS: The primary outcomes of this analysis were mean total health care cost per life-year and per quality-adjusted life-year (QALY) from randomization to 2 years after. QALYs were calculated from EuroQol (EQ)-5D questionnaires collected at baseline and annually. Health care utilization data were obtained directly from patients and from national VA and Medicare data sources. VA costs were obtained from national VA sources using methods previously developed by the VA Health Economics Resource Center. Costs for non-VA care were determined from Medicare claims data or billing data from the patient's health care providers. RESULTS: After 2 years of follow-up, mean life-years were 1.78 in the endovascular repair group and 1.74 in the open repair group (difference, 0.04; 95% confidence interval [CI], -0.03 to 0.09; P = .29). Mean QALYs were 1.462 in the endovascular group and 1.461 in the open group (difference adjusting for baseline EQ-5D score, 0.006; 95% CI, -0.038 to 0.052; P = .78). Mean graft costs were higher in the endovascular group ($14,052 vs $1363; P < .001), but length of stay was shorter (5.0 vs 10.5 days; P < .001), resulting in a lower mean cost of the hospital admission for the AAA procedure in the endovascular repair group of $37,068 vs $42,970 (difference, -$5901; 95% CI, -$12,135 to -$821; P = .04). After 2 years, total health care costs remained lower in the endovascular group, but the difference was no longer significant (-$5019; 95% CI, -$16,720 to $4928; P = .35). The probability of endovascular repair being less costly and more effective was 70.9% for life-years and 51.4% for QALYs. CONCLUSIONS: In this multicenter randomized trial, endovascular AAA repair resulted in lower cost and better survival than open repair after the initial hospitalization for repair; but after 2 years, survival, quality of life, and costs were not significantly different between the two treatments.

Acuity Differences Among Newly Admitted Older Residents in Rural and Urban Nursing Homes.

BACKGROUND AND OBJECTIVES: Our primary objective was to assess rural-urban acuity differences among newly admitted older nursing home residents. RESEARCH DESIGN AND METHODS: Data included the 2015 Minimum Data Set v3.0, the Area Health Resources File, the Provider of Services File, and Rural-Urban Commuting Area codes. Activities of daily living, the Cognitive Function Scale, and aggression/wandering indicators were used to assess functional, cognitive, and behavioral status, respectively. Excluding assessments for short stays (less than 90 days), assessments for 209,719 newly admitted long-stay residents aged 65 and older across 14,834 facilities in 47 states were evaluated. Difference in differences (DID) generalized linear models with state-fixed effects and clustering by facilities were used to assess the interaction effect of older age (75 plus) on rural-urban acuity differences, controlling for socioeconomic factors, admission source, and market characteristics. RESULTS: Residents admitted to rural facilities were less functionally impaired (incidence rate ratio: 0.973-0.898) but had more cognitive (odds ratio [OR]: 1.03-1.22) and problem behaviors (OR: 1.19-1.48) than urban. Although older age was predictive of higher acuity, in DID models, the expected decline in functional status was comparable in rural and urban facilities, while the cognitive and behavioral status for older admissions was 8.0% and 8.5% lower in rural versus urban facilities, respectively. DISCUSSION AND IMPLICATIONS: Although the higher prevalence of cognitive impairment and problem behaviors among rural admissions was attributable in part to older age, rural facilities admitted less complex individuals among older age residents than urban facilities. Findings may reflect less capacity to manage older, complex individuals in rural facilities.

Telehealth Use in a Rural State: A Mixed-Methods Study Using Maine's All-Payer Claims Database.

PURPOSE: This study assesses trends in telehealth use in Maine-a rural state with comprehensive telehealth policies-across payers, services, and rurality, and identifies barriers and facilitators to the adoption and use of telehealth services. METHODS: Using a mixed-methods approach, researchers analyzed data from Maine's All Payer Claims Database (2008-2016) and key informant interviews with health care organization leaders to examine telehealth use and explore factors impacting telehealth adoption and implementation. FINDINGS: Despite a 14-fold increase in the use of telehealth over the 9-year study period, use remains low-0.28% of individuals used telehealth services in 2016 compared with 0.02% in 2008. Services provided via telehealth varied by rurality; speech language pathology (SLP) was the most common type of service among rural residents, while psychiatric services were most common among urban residents. Medicaid was the primary payer for over 70% of telehealth claims in both rural and urban areas of the state, driving the increase of telehealth claims over time. Issues challenging organizations seeking to deploy telehealth included provider resistance, staff turnover, provider shortages, and lack of broadband. Key informants identified inadequate and inconsistent reimbursement as barriers to comprehensive, systematic billing for telehealth services, resulting in underrepresentation of telehealth services in claims data. CONCLUSIONS: Claims covered by Medicaid account for much of the observed expansion of telehealth use in Maine. Telehealth appears to be improving access to behavioral health and SLP services. Provider shortages, broadband, and Medicare and commercial coverage policies limit the use of telehealth services in rural areas.

National trends in the provision of smoking cessation aids within the Veterans Health Administration.

OBJECTIVES: To evaluate the effectiveness of the Veterans Health Administration (VHA) in providing treatment for tobacco dependence, accomplished by estimating national trends in the number and percent of smokers receiving smoking cessation aids (SCAs) within the VHA, trends in SCA utilization and expenditures, and the impact of lifting restrictions on patient access to SCAs. STUDY DESIGN AND METHODS: All patients receiving an outpatient SCA prescription were identified within the Veterans Affairs (VA) Pharmacy Benefits Management database over a 4-year period- October 1, 1998 (n = 61 968) to September 30, 2002 (n = 76 641). Smoking prevalence was based on data from the VA's 1999 Large Health Survey of Enrollees. A subsample of sites was classified as having restricted access to SCAs if patients were required to attend smoking cessation classes. Changes in annual SCA utilization rates and expenditures by SCA type and restriction status were measured to assess changes in treatment of tobacco dependence. RESULTS: Approximately 7% of smokers received SCA prescriptions, and SCAs accounted for less than 1% of the VHA's annual outpatient pharmacy budget in any given year. Following downward trends in the cost of 30-day SCA prescriptions, annual SCA expenditures per patient decreased over time. Expenditures were lower for restricted than unrestricted sites. More than two thirds of smokers who were prescribed medications received the nicotine patch, a quarter received bupropion sustained-release, and fewer than 10% received nicotine gum. CONCLUSIONS: Measures of SCA utilization and cost are low, stable, and less than the recommended rates in national smoking cessation guidelines, suggesting that this population of smokers is undertreated. Removing SCA restrictions is not prohibitively expensive and improves access to cost-effective care.

The impact of Telephonic Health Coaching on Health Outcomes in a High-risk Population.

BACKGROUND: Health coaching is a client-centric process to increase motivation and self-efficacy that supports sustainable lifestyle behavior changes and active management of health conditions. This study describes an intervention offered as a benefit to health plan members and examines health and behavioral outcomes of participants. METHODS: High-risk health plan enrollees were invited to participate in a telephonic health coaching intervention addressing the whole person and focusing on motivating health behavior changes. Outcomes of self-reported lifestyle behaviors, perceived health, stress levels, quality of life, readiness to make changes, and patient activation levels were reported at baseline and upon program completion. Retrospectively, these data were extracted from administrative and health coaching records of participants during the first 2 full years of the program. RESULTS: Less than 7% of the 114 615 potential candidates self-selected to actively participate in health coaching, those with the highest chronic disease load being the most likely to participate. Of 6940 active participants, 1082 fully completed health inventories, with 570 completing Patient Activation Measure (PAM). The conditions most often represented in the active participants were depression, congestive heart failure, diabetes, hyperlipidemia, hypertension, osteoporosis, asthma, and low back pain. In 6 months or less, 89% of participants met at least one goal. Significant improvements occurred in stress levels, healthy eating, exercise levels, and physical and emotional health, as well as in readiness to make change and PAM scores. DISCUSSION: The types of client-selected goals most often met were physical activity, eating habits, stress management, emotional health, sleep, and pain management, resulting in improved overall quality of life regardless of condition. Positive shifts in activation levels and readiness to change suggest that health coaching is an intervention deserving of future prospective research studies to assess the utilization, efficacy, and potential cost-effectiveness of health coaching programs for a range of populations.

Using the Medicare Current Beneficiary Survey to conduct research on Medicare-eligible veterans.

The Medicare Current Beneficiary Survey (MCBS) is a longitudinal, multipurpose panel survey of a nationally representative sample of Medicare beneficiaries sponsored by the Centers for Medicare and Medicaid Services (CMS). The MCBS serves as a comprehensive data source on self-reported health and socioeconomic status, health insurance, healthcare utilization and costs, and patient satisfaction. CMS uses Medicare claims data to validate self-reported Medicare Fee-For-Service (FFS) utilization. Because the Veterans Health Administration (VHA) does not bill for services, CMS imputes VHA costs. This article addresses the quality of the MCBS dataset for conducting research on Medicare-eligible veterans by addressing the sample's representativeness, quality of self-reported data, and accuracy of imputed VHA cost estimates. We compared demographic data from the 1992 and 2001 National Survey of Veterans (NSV) with the MCBS 1992 and 2001 Cost and Use files. We compared self-reported VHA utilization and CMS's imputed costs with VHA administrative datasets. The VHA's Pharmacy Benefits Management (PBM) database is available from fiscal year (FY) 1999 onward, and the VHA Health Economics Resource Center's (HERC) Average Cost datasets are available from FY1998 onward. While the samples were comparable in terms of age, sex, and race, the MCBS respondents were in better health, less likely to be married, and more likely to be widowed than NSV respondents. MCBS underreporting rates were higher for VHA than Medicare outpatient events. Underreporting and differences between CMS's and HERC's costing methodologies contributed to lower MCBS versus VHA administrative person- and event-level costs. Alternatively, average annual VHA prescription costs per capita were higher in the MCBS than in the PBM data. Differences in socioeconomic characteristics of the NSV and MCBS samples may be attributable to differences in sampling methodologies. Higher underreporting rates for VHA versus Medicare FFS outpatient events are likely due to systemic differences between the VHA and private healthcare sectors. While VHA formulary discounts may not be reflected in MCBS's VHA prescriptions costs, lower PBM prescriptions costs are also due to deficient indirect cost data. Since reliable VHA utilization and cost data existed in either FY1998 or FY1999 onward, study goals include estimating the relative share and/or cost of care provided by Medicare and the VHA. Researchers with access to VHA datasets should consider merging them into the MCBS and replacing self-reported utilization and CMS's imputed costs with VHA administrative data. This replacement would significantly improve the accuracy, quality, and usefulness of the MCBS dataset for policy research.

Outcomes of a Hepatitis C screening program at a large urban VA medical center.

GOALS: To determine the outcomes of implementing clinical care guidelines for Hepatitis C screening, evaluation, and treatment in a large urban Veterans Affairs Medical Center. BACKGROUND: Little information exists regarding the actual outcomes of institutional screening programs for Hepatitis C. STUDY: Retrospective review of all patients tested for Hepatitis C at the Minneapolis Veterans Affairs Medical Center from January 1, 2000 to December 31, 2001. Logistic regression was used to determine factors related to successful referral and treatment. RESULTS: During this period 36,422 unique patients were screened for Hepatitis C virus (HCV) risk factors, resulting in 12,485 HCV enzyme-linked immunoassay antibody tests. HCV antibodies were positive in 681 (5.4%) patients and 520 (4.2%) were HCV-RNA-positive. Of HCV-RNA-positive patients, 430 (83%) were referred, 382 (73%) attended the Hepatitis clinic, and 232 (44.6%) received liver biopsies. Patients referred had significantly fewer comorbidities, known marital status, and greater prior clinic attendance than those not referred. Overall, 124 patients with established fibrosis received antiviral therapy (32% of patients attending clinic or 24% of viremic cohort). White race, fewer major medical problems, and age less than 60 years predicted antiviral treatment. Sustained virologic response occurred in 46 (37%) of treated patients (9% of the viremic cohort). Patients with a sustained virologic response include 17 patients with stage 3 to 4 fibrosis. CONCLUSIONS: This screening and referral program resulted in 73% of HCV-RNA-positive patients attending a specialty Hepatitis C clinic and 24% of those most likely to benefit received antiviral therapy. Measures to increase referral, engagement in care, and antiviral treatment are needed.

Cost-effectiveness of abdominal aortic aneurysm repair: a systematic review.

OBJECTIVES: A systematic review of the cost-effectiveness of abdominal aortic aneurysm (AAA) repair was conducted. Although open surgery has been considered the gold standard for prevention of AAA rupture, emerging less-invasive endovascular treatments have led to increased interest in evaluating the cost and cost-effectiveness of treatment options. METHODS: A systematic review of studies published in MEDLINE between 1999 and 2005 reporting the cost and/or cost-effectiveness of endovascular and/or open surgical repair of nonruptured AAAs was conducted. Case series studies with less than fifty patients per treatment were excluded. RESULTS: Of twenty eligible articles, three were randomized controlled trials, twelve case series, four Markov models, and one systematic review. Regardless of time frame, all studies found that endovascular repair costs more than open surgery. Although the high cost of the endovascular prosthesis was partially offset by reduced intensive care, hospital length of stay, operating time, blood transfusions, and perioperative complications, hospital costs were still greater for endovascular than open surgical repair. For patients medically fit for open surgery, mid-term costs were greater for endovascular repair with no difference in overall survival or quality of life. For patients medically unfit for open surgery, endovascular repair costs more than no intervention with no difference in survival. CONCLUSIONS: Although conclusions regarding the cost-effectiveness of AAA treatment options are time dependent and vary by institutional perspective, from a societal perspective, endovascular repair is not currently cost-effective for patients with large AAA regardless of medical fitness.

Comparison of endovascular and open surgical repairs for abdominal aortic aneurysm.

OBJECTIVES: Evaluate treatment options for nonruptured abdominal aortic aneurysms (AAA); the relationship of hospital and physician volume to outcomes for endovascular repair (EVAR); affect of patient and AAA factors on outcomes; cost-benefits of treatments. DATA SOURCES: PubMed, Cochrane Library, FDA, and other electronic websites until May 2006. Reference lists and content experts were used to identify additional reports. REVIEW METHODS: Randomized controlled trials (RCT) of open surgical repair (OSR), EVAR, or active surveillance, systematic reviews, nonrandomized U.S. trials, and national registries were used to assess clinical outcomes. Volume-outcome articles published after 2000 were reviewed if they reported the relationship between U.S. hospital or physician volume and outcomes, were population-based, and the analysis was adjusted for risk factors. Cost studies included at least 50 EVAR and provided data on costs or charges, and cost-effectiveness analyses. RESULTS: Initial or attained diameter is the strongest known predictor of rupture. The annual risk of rupture is below 1 percent for AAA <5.5 cm in diameter. Among medically ill patients unfit for OSR with AAA >/=5.5 cm, the risk of rupture may be as high as 10 percent per year. Early/immediate OSR of AAA <5.5 cm (two trials n=2,226) did not reduce all-cause mortality compared with surveillance and delayed OSR. Results did not differ according to age, gender, baseline AAA diameter or creatinine concentration. Two RCT with followup of at least 2 years compared EVAR to OSR for AAA >/=5.5 cm. EVAR reduced postoperative 30-day mortality compared to OSR (1.6 percent EVAR vs. 4.7 percent OSR, RR = 0.34 [0.17 to 0.65]). Early reduction in all-cause mortality with EVAR disappeared before 2 years. Post-operative complications and reinterventions were higher with EVAR. Quality of life differences were small and disappeared after 3-6 months. One RCT of patients with AAA >/=5.5 cm judged medically unfit for OSR (n=338), reported no difference in all-cause mortality or AAA mortality between EVAR and no intervention (HR = 1.21; 95 percent CI 0.87 to 1.69). Forty-eight nonrandomized reports evaluated EVAR. Patient, AAA characteristics, and outcomes were similar to RCT comparing EVAR to OSR. A volume outcome relationship has been shown for OSR, but there are no data adequate to estimate the effect of hospital or physician volume on EVAR outcomes or to identify a volume threshold for policymakers. Immediate OSR for AAA <5.5 cm costs more and does not improve long-term survival compared to active surveillance and delayed OSR. The cost effectiveness of EVAR relative to OSR is difficult to determine. However, compared to OSR for AAA >/=5.5 cm, EVAR has greater in-hospital costs primarily due to the cost of the prosthesis. EVAR has shorter length of stay, lower 30-day morbidity and mortality but does not improve quality of life beyond 3 months or survival beyond 2 years, and is associated with complications, need for reintervention, long-term monitoring, and higher long-term costs. Compared to no intervention in patients medically unfit for OSR, EVAR costs more and does not improve survival or quality of life. CONCLUSIONS: For AAA <5.5 cm in diameter, active surveillance with delayed OSR results in equivalent mortality but lesser morbidity and operative costs due to fewer interventions compared to immediate OSR. For AAA >/=5.5 cm, EVAR has not been shown to improve long-term survival or health status over OSR though peri-operative outcomes are improved. EVAR does not improve survival in patients who are medically unfit for OSR. EVAR is associated with more complications, need for reintervention, monitoring, and costs compared to OSR or no intervention. U.S. RCT are needed using approved EVAR devices to evaluate patient outcomes.

Health care coverage and access to care: the status of Minnesota's veterans.

OBJECTIVES: The primary objective of this study was to examine veterans' reliance on health care services provided by the Veterans Health Administration (VHA) within Minnesota and estimate the potential effect on uninsurance rates if all eligible veterans relied on VHA coverage. Secondary objectives were to compare veterans and nonveterans' by geographic location, demographic characteristics, health status, and health insurance coverage and to compare insured and uninsured veterans especially with regard to access to care. RESEARCH DESIGN: Data are from the 2001 Minnesota Health Access Survey of a stratified random sample of more than 27,000 respondents, of whom 3,500 were self-identified veterans. Although all veterans were eligible to obtain health care services from the VHA in 2001, veterans not reporting VHA coverage and having no other source of insurance coverage were considered uninsured. Differences in weighted population characteristics are reported. Logistic regression analysis is used to identify factors associated with veterans' reliance on VHA coverage. RESULTS: Veterans represented 13.4% of the state's adult population and 9.3% of the state's uninsured nonelderly adult population in 2001. Uninsured veterans were more likely to be single, unemployed, living in rural areas, and reporting constrained access to services than insured veterans. Veterans with a non-VHA source of insurance were less reliant on VHA services. CONCLUSIONS: The state's uninsurance rate would significantly decrease if VHA capacity constraints were alleviated and veterans relied on the VHA safety net. If veterans' insurance status matters in states with low uninsurance rates, VHA coverage has broader implications for states with higher veteran concentrations and higher uninsurance rates.