title: The relationship between local area labor market conditions and the use of Veterans Affairs health services.
abstract: BACKGROUND
  In the U.S., economic conditions are intertwined with labor market decisions, access to health care, health care utilization and health outcomes. The Veterans Affairs (VA) health care system has served as a safety net provider by supplying free or reduced cost care to qualifying veterans. This study examines whether local area labor market conditions, measured using county-level unemployment rates, influence whether veterans obtain health care from the VA.
  
  
  METHODS
  We used survey data from the Behavioral Risk Factor Surveillance System in years 2000, 2003 and 2004 to construct a random sample of 73,964 respondents self-identified as veterans. VA health service utilization was defined as whether veterans received all, some or no care from the VA. Hierarchical ordered logistic regression was used to address unobserved state and county random effects while adjusting for individual characteristics. Local area labor market conditions were defined as the average 12-month unemployment rate in veterans' county of residence.
  
  
  RESULTS
  The mean unemployment rate for veterans receiving all, some and no care was 5.56%, 5.37% and 5.24%, respectively. After covariate adjustment, a one percentage point increase in the unemployment rate in a veteran's county of residence was associated with an increase in the probability of receiving all care (0.34%, p-value = 0.056) or some care (0.29%, p-value = 0.023) from the VA.
  
  
  CONCLUSIONS
  Our findings suggest that the important role of the VA in providing health care services to veterans is magnified in locations with high unemployment.
authors.affiliation: Northwest Center for Outcomes Research in Older Adults, VA Puget Sound Health Care System, 1100 Olive Way, Suite 1400, Seattle, WA 98101, USA. edwin.wong@va.gov
authors.forename: Edwin S
authors.initials: ES
authors.lastname: Wong
authors.forename: Chuan-Fen
authors.initials: CF
authors.lastname: Liu
mesh_terms: D000368:Aged; D040343:Behavioral Risk Factor Surveillance System; D057172:Economic Recession; D005260:Female; D006787:Hospitals, Veterans / Q000706:statistics & numerical data*; D006801:Humans; D008297:Male; D008875:Middle Aged; D014478:Unemployment / Q000639:trends*; D014481:United States; D014493:United States Department of Veterans Affairs; D014728:Veterans