title: Association between local area unemployment rates and use of Veterans Affairs outpatient health services.
abstract: BACKGROUND
  Prior research indicates that federal spending on Medicare, Medicaid, and other government health programs accelerated during the Great Recession.
  
  
  OBJECTIVE
  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.
  
  
  METHODS
  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.
  
  
  METHODS
  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.
  
  
  METHODS
  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.
authors.affiliation: *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.
authors.forename: Edwin S
authors.initials: ES
authors.lastname: Wong
authors.forename: Paul L
authors.initials: PL
authors.lastname: Hebert
authors.forename: Susan E
authors.initials: SE
authors.lastname: Hernandez
authors.forename: Adam
authors.initials: A
authors.lastname: Batten
authors.forename: Sophie
authors.initials: S
authors.lastname: Lo
authors.forename: Jaclyn M
authors.initials: JM
authors.lastname: Lemon
authors.forename: Stephan D
authors.initials: SD
authors.lastname: Fihn
authors.forename: Chuan-Fen
authors.initials: CF
authors.lastname: Liu
mesh_terms: D000367:Age Factors; D000368:Aged; D000553:Ambulatory Care / Q000706:statistics & numerical data; D017047:Cost Sharing / Q000706:statistics & numerical data; D057172:Economic Recession / Q000706:statistics & numerical data; D005260:Female; D006787:Hospitals, Veterans / Q000191:economics / Q000706:statistics & numerical data*; D006801:Humans; D008297:Male; D008875:Middle Aged; D014478:Unemployment / Q000706:statistics & numerical data*; D014481:United States / Q000453:epidemiology