Rural-Urban Access to Telemedicine Remains Divided for Veteran Affairs Care


The COVID-19 pandemic was associated with an increase in rural-urban telemedicine divide across the Veteran Affairs health care system.



Despite a federal response, there is still a rural-urban digital divide after the onset of the COVID-19 pandemic, especially in mental health integrated services, for those who are veterans, according to the results of a study published in JAMA Network Open.

The pandemic was associated with an increase in rural-urban telemedicine divide across the Veteran Affairs health care system.

Investigators suggest that the health care system’s telemedicine response could benefit from addressing rural disparities, including internet bandwidth, and tailoring the technology for adaption among rural users.

They aimed to examine the changes over time in rural and urban differences in telemedicine for use in the primary-care and mental-health settings among those in Veteran Affairs care. Telemedicine can help close the gap in access to care, but the uptake has been low among those in rural areas.

Investigators examined 63.5 million primary-care and 3.6 million mental-health integration visits in 138 Veteran Affairs health care systems in the United States between March 16, 2019, and December 15, 2021. The statistical analysis occurred between December 2021 and January 2023.

There were more than 6 million unique patients in primary-care visits and 972,578 unique patients in mental-health-integration visits. For every system, monthly visits were counted for primary-care and mental-health-integration specialties from 12 months before to 21 months after the COVID-19 pandemic onset. The visits were categorized as in person or telemedicine, which included video.

Furthermore, a difference-in-difference approach was used to see association in visit modality by whether the health care system was rural or urban and pandemic onset. The investigators used regression models that were adjusted for health care system size as well as patient characteristics, including broadband internet access, comorbidities, demographics, and tablet access.

Investigators reported that rural Veteran Affairs health care systems had higher proportions of telemedicine use than urban ones at 34% and 29%, respectively, for primary-care services.

However, they found that the rural health care systems had lower proportions of telemedicine use than urban health care systems after the onset of the COVID-19 pandemic at 55% and 60%, respectively.

Additionally, they found that the gap between rural and urban telemedicine was even larger for mental-health than primary-care services. Before the pandemic, there were about 2% of rural video visits compared with 1% for urban video visits. After the pandemic, there were 4% and 8%, respectively.

Investigators concluded that there were rural and urban divides for video visits in both primary-care and mental-health integration services.

Limitations of the study included that telemedicine visits in rural and urban health care systems may have been misclassified for some rural individuals, such as those who had to travel to urban locations. Second, there were no data on individuals who received non-Veteran Affairs care in the community, for which rural patients may have opted.


Leung LB, Yoo C, Chu K, O’Shea A, et al. Rates of primary care and integrated mental health telemedicine visits between rural and urban Veterans Affairs beneficiaries before and after the onset of the COVID-19 pandemic. JAMA Netw Open. 2023;6(3):e231864. doi:10.1001/jamanetworkopen.2023.1864

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