OBJECTIVES. This study examined factors that affect access to Veterans
Administration mental health services. METHODS. Data from national Ve
terans Affairs databases and the 1990 Decennial Census were used to es
timate rates of Veterans Affairs mental health service use in each US
county (n = 3,156) among all US veterans and in three subpopulations d
efined by eligibility and clinical status. Independent variables exami
ned in standard multivariate analyses and using hierarchical linear mo
deling techniques included county-level sociodemographic characteristi
cs (age, race, and income); ''unmanaged'' service system characteristi
cs (those not directly controlled by Veterans Affairs program managers
, eg, distance from residence to Veterans Affairs and to non-Veterans
Affairs services, local supply of non-Veterans Affairs services); and
''managed'' service system factors (those directly controlled by Veter
ans Affairs program managers, eg, per capita Veterans Affairs funding
level and the efficiency of Veterans Affairs service delivery). RESULT
S. Altogether, 2.0% of US veterans used Veterans Affairs mental health
services. More than one third (36%) of the variance in utilization wa
s explained by sociodemographic factors; 8% was explained by unmanaged
service system factors and 7% was explained by managed service system
factors, with variations among subgroups. Substitution effects were d
emonstrated between Veterans Affairs and non-Veterans Affairs systems
and appeared to be diagnosis-specific. CONCLUSIONS. Both per capita fu
nding levels and efficient service delivery were significantly associa
ted with increased access to mental health services. Implications for
health system performance assessment and management are discussed.