WASHINGTON • Frank Munk earned his veteran's medical benefits more than four decades ago in Quang Tri province, a hard-fought, bloody piece of ground in Vietnam. Yet he doesn't always choose to use them.

Munk, 64, a truck mechanic from western Kansas, instead spends $2,500 out of his own pocket on a private doctor for such things as hearing tests. It's either that or drive nearly 300 miles to a Department of Veterans Affairs hospital in Wichita or Denver.

"I can't afford to take two days off," said Munk, who's self-employed. "The VA care is getting cost-prohibitive for people in the rural areas because of the time, and a lot of them can't drive themselves."

Other veterans who live beyond America's cities and suburbs share Munk's dilemma. Long distances and restrictive rules have become obstacles to health care for many of the more than 3 million rural veterans enrolled in the VA health system. They account for 41 percent of enrollees.

But the agency's effort to aid rural veterans has other problems as well. An April internal VA audit found that it couldn't determine whether much of the money spent on rural health care in recent years did any good.

The VA Office of Inspector General, the agency's internal watchdog, concluded that the VA "lacked reasonable assurance" that its use of $273 million of the $533 million in rural health funding it received in 2009 and 2010 had "improved access and quality of care" for veterans.

"We basically couldn't tell how effective each of these projects was because of the lack of project performance measures," said Gary Abe, a director in the inspector general's office who oversaw the audit. "The report's message was the VA couldn't determine if it was money well spent."

The report noted that the VA Office of Rural Health did an inadequate job of assessing the health care needs of rural veterans and managing the money for expanding care. In addition, oversight of rural health care programs was ineffective, and communication with other agencies and services involved in rural care was poor, it said.

VA officials agreed with the report's recommendations for improving the rural health program, including the use of financial controls to check spending. VA spokesman Josh Taylor said the department was committed to expanding access to rural veterans.

"We take very seriously our responsibility to ensure veterans receive the health care and benefits they have earned," he said.

Democratic Sen. Patty Murray of Washington, the chairman of the Senate Veterans' Affairs Committee, said the inspector general's report was worrisome.

"At a time when we have to fight for every dollar our veterans get, it is unacceptable that VA can't say whether hundreds of millions of dollars spent to improve health care for rural veterans had any impact on improving access or quality," she said.

SYSTEM UNDER STRESS

Although there appears to be general agreement that VA hospitals provide good medical care, the system has been under extreme stress because of the wars in Iraq and Afghanistan.

Few expected that the wars would last so long, or planned for the flood of patients or the severity of their injuries. VA officials are trying to manage a generation of combat veterans who have come home bearing not only the deep physical scars of battle but invisible psychological wounds as well that will require years — if not a lifetime, in many cases — of care.

Indeed, suicides among Iraq and Afghanistan veterans have reached record levels.

The VA recently lost a two-year court battle against two veterans groups that had sued the agency over its delay and denial of mental health care and benefits for former service members suffering from post-traumatic stress disorder, traumatic brain injury and other psychological problems.

1 OUT OF EVERY 3

Rural America is home to more than a third of the Iraq and Afghanistan veterans who are enrolled in the VA; not all have combat-related health problems. But the VA has stepped up efforts to reach out to rural veterans from all eras.

Telemedicine — in which patients are diagnosed and treated via electronic communication — is one way that veterans can get treatment at home. A network of about 800 community-based outpatient clinics that provides rural veterans with basic medical care such as checkups, X-rays and prescriptions is another.

"It's an attempt to cut costs," said Lana McKenzie, the director of medical services for Paralyzed Veterans of America, a veterans service group. "If you are a healthy vet and ambulatory and live in the area, and need insulin or blood pressure medicine, it works. But it doesn't work if you get further complicated than that."

In general, the VA won't pay for a veteran to see an out-of-network doctor if the same care is available within the system — even if it's more convenient.

Frank Di Piano, 33, an ex-Marine and Iraq veteran who lives near Springfield, Mo., suffered traumatic brain injury after a mortar exploded outside a command tent in Ramadi in 2004. He also has a bad shoulder injury from boot camp that never healed properly.

He drives nearly 300 miles every few weeks to the VA medical center in Oklahoma City to see doctors about his shoulder. It initially took him six months to schedule an MRI.

He also regularly makes the 130-mile trip to the VA hospital in Fayetteville, Ark., for treatment for PTSD.

Di Piano said some physicians he knew had told him that he could get the same care for his shoulder at a hospital in Springfield if the VA would allow him to go outside the network. So he asked.

"They said they couldn't get authorization to do that because it was just too much red tape," Di Piano said.