The Rural Health Care Crisis

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97 Responses

  1. NewDealer says:

    I think you are largely right about how are you going to get them to stay on the farm mentality.

    I know one couple that moved from San Francisco to upstate New York. They are not medical professionals. They were neo-hippie (or at least she was) foodie types who wanted their own farm. They probably would have preferred Northern California but the land was too expensive. I suspect that land is fairly cheap up near Ithaca. Not many people go from being college-educated city types make this switch even if many have “getting away from it all fantasies.”

    There is one potential solution and that is immigration. Louis Malle had a PBS documentary in the 1980s about immigrants in the US. One was a doctor from Asia (probably Vietnamese) who was able to come over and I think the condition was that he would practice medicine in rural Iowa or Kansas. I have no problem with a condition on immigration like this. The chance of this happening is roughly a snow ball’s chance in hell.

    I have no special love for the heartland. My ancestors came here and settled into New York City like many other Jews. Scientific and technological advancement means we can produce a lot more food with a lot less manpower. We are no longer an agricultural nation and many people don’t want to do farm work. Living in any kind of area has pluses and minuses. The minus of rural areas might be a lack of access to healthcare and people are going to need to make the decision about whether this is worth it just like people make the decision that the high cost of living of SF or NYC is worth it or not.Report

  2. Will Truman says:

    This is posted while I am on a roadtrip? Uncool!Report

  3. Cascadian says:

    This is a troll right? Why are we subsidizing rural medicine? Now is the time for rugged individualism and pulling yourself up by your bootstraps.Report

    • Rod in reply to Cascadian says:

      Now that’s just impolite, pointing out how much socialist redistribution these Republican strongholds benefit from (and feel fully entitled to) .Report

    • zic in reply to Cascadian says:

      I’m having that disgusting feeling that happens when you find yourself included in a group you don’t belong in.

      We turned our legislature blue because of crap like this. And we’ll turn the Governor’s mansion blue, too. Soon as we get the chance.Report

    • Rod in reply to Cascadian says:

      While I agree with you. @cascadian , insofar as the politics of late has been pretty obnoxious, particularly from the red/rural side, the reality is that cities only exist by dint of an extensive supply chain that starts out here. You like to eat, right?

      Likewise, rural folks depend on products and services from cities as well.

      It would be good if both tribes acknowledged their mutual dependencies and quit being so dismissive of the other side. Some modest subsidies to enhance the quality of life out in the sticks is a small price to pay for the cornucopia on your grocery store shelves. And a smidgen of gratitude from the rural folks for the electricity, phone service, and healthcare would be helpful as well.Report

      • Cascadian in reply to Rod says:

        No deal. If the particular farmer has increased costs, let him or her pass the costs on to the extent they can. If I’m going to subsidize agriculture, I would rather limit the ability to develop arable land near the cities. Otherwise, I’m not only subsidizing the farmer but his neighbor and the retired guy that was looking for cheap property. If the farmer can’t compete? Well that’s the market for you.

        Have you ever been in a relationship and had that one thing happen where you know it’s over… no going back? I’m there.Report

      • North in reply to Rod says:

        The basic problem, Rod, is that agriculture doesn’t take the people it used to. There’s zero danger that the rural areas will wither away entirely but there’s significant danger that large amounts of marginally productive rural areas will depopulate.
        Rural America*, then, would transform into ever more sprawling expanses of farmland with ever more scattered heavily mechanized rural town hubs punctuated by large expanses of wilderness with seasonal cottage landscape and seasonal service/access hubs. Ecologically and economically it’d be a stellar development but it’d be devastating for rural populations and communities.
        *The parts around the cities of course would urbanize into suburbs, exurbs and commuter home communities.Report

      • Rod in reply to Rod says:

        With all due respect, North, do you imagine I’m not aware of the dynamics? We’ve been steadily depopulating for a century. We adjust (shrug). But I think it’s a little cold to just write us off as if we’re a bunch of antisocial hermits. After all, we DO feed the cities and make your lifestyle possible.Report

      • Kim in reply to Rod says:

        I’m all for more farming in cities, personally. gotta lot of rooftops here, lotta sun. Why not farm ’em?

        (and I’m fine with acknowledging that the rural folks are helpful. That’s why I’m pro-subsidies for ’em. National Security issue, ya?)Report

      • North in reply to Rod says:

        Sure Rod, and for that consideration (in addition to all the practical things cities give the rural areas) rural areas in America are politically privileged and economically subsidized to an enormous degree.Report

      • BlaiseP in reply to Rod says:

        The opposite is true. Rural America has ruthlessly industrialised. Million dollar combines working enormous fields — satellite feeds in the infrared telling farmers where to fertilise, barns full of tech. Homes, too.

        I architected the rewrite of RULSS/RUS program for USDA. RUS is a massive barrel o’ pork, going right back to the 1930s with every member of Congress dipping into it. Fat fiber going out to damned near everywhere. Put it this way, I got the best Internet ever in Augusta, WI, about as rural as you’re going to get in this part of the planet.

        RUS has an entire bank within it, the Cushion of Credit. Prepay your RUS loan, earn competitive interest on it, then 5% in 2005, paid directly from the General Receipts of the Treasury. And your loans can be rescheduled, a large percentage of them forgiven outright. Rural American is completely propped up with all sorts of interesting schemes. Red America takes far more in federal tax money than it generates.

        And let’s put to rest this idea wherein rural America is hard done by. It’s been increasingly difficult to get into farming. A kid starting out would need massive sums of capital — or inherit the family farm. The big wheat farms export their grain in competition with Australia and Argentina and half a dozen other nations. Farming is an industry. It’s dominated by a few big dealers, Cargill, ADM and the like.

        Cornucopia: Chile and the San Joaquin Valley are producing the veggies on the shelf just now, what with harvest over. Maybe a few pumpkins and apples are American. The produce sections being what they are, that’s factory farming in the San Joaquin Valley, stoop labour, done by Mexicans and Chileans mostly.

        For all their condescending, whinging malarkey about the American Farmer and Gummint Subsidies, the GOP’s got all these rural states wrapped up with simple bribery. The American ag system is completely distorted. Louisiana and Florida. American cane sugar is so heavily subsidised we’re paying 3x anyone else’s price. If Cuban sugar was let into the USA, which won’t happen, — and guess who won’t let it in? That’s right. Good old Ted Cruz. We’re polluting the fuck out of the Everglades with all the runoff from those sugar cane fields.

        Gets me angry every time I think about it. Rural America deserves help. But by God, the current system is completely warped in their favour, by some stupid and cruel people who despise the urban poor.Report

      • North in reply to Rod says:

        BlaiseP, yes I remember reading that there’s a reason that so much candy is made in Ontario, Canada and that’s because the Canadians import their sugar without tarriffs.Report

      • BlaiseP in reply to Rod says:

        Ted Cruz is an enormous, sweaty dick. Here’s Cruz in action. He just hates Food Stamps, that’s his only bitch with the Farm Bill.Report

      • BlaiseP in reply to Rod says:

        It’s been the Democrats who’ve opposed Big Sugar in any meaningful way in Florida.Report

      • Kolohe in reply to Rod says:

        “He just hates Food Stamps, that’s his only bitch with the Farm Bill.”

        From your link:

        “It fails to provide a true safety net for farmers in difficult years, fails to fully target assistance to those most in need, subsidizes massive agri-businesses, and fails to prioritize farm aid over duplicative programs, promoting unrelated programs from green energy to housing.”

        So no, he states that food stamps are not his only complaint about the farm bill.

        But that’s changing the subject from your specific complaint on Cruz vis a vis sugar subsidies – as pointed out above, Cruz voted for reform, along with an eclectic group of Senators.

        And has very little to do with Cuba policy, which is its own stupidity. US sugar policy keeps sugar from Brazil and Mexico (and India – though trade policy with India is also its own separate thing) out. Cuba is an intensive producer, but small on the world scale – they would not be the critical market mover (Brazil is). Plus, were Cuba ever to get on an economic development track to get them closer to OECD wage levels (and first world environmental standards), their sugar production would likely diminish, as Hawaii’s and Puerto Rico’s has from their heyday.Report

      • BlaiseP in reply to Rod says:

        Stop trying to defend the indefensible. Cruz takes agribusiness money.Report

      • Kolohe in reply to Rod says:

        It’s indefensible to point out factual and analytical errors?

        Cruz takes Agribusiness money. As does just about everyone. But that wasn’t your original assertion.

        Furthermore, the amount Cruz gets from agribusiness (around 270K from all sources) is about 2% of the some 11.8 million he’s raised in his lifetime. Even your own link shows a paltry 12K out of 1.5 M he has from PACs – which is also less than 1/2 of 1% of the some 6 million Agribusiness PACS has given so far just in this cycle. And he’s well out of the top 20 Senators on this or the previous cycle.

        Even if your assertion is shifting from Cruz is responsible for high price of sugar in the US and the concomitant environmental degradation, to an assertion Cruz is a shill for Big Ag, the latter assertion is still wrong.Report

      • BlaiseP in reply to Rod says:

        Ted Cruz is the biggest hypocrite in Washington. Big Sugar owns Florida politics. It’s perfectly bipartisan, it supports Democrat Bill Nelson who was and remains in the pocket of Big Sugar. So is the entire Republican Party. Marco Rubio voted against repealing the sugar subsidies.

        The only reason Ted Cruz voted against them is for the reason I’ve laid out: it was a little gimme so the Democrats could keep Food Stamps aboard. That’s the only reason. If there was a chance in hell of repealing big sugar subsidies, the bipartisan flood of money from Big Sugar would kill it aborning.Report

      • Kolohe in reply to Rod says:

        “So is the entire Republican Party.”

        Um, no. Hence the vote of the Shaheen amendment. Incidentally, the biggest of the Big Sugar has given to over twice as many Senate Democrats as it has Senate Republicans over the last cycle. So it would have been closer (but still absolutely wrong) to have said “So is the entire Democratic Party.”

        “The only reason Ted Cruz voted against them is for the reason I’ve laid out: it was a little gimme so the Democrats could keep Food Stamps aboard.”

        You know Senator Shaheen is a Democrat right? As are Senator Warren, Senator McCaskill, Senators Kaine and Warner, and Senator Manchin. A rather broad spectrum of Democrats who aligned with an idiosyncratic collection of Republicans voted for the amendment to reform sugar subsidies. Which failed, because Big Sugar owns a critical mass of key legislators. There was no horsetrading over food stamps or any other aspect of the Farm bill (or any other source of give and take) in pursuit of the Shaheen amendment.

        The amendment had nothing to do with the attempts to split the two pillars of the farm bill. That was done on route to and in final passage – an overall bill which Cruz, yes, voted against, because he is indeed against food stamps, and *not* in the pocket of Big Ag much less Big Sugar, as you have previously make allegations of. In any case the real cleavage of the farm bill was done later in the House, and why we don’t have a passed farm bill.Report

      • J@m3z Aitch in reply to Rod says:


        There’s a town about an hour from me, Bryan, OH, home of the Spangler Candy Company. You know those Dum Dum suckers available at every bank teller’s stand and given away by every pediatrician when kids get their shots? That’s them. They also make about 90% of the candy canes you’ll see at Christmas, and lots of high-end specialty candies for other companies. They keep as much production in Bryan as they can, but have moved a lot to Mexico and Ontario. About 8 years ago they estimated that U.S. sugar tariffs cost them about $10,000 per day.Report

      • North in reply to Rod says:

        Yeah Prof, I had that impression.Report

  4. greginak says:

    I think rural areas have always been hard to live in. If it was easier in the 1800’s that was only because there wasn’t a ton of difference between the city and rural areas. Rural life is hard and is only easy through rose colored glasses. Rural areas have always needed cities and towns as places to sell their products and for access to things from the rest of the world. Of course populated areas have needed the crops and products of rural areas. In general my experience is that people from rural areas don’t really want to see their dependence on cities. I don’t have a problem with some level of subsidies from rural areas as long as people are there. Some towns are just going to fade like they always have and they can’t be propped up.Report

  5. zic says:

    I live in a rural state.

    I also live in the oldest state.

    There are not enough dentists here. I have special needs, and travel two hours each way for dental care. I know some people who go to Canada for dental care.

    I remember having an argument with McArdle once, back when she was at The Atlantic where she said something like (and I paraphrase), “Medicaid health care is not all that great,” meaning the quality of care you got when you are on Medicaid is sub-par. And I thought, “wait a minute, that’s what I get for care, even with other health insurance.”

    I have some of the most expensive junk health insurance in the nation. And my dumb-ass 38% governor opted out of the ACA Medicare expansion.

    This is the Northeast, not the rural heartland. And most folk know don’t want to be rugged individualist, they just want health care that doesn’t eat up 25% or more of their income.Report

  6. Rod says:

    Even by rural standards, Eastern Colorado is the boonies. I live in northwest Kansas, and the difference in population density versus what Michael describes is considerable. I would chalk it up to path-dependency, particularly the Homestead Act. We started out in the late 19th century with four families per square mile plus gobs of little towns.

    Our counties out here are all squares thirty miles to a side with the county seat smack dab in the middle. In each seat we have a publicly owned and operated hospital and clinic. Larger regional medical centers appear in the larger towns along the I-70 corridor.

    There’s a lot of coordination of services to spread the capital expense around. For instance, our local hospital has the CAT scanner that serves about a nine county area. Specialists have local office hours in rotation with neighboring clinics or regional centers.

    Overall it works fairly well, but it’s a lot more coordinated and socialist than a lot of folks would be willing to admit.Report

    • zic in reply to Rod says:

      This exactly.Report

    • Michael Cain in reply to Rod says:

      Even by rural standards, Eastern Colorado is the boonies.

      Yes, it is, particularly the SE corner. NW Kansas started from a higher population density, but has the same problem [PDF] of declining population. As much as I like all of the varieties of Great Plains geography, I’m finding myself more and more convinced that the Poppers may well be right: settlement will turn out to be a failed agricultural experiment. It won’t take large changes in climate to have large impacts. IIRC from my days at UNL, the experts think that a couple of inches less of effective rainfall (a function of precipitation and temperatures) per year for a century and the Nebraska Sandhills lose their plant cover and become mobile dunes again.Report

      • As a follow-up, this [PDF]. There’s the rural America where most of the rural population lives, and then there’s the West (and a few other bits here and there). My views on the subject are affected by the fact that I live in the West, with its more extreme definition of what “rural” means.Report

  7. Fantastic piece, Michael. And one I can comment on firsthand.

    For the first five years out of postgraduate training, I practiced in a community-based hospital. While it was by no means as rural as some medical centers, compared to the places where I had trained… it was very rural. And it had a catchment area that was deeply rural indeed.

    When there was a pediatric emergency, the cavalry that was called in was… me, or one of my colleagues. There were no pediatric emergency medicine specialists. There were, in fact, no pediatric specialists to speak of. One of the other pediatricians and I were the only two who were board certified in a subspecialty in the community, which happened to be adolescent medicine for both of us. So if you happened to have PID or an eating disorder, you were in luck. Inflammatory bowel disease? Not so much.

    Which meant that we did a lot of care ourselves that would have been handled by subspecialists in a major metro. The wait list for an actual subspecialty appointment was months and months long in almost all cases, and the nearest hospital that provided such services was over an hour away for many people. So we did a lot in our office. On the one hand, I think we offered better and more comprehensive care than is often offered by providers with easy access to consultants they can punt to. On the other hand… well, sometimes you need to punt!

    It was that same somewhat distant hospital that would need to dispatch a transport team to get any critically ill neonate, but often it would be us who had to stabilize them in the meantime. I found those situations incredibly stressful, and it was the stress of such events that contributed to a large degree to my seeking a different position.Report

  8. LeeEsq says:

    The main problem with providing healthcare to rural areas seems to be two-fold, its hard to convince doctors to stay in rural areas and the population is so dispersed delivery of care is difficult. Both problems are going to be nearly impossible to solve. I suppose you can convince doctors to relocate or at least stay partly in rural areas by providing incentives like paying off their student loans on a condition of x years of service in a rural area and providing money to set up practices there. The dispersal issue is going to be more difficult. Its a bit easier in the older states, where distances are smaller and rural life is more village-like than homestead like. Maybe you can turn the seat of a rural county into a sort of service center but I imagine they function that way now. Doctors could do house visits if necessary.Report

    • Rod in reply to LeeEsq says:

      It depends on what you mean by rural. There’s New England rural and then there’s “50 miles to the next gas station” rural. There’s great swaths of territory from the Western great plains to the Pacific states where very few people live. What ya gonna do? At least the lack of healthcare doesn’t affect many people (sorta by definition). If you want to live on a ranch in Wyoming I guess that’s just part of the deal.Report

      • LeeEsq in reply to Rod says:

        I meant both. The rural areas in the more densely settled parts of this country are close enough to major populations centers where delivering health care isn’t problem. Elsewhere it is.Report

      • BlaiseP in reply to Rod says:

        You do what the military does. If you’re out there on some ranch in Wyoming, you learn to use a tourniquet and an Israeli bleed bandage, learn to clear an airway and have enough sense to know to call in a medevac. Having a working Life Flight system is absolutely critical. Absolutely everyone in the military carries a medkit.

        Doesn’t matter if you’re in the city or out in the far boonies, exsanguination is the same. You have the same amount of time. Obstructed airway, same amount of time. Time is what money won’t buy in those situations.Report

    • Kim in reply to LeeEsq says:

      Go ask doctors without borders. They’ve already solved a decent amount of “ordinary care” issues online.
      Then get the rural folks high speed internet.Report

      • Will Truman in reply to Kim says:

        Satellite internet is supposedly making great improvements as of late.Report

      • Glyph in reply to Kim says:

        On the downside, the NSA is providing the satellites.Report

      • Will Truman in reply to Kim says:

        They don’t even need to provide the satellites. They allowed the sats to launch and so you didn’t build that and they expect reciprocity.Report

      • Glyph in reply to Kim says:

        As a PR measure, the NSA should announce that they will start devoting 15% of their budget and resources to virus/malware/spam interdiction and cleaning, if you just route all your web traffic through their servers.

        Porn hounds (which is to say, nearly everyone) would be BEGGING for them to read their mails.Report

      • BlaiseP in reply to Kim says:

        Oh Lord. Let’s sing another chorus of “Wicked ol’ NSA”. Those people merely do the bidding of their political masters, all of whom think they’re doing us a big favour thereby. Conversely, NSA have been trying to persuade folks to secure their Internet connections and provided several useful tools for doing so, notably the open source SELinux software.

        If people actually did as the NSA suggested, we wouldn’t be troubled with all these viruses and malware. Praise and thanks ought to go to the closed-source vendors, chiefly Microsoft, who are forever making life more convenient and ever less secure.Report

      • Glyph in reply to Kim says:

        At least they are keeping us safe from a resurgent Germany. Maybe Bush was planting a bug on Merkel when he gave her that weird backrub.Report

      • BlaiseP in reply to Kim says:

        Heh. And of course, none of our friends ever spied on the USA.

        I’ve taken to quoting Kenneth Waltz with tiresome frequency of late. If we gather more and more data and establish more and more associations, however, we will not finally find that we know something. We will simply end up having more and more data and larger sets of correlations.Report

      • Glyph in reply to Kim says:

        Eh, the Germany thing (like the satellite thing) was mostly for comedy. I expect us to be spying on non-Americans, that’s what spying is for…though I do expect a bit of subtlety about it. The Germans are PISSED.

        But the spying on Americans has gotta stop.

        One of those senators, Mark Udall, D-Colo., challenged the head of the NSA, Gen. Keith Alexander, on just how far his agency could go when gathering those records.

        “Is it the goal of the NSA to collect the phone records of all Americans?” Udall asked at Thursday’s hearing.

        “Yes, I believe it is in the nation’s best interest to put all the phone records into a lockbox that we could search when the nation needs to do it. Yes,” Alexander replied.

        Anyway, this is all *way* off-topic, so I will leave it there.Report

      • BlaiseP in reply to Kim says:

        Back on track, I was out taking pictures in rural Arizona, on the road between Phoenix and Globe. Stopped in Superior for some Gatorade. Struck up a conversation with the clerk at the store, who said the town was in terrible shape.

        “You realise, Superior could get a nice fat Internet pipe, courtesy of RUS. Just call up your representative in Congress, he’ll help the town get through the bureaucracy. Can’t do it without him or her, anyway. Get a bid from a contractor, they’ll help you line up a cableco/ISP. First thing you want is a call center, that will provide employment. These outfits all want people with American accents, it’s good money for working moms and such.”

        Satellite Internet isn’t viable. Fiber is viable, mostly because it’s so heavily subsidised. There really is no excuse for these little towns. The money’s there.Report

      • Kim in reply to Kim says:

        you know vastly less about the NSA than you pretend to.Report

      • Mike Schilling in reply to Kim says:

        Satellite internet is supposedly making great improvements as of late.

        There’s still that pesky speed-of-light problem.Report

      • BlaiseP in reply to Kim says:

        Oh, Kim. The day I take you seriously, there will be two moons in the sky. Do paste the results of this command in your next comment

        cat /etc/selinux/config

        Are you even running over a Linux box?Report

      • Kim in reply to Kim says:

        Three moons in the sky, you mean.Report

      • Michael Cain in reply to Kim says:

        Will Truman: Satellite internet is supposedly making great improvements as of late.
        Mike Schilling: There’s still that pesky speed-of-light problem.

        Back in the day when the telcos I worked for were still deciding if they wanted to pursue IP or (in my then-published opinion) continue to waste their time on ATM and X.25, I built a nifty patented box that simulated IP network impairments (packet loss, packet delays, jitter, out-of-order delivery) in real time. Satellite internet adds 500-600 milliseconds of round-trip delay, most due to speed-of-light up to geosynchronous orbit and back twice, the rest due to queueing and such in the terrestrial network.

        You can work around the delay for bulk data transfer or one-way streaming. Two-way real-time communication can be very challenging. Two-way voice becomes a problem with 600 ms of delay — people tend to tromp on the beginning of each other’s sentences [1]. Precision motion control that requires feedback is really bad — I used handwriting on a covered graphics tablet with visual feedback on a monitor as an example. That can be difficult even without any delay — with 600 ms latency, it gets to be ridiculous. I for one would be very reluctant to allow a surgeon to cut by remote control with that much delay in the loop.

        [1] At least in English, 500 ms is almost exactly the amount of time we allot the other person to begin/resume speaking before we decide that it’s our turn. This is one of the circumstances where having a low-quality reasonably-high-frame-rate video window (13 fps or higher) is useful. Even without details, we’re pretty good at reading the body language as an indicator of whether someone is done speaking, or just pausing.Report

      • Fnord in reply to Kim says:

        For speaking, could that perhaps be dealt with by training and protocol? An explicit procedure for deciding who’s turn it is to talk similar to the use of “over” in radio?Report

      • Michael Cain in reply to Kim says:

        For speaking, could that perhaps be dealt with by training and protocol?

        Training works. When it first became possible for US news people to do interviews with people overseas, there were some hilarious screw-ups. The networks figured it out and put all of the big names through training. It all happened again when local news teams got hold of technology to do field reports using digital video (roughly the same amount of delay, but it’s a compression artifact rather than speed-of-light). I still find it amusing to watch the local news anchor and the field reporters very carefully taking turns talking.Report

      • KatherineMW in reply to Kim says:

        What would high speed internet solve? (What are we defining as “high-speed”?)

        I’ve had both high-speed and slow Internet. The only difference I noticed was that with the fast kind you can download a movie in an hour instead of ~12 hours.

        All rural areas in the US and Canada should have some kind of internet access, given how vital the internet is to everything these days, but I was under the impression that pretty much everywhere already did have access to it.Report

      • Michael Cain in reply to Kim says:

        What would high speed internet solve? (What are we defining as “high-speed”?)

        The FCC’s definition is “always on and faster than dial-up,” which I think is woefully inadequate. I define high-speed as >1.0 Mbps (million bits per second) in both directions simultaneously for the end user. Even a small community needs a much bigger pipe than that to allow aggregation of many users — say at least 150 Mbps in both directions simultaneously. In rural areas, these are two distinct problems. The “last mile” local connection, and a fiber or other high-speed connection to a backbone service provider.

        I draw my line at a megabit for both sending and receiving data because I think that’s the rate the makes two-way multi-media real-time communication possible. Sometimes it’s called “tele-presence”, sometimes other things. What I want is to come as close as possible to the ability to do “Let me step down the hall and talk to Bob and Mary about this.” High-quality audio; video in various sizes/qualities; shared high-quality still images; simultaneous use of a virtual piece of paper; shared use of presentations of data (eg, heart rate or oil-field instrumentation presented as appropriate gauges/monitor images, not just numbers); combinations of all of those. You can build all sorts of medical/education/other stuff on top of those capabilities.Report

      • Kim in reply to Kim says:

        I can send a video feed of a rash, can do simple manipulations and a consult over the internet.Report

  9. Art Deco says:

    There is no crisis. It is a condition of living in the country. People who elect to live in the country accept long commuting times in return for the benefits they gain from rural residence.

    Turn your attention to genuinely isolated populations (e.g. reservation Indians) and stop second-guessing the choices people make.Report

    • Rod in reply to Art Deco says:

      You’re thinking more of exurban living. One of the joys of rural life is specifically not having to commute to work. Or if you do (like to the next town over) it’s an easy, fast drive. I know because I’ve done both.Report

    • Rod in reply to Art Deco says:

      I would agree though, that it’s less a crisis than an endemic problem inherent to rural living. Our solution has been neither top down (government run) nor bottom up (markets, yay! ) but rather a combination of non-profit hospitals, private providers, government subsidies and incentives, and regional coordination. It doesn’t look like either Chicago or Wyoming, nor should it.Report

  10. Will Truman says:

    A few observations:

    1. I’m not particularly concerned about MRI machines. One of the things that living in the sticks means is that you get used to long drives. When Clancy was pregnant, we had to drive 3 hours to see a Maternal Fetal Medicine doctor. When he took leave, we had to drive 4.5 hours. It’s just a fact of life. It’s something that one can grow accustomed to.

    2. I am more concerned about emergency care and obstetrics. My wife’s former employer is dangling by a thread in its ability to offer obstetrical care. They are one doctor away from having to close it, which would be bad for the community and for the hospital’s financial picture.

    3. When you talked about the spiral, I thought you were referring to something else. Which is that the fewer physicians exist in a particular area, the more call each physician has to take, the less desirable the job becomes, the fewer physicians you can find, the more each call each physician has to take, the less desirable the job becomes, etc. This is huge. My wife didn’t leave rural medicine because of the pay. She left it, among other reasons, because she was on call two nights out of every three.

    4. The loan reimbursement programs are not going to move a whole lot of people. Where my wife worked such a program existed because she was filling an obstetrical shortage. If she had stayed for eight years, it would have paid her entire loan ($90k or so) off. The job itself didn’t pay that poorly in total (it was less impressive when you broke it down by hour worked…), and yet she could have earned a lot more by working elsewhere. It’s hard to be impressed by $90k over eight years, when jobs posted in Fargo paid $80k more than hers per year.

    5. It’s possible that such incentives help make things slightly more palatable for those with student loans to pay off. It could make the difference for people who owed more in student loans, or are making less money. Maybe. Given the modest sums involved it could well be a high-bang-for-buck ticket item, if people don’t break down exactly how much money is involved.Report

    • Art Deco in reply to Will Truman says:

      I think in New York’s outlying zones, non-metropolitan hospitals tend to have catchment populations of about 80,000. If you apply that nationally, you would have catchments with a mean area of somewhat north of 3000 sq mi, or with a radius of 32 miles, or with a mean distance to the center of 23 miles. I do not think there is much of a lower limit to the size and sophistication of a population center necessary to support fire and ambulance corps. I lived in a village with 750 people in it and it had a fire house.Report

    • Art Deco in reply to Will Truman says:

      The GI clinic I was assigned to was headquartered in Syracuse but had a satellite office 40 miles away. I think doctors rotated in and out.Report

    • Your version of the spiral in #3 is interesting, with remaining physicians being overloaded. That same sort of problem presumably doesn’t happen with some of the other professional services. Eg, an overloaded lawyer can put off court dates (and presumably the judge understands the situation), but an overloaded doctor can’t.Report

  11. Nob Akimoto says:

    I believe this and my labor mobility piece suggest that there is only one acceptable solution: TRANSPORTERS.Report

  12. Kim says:

    We ARE incentivizing EHRs. We ARE paying hospitals more to have ’em.
    Better yet, we’re letting the big fish “help out” by providing the infrastructure so the little fish don’t need to hire techs.

    Here’s ours:

  13. Glyph says:

    This doesn’t solve every problem, but would there be any benefit to looking at the FAA regulations that govern, say, ultralight helicopters, and seeing if they could be relaxed enough to allow many rural communities to own/operate one? The ‘copters could also be used for, I dunno, crop dusting and cattle fence inspection, when not needed to ferry critical patients to urban centers for medical care.

    If it’s cheap enough, maybe it could also be used for non-critical care (does greginak know anything about the typical fare charges of AK bush pilots)?

    It just seems like it could be cheaper for many rural communities to have a way to quickly get to where the equipment and doctors are, rather than get equipment and doctors to them.Report

    • BlaiseP in reply to Glyph says:

      It’s already out there. It could easily be extended into National Guard and other orgs with helo facilities.Report

    • Michael Cain in reply to Glyph says:

      …ultralight helicopters… The ‘copters could also be used for, I dunno, crop dusting…

      Random bits from memory…

      Crop-dusting helicopters are generally small but grossly overpowered brutes. Even a hundred gallons of water plus whatever to be sprayed weighs a lot, and depending on the situation they may be required to pull some fairly extreme maneuvers. The one time I rode one, I puked my breakfast out the open (well, non-existent actually) side door. As the copter was tipped 90 degrees up on its side at the time, I was puking straight down.

      One summer my daughter was working at a Girl Scout camp well up into the foothills and took a nasty spill from a horse. Flight for Life came to get her. We saw the bill (paid for by workers comp). I don’t remember the amount, only that it was startlingly high, even when you thought about it being a helicopter.

      There seem to be a surprising number of days (and reasons) here when helicopters can’t fly. Fog in the mountains. Blizzards. Thunderstorms. High-velocity straight-line wind.Report