by Michael Caine
From time to time I leave comments here at Ordinary Times to the effect that rural America is facing its greatest existential crisis since the Great Depression. One of the factors that leads me to that claim is the apparent existence of positive feedback loops that manifest as declining availability of a variety of services in rural areas (or for newer services, failure to introduce them). The long-term ongoing crisis in rural health care — declining availability to modern medical services — is an example. The various debates about the PPACA that have appeared here have largely ignored this problem; this guest post is an attempt to rectify that somewhat.
Where the PPACA is largely about access to health care insurance, the rural crisis is about access to health care. The situation can be summed up in one statistic: 21% of Americans live in rural counties, but only 9% of physicians do. Things get even more lop-sided when specialists are considered. Small local hospitals generally have a more limited range of equipment compared to their urban and suburban counterparts, sometimes much more limited. As one of my public policy professors said, “A high-end MRI is a million-dollar piece of expensive-to-maintain machinery which is profitable only if you have a steady stream of patients to run through it. That’s just not going to happen in southeastern Colorado where six largish counties have a total population of less than 60,000 people.” 
This is not a new problem. Formal federal reports on the inadequacy of rural health care facilities go back to the 1920s. Congress has held periodic hearings on the subject since at least the early 1970s. The federal government and many state governments have created organizations with titles like “Office of Rural Health Policy” that try to address the problem. This month, the Oregon Health & Science University held its 30th Annual Oregon Rural Health Conference. It’s a long-term problem and it certainly doesn’t appear to be getting fixed. I’ll get back to the question of whether I think it is fixable at all in a moment.
Does the shortage of, and difficulty in accessing, care providers affect health outcomes? Yes, and in a variety of ways. An obvious one is response time in the case of serious accidents. In the Denver suburb where I live, an ambulance with a trained EMT reaches the scene within six minutes thirty seconds 90% of the time, and within nine minutes 98% of the time. In parts of rural Colorado, arrival may take as long as 45 minutes  and the first responders will almost certainly have less training. That’s a life-and-death difference, and it shows up in the fatality statistics when urban and rural auto accidents are compared. In an increasing number of rural Colorado areas, emergency ambulance service is being curtailed or eliminated entirely.
Governments at multiple levels have tried to solve the problem by the usual expedient of throwing money at it. Many states have programs where recent medical school graduates get a (sometimes substantial) portion of their student loans forgiven if they will practice family medicine in a rural area. Medicare has a variety of hospital classifications; Congress created the critical access hospital designation in response to a rash of rural hospital closures in the 1990s. CAHs receive substantially higher compensation for providing care (more recently, tightening requirements for the CAH designation has been proposed as a deficit-reduction measure by the Obama administration). Telemedicine offers some potential for allowing specialists to practice part-time in rural areas, but is often handicapped by limited rural broadband infrastructure.
The PPACA does include provisions that affect rural health care problems. Some types of services provided through Medicare and Medicaid will temporarily receive increased payments. Of more concern, I think, are the number of practitioners and small hospitals in rural areas who assert that the cost of mandatory electronic records systems may put them out of business. This would seem to be one of those cases where the law could be improved by recognizing that subsidies may be needed. I find it unfortunate that the Republicans’ single-minded fixation on repealing rather than improving the PPACA has resulted in them ignoring some problems that fall largely on their constituency.
Can the problem be fixed? To be honest, I am very much afraid that the answer is no. Up at the beginning of this piece, I mentioned positive feedback loops. The primary factor mentioned in most rural hospital closures is low numbers of patients. Lack of access to health care facilities makes it difficult to attract new residents, and in some cases drives away existing ones. In many cases, the rural hospital is the largest employer in town, so closures have a seriously detrimental effect on the local economy, driving away more people. At least one report points out that fewer students originally from rural areas are entering medical school these days, and a majority of the rural students who do enter say they have no interest in returning to a rural area to practice. I suspect that there’s more than a bit of a “How Ya Gonna Keep ‘Em Down on the Farm?” effect here, as rural areas have already fallen behind in other services. All of this suggests to me the possibility that people living in rural America will be consigned to a permanent second-class status for medical care and for a variety of other services.
 For comparison, those six largish counties have a combined area almost exactly equal to the combined area of Massachusetts, Connecticut, and Rhode Island (with a combined population of 11.3 million).
 Anecdotal data point… When I was an undergraduate at the University of Nebraska, I used to visit friends’ homes in out-state Nebraska near the Colorado border. I recall one in particular where they lived “in town” (as opposed to out in the country). It was a 20-mile drive to the nearest movie theater, and a 60-mile drive to the nearest place that had a choice of movies. The same 60 miles was what it took to get to a health-care facility with a real surgical theater. The population in that area has declined since then.