One of the participants in the discussion is, Dr John Waits, who with his colleagues and staff at Centreville Clinic Staff, are doing their best to help their community afford their healthcare.
Dr Waits struggles valiantly in the discussion to avoid using the terms profit and subsidy. This is a mistake in my opinion, while you can talk about healthcare efficiencies, people need to hear that large hospital groups are for profit, yes even the not-for-profit ones. People need to understand that rural hospitals are not affordable without subsidy. Equally, urban communities need to understand that without rural communities, we have an entirely different set of problems.
Subsidy isn’t a bad word, nor is tax that ultimately is used to pay for it. You can either levy tax at a state level or at the federal level, preferably on big hospital groups and medical providers revenue(not profit). You can then use that tax money to subsidise rural healthcare. Or you can use general federal taxation, and use the additional money to fund a medicaid hospitals in rural community cities.
Struggling along with no real honesty, and without confronting the elephant in the room, will just mean more rural hospitals closing, leading the to further decline of rural communities and the increased pressure on cities.
I’ve written a number of harsh posts about those living in rural America, mostly based off the perception that is pushed by the Republican party, that is, rural Americans don’t understand, and resent urban Americans. That rural Americans are the god-fearing, backbone of America and urban and city dwellers are welfare dependents, and worse still, socialists. Certainly, the Republican party continue to push this agenda today, dividing sub-urban and rural communities from the cities.
As shown here, rural Americans claiming benefits has sky rocketed between ’96 and 2015; increasingly, the programs getting cut, adversely hit rural America harder, as rural Americans are smaller in total number; medical coverage may not “be a right” according to the Republican party, it should be a “choice”, try maintaining a community without easy access to modern healthcare; schools are also a right, without them, not only are local taxes higher, more subsidy is needed to get kids to schools outside the city. School Choice won’t save rural schools without a massive rethink.
However, rural Americans, and farmers especially, deserve another perspective. They’ve largely been screwed by the “agricultural industrial machine”. Sure, many farmers have sold out and reaped substantial profits, more though are barely getting by. There is a lot to be said about a community completely upended over the last 30-years.
Laura Dunn, Two Birds Film (Austin TX) has produced a beautifully filmed, subtle, but brilliantly edited, and panoramic, poignant portrait of the changing landscapes and shifting values of rural America in the era of industrial agriculture, as seen through the eye of American novelist, poet, and activist, Wendell Berry.
Berry represents, if not the best known defender of rural, natural America, then certainly the most eloquent. His contributions to Lauras’ other major work, The Unforseen, were the first I’d heard of him. Certainly, this profile certainly made me think again. You can watch the trailer on youtube(below) or the complete film on Netflix.
“To cherish what remains of the Earth and to foster its renewal is our only legitimate hope” American author and poet, Wendell Berry.
Farmers are getting approximately the same per pound now as they were in the 70’s. In the 70’s a pickup truck cost $7500, today it costs $35,000… Industrialization and automation killed the small farms.
Through soil erosion, toxicity, polluted rivers and polluted air. What we have sacrificed for all the choice we have is to be absolute slaves, to the people who want to to sell us what we need to survive.
Overdose deaths in Colorado in general have grown in the last decade, according to the Colorado Health Institute. In 2014, San Luis Valley-area healthcare providers began limiting how opioid drugs are prescribed. But, as High Country News reported, the resulting decline in how often painkillers were prescribed was followed by a surge in heroin use.
It is worth stating the obvious, that since rural counties as much more sparsely populated, the numbers per 100,000 can be illustrated much more starkly. A rural county may have only 100,000 or fewer people. It is also worth noting that Colorado is a recreational Cannabis legal state, and this is allegedly under threat from new Attorney General, Jeff Sessions. While it’s pretty impossible to die from direct overdose of cannabis, it does cause indirect death through accidents, but the total number of cannabis related deaths is miniscule compared to opioid overdose alone.
The three post illustrate the real problem with rural America, and this one for me explained one way HOW the opioid epidemic has come about.
We hear a lot about the “takers” in America, a classification for, usually inner-city people who survive on benefits, unemployment, housing, medical, food stamps and more. Mostly the venom about takers also contains a racial element, it’s directed at black and minority groups who many assume benefit from Government programs without paying in.
What we don’t hear much about is the affordability of rural towns, and even many of the suburbs. One of America’s greatest strengths, it’s size, is also one of it’s biggest problems, small town sustainability. I’m no expert on the economy and sustainability, but if you drive long distance in America away from the Interstates, you can see the problem everywhere. Decaying towns, decaying infrastructure, slowing or declining population growth. I own and subsidize a rental home in one such town in Texas.
Back in 2014, I made my only drive from Austin TX to Boulder CO with my Mum, on what was to be her last grand tour. What struck me at the time were the endless poor quality roads, and the nearly, seemingly deserted small towns.
We covered 2,500 miles, mostly north west Texas, also New Mexico, and Colorado. On the way back we went via Taos, Santa Fe, and Roswell and then back through west Texas.
They had almost no choice in terms of food, restaurants and shops. I wrote this blog post “Decaying Texas”. It has a couple of slideshows of pictures taken along the way home.
The question of affordability will be right in the headlights in the coming years of the Trump administration. Almost every major program that the administration seems to want to change or cut will have a major impact on these rural societies. Downsizing the Federal government, a project of the Cato Institute, says:
Even if rural subsidy programs were administered efficiently, they represent an unfair redistribution of wealth. In many ways, rural Americans are better off than urban and suburban Americans. They enjoy cheaper housing, cleaner air, less congestion, and other advantages. So people who live in rural areas should not be a privileged class receiving special subsidies.
The Cato Institute couches the benefits in the usual political-speak weasel words as “Scholars at Cato believe that cutting the federal budget would enhance personal freedom, increase prosperity, and leave a positive fiscal legacy to the next generation.”
Rural communities for the most part exist to allow the exploitation of the land and resources. Hence the reason why America’s size is a strength, there is plenty to exploit. From farming for cattle, corn, wheat, to mineral extraction, to oil and gas fracking, America has it in abundance.
However, most of the infrastructure to support the communities is decades or more old and needs investment to sustain. Building roads, laying pipelines for water, sewage, telephone and internet service are expensive per capita. Roads particularly require a massive subsidy given the distances involved and the low number of people they service.
What is clear is that the new administration wants to cut regulations, budgets, and “Make America Great Again” #MAGA. I fear though for these communities, as they are likely to become unintended consequences of poorly thought through, and rushed changes in policy.
School choice has been a great boon for suburban America. It has also been a positive benefit for the re-segregation of schools. Rich, often white people move from urban centers to suburban centers where they not only have choice, but can have their choice subsidized through vouchers, funded at the expense of public schools whose budgets are impacted by funding vouchers. Forget the furor about DeVos and if she is even qualified as U.S. secretary of Education. What is clear is that if she chooses to drive her professed support for school choice through vouchers as a policy, rural education will be screwed. Rural areas, without huge subsidy, will not have choice. Private businesses are not going to rush into towns and build new alternative charter schools, they can never make money from them.
If the alternative is distance learning, it has a double impact. 1. Distance or e-learning has typically less than optimal results, 2, by opting for choice through voucher, the local public schools are further devalued by lower attendance and either great subsidy, or lower budgets. This is a major issue, as schools in rural areas don’t just teach children, they are major social hubs for community interaction. Destroying public schools in rural areas, will further destroy their communities. The Atlantic has a great article covering DeVos and the potential impact on rural schools and communities.
Health care (ACA and replacement)
This blog post was kicked off while driving to swimming this morning. I heard this Colorado Public Radio (CPR) piece on the rural hospitals fears for post “Obamacare”. Like schools, access to medical facilities in rural America is crucial to their survival(literally). Asides from concerns of access to healthcare and the affordability of it, the thing that struck me about the CPR interview was that San Luis Valley Health in Alamosa provides 670 jobs and is the region’s largest employer. This is consistent with what I’ve observed elsewhere in Colorado and Texas, both large and small towns with massive health care employment.
In the UK, where the National Health Service (NHS) employees around 1.6-million people, making it the world’s 5th largest employer. The NHS is notionally is single organization, the NHS employs just under 2.5% of the UK population. Using the US Bureuau of Labor Statistics data for 2009, health care employment in private-sector health care industry employees just shy of 11-million people, add to that 100,000 of the 350,000 at the Veterans Administration, and then all the small town public health care clinics that deal with vaccinations etc. and it’s safe to say some 12-million work in health care in the USA. So, nearly 3.75% of the American population work in healthcare.
Health care in the US is much more expensive than the UK and most other developed countries in the world. This is in part due to the massive over provision and duplication of healthcare facilities. The simplest way to reduce the cost of Government programs, would be to drastically cut the provisions that support poor, rural communities. Make them travel further, pay hospitals less for the procedures, make fewer people qualify for the programs. That is exactly what these rural and small regional hospitals are concerned about, as discussed in the earlier referenced CPR piece.
While the President talks up his infrastructure goals, and decries the state of the roads, bridges and airports, outside of the wall, it’s not clear the Administration understands how much we currently spend and how poorly we budget and account for infrastructure. It’s already clear that Drivers are not paying their fair share, and that we are swimming in debt for road expansion and funding. It is hard to imagine that fiscal conservatives, the GOP and the TEA party are going to swallow more debt on a massive scale to fund this. In many rural areas, pot holed roads are being downgraded already to gravel roads also known as “unpaving“. States, cities and municipalities account for infrastructure in entirely the wrong way. They assume infrastructure itself has no value in their financial statements. They depreciate the assets over the course of its useful life until it has a no value. The problem is at that point, you can’t simply walk away.
As Strong Towns pointed out “Current accounting practices do not bear any relation to the future cash flow or the actual financial health of the city. When cities take on obligations, they should be properly accounted for as liabilities, not assets.” Given Rural towns tax base, population and business are declining, they are hit even more substantially by the errors in accounting from the past.
There is significant investment by way of investment and development grants in rural areas, as well through crop subsidies. The top subsidized commodities are Feed grains, mostly corn, cotton, wheat, rice, soybeans, and dairy. Many of these would be uneconomical if the mega-corporations and farming cooperatives went unsubsidized. America currently pays around $20 billion per year to farmers in direct subsidies as “farm income stabilization” via farm bills. These bills pre-date the economic turmoil of the Great Depression with the 1922 Grain Futures Act, the 1929 Agricultural Marketing Act, and the 1933 Agricultural Adjustment Act creating a tradition of government support.(Source: Wikipedia).
USDA goes way beyond that, it runs three other major programs through these agencies: Rural Housing Service, the Rural Utilities Service, and the Rural Business-Cooperative Service. They spent $6.5 billion in 2016 alone. USDA has about 100,000 employees, and is represented in most counties, in every state in America. It’s responsibilities include USDA oversees school lunches, meat inspection, food stamps, the Forest Service, rural electrification and much more. It’s total budget is some $140 billion in programs. The late pick of Georgia Governor Sunny Perdue concerned many in the rural community, some of his actions as Governor raise more questions, especially on his brand of rural endorsement. As governor, Perdue was caught in a more than a few scandals involving his businesses and personal property deals. He is also the first from a southern state, where rural and agriculture challenges are very different from the mid-west.
For many people HUD stands for the “U” in Housing and Urban Development, they mostly focus on urbans areas, nothing could be further from the truth. HUD operates many rural programs, in many cases funds pass through state agencies or other entities to rural communities. As well as development and assistance grants, HUD invests around $6.2 billion per year to provide affordable housing to low-income residents. Much of this through guaranteed low interest mortgages. How these programs will fare under Ben Carson is unknown. But without clear differentiation between urban and rural communities, many in the GOP and Administration will be going after cutting back HUD in general. HUD is also a major contributor to disaster assistance and provides many grants, relocation programmes and more.
In an era when the GOP have spent forever convincing everyone that TAX=BAD, and portraying city folk as moochers and takers, can we really afford rural communities anymore? It’s very likely that these rural communities will experience the bulk of the pain from the Administration policy changes. Not through a single policy change, or executive order, but but through death by a thousand cuts.
If that happens, there will be no one but the current Administration and the Republican party to blame.