Are rural residents incapable of understanding government's role in health care availability?

I don't know the answer to that question, but that is the conclusion suggested by two stories in the mainstream media today.  

First, Hannah Knowles reports from Curtis, Nebraska, for the Washington Post under the headline, "A clinic blames its closing on Trump’s Medicaid cuts. Patients don’t buy it."  That headline sums up the gist of the story--and the reason why Medicaid cuts won't have the political impact on rural Trump voters that Democrats are hoping for.  

Community Hospital, the nonprofit that runs the clinic known as the Curtis Medical Center and a couple of other facilities in the region, plunged into the center of that national story when it announced on July 2 — one day before the bill’s passage — that a confluence of factors had made its Curtis outpost unsustainable. It cited years-long financial challenges, inflation and “anticipated federal budget cuts to Medicaid,” the public health insurance program for lower-income and disabled Americans.

* * *  

The clinic has been here longer than many people in town can remember, and people are struggling to make sense of the shutdown. The changes coming for Medicaid are complicated, and some won’t take effect for years, which makes the timing even harder for residents to understand.

Many know that Trump’s bill will impose work requirements for Medicaid recipients, which seems reasonable to them, and some think — inaccurately — that the legislation was designed to end Medicaid coverage for undocumented immigrants.

* * * 

Community Hospital was already losing money, and officials said they are trying to make sure they remain financially viable for the 30,000 people they serve throughout their facilities. But the timing of their decision to announce the Curtis closure has stoked suspicions in the town, leaving some residents convinced their health provider was using the president as a scapegoat.

Here are key--and colorful--quotes from two different Curtis residents: 

“Anyone who’s saying that Medicaid cuts is why they’re closing is a liar,” April Roberts said, as she oversaw lunch at the Curtis Area Senior Center.

* * *

Arriving for lunch, retired Navy veteran Jim Christensen said he’d read an op-ed that “tried to blame everything on Trump.”

“Horse feathers,” he said, dismissing the idea.

Much more detailed re the consequences of the Medicaid cuts for rural hospitals is this episode of the New York Times "The Daily" headlined, "One Rural Doctor on the Real Costs of Medicaid Changes."  Natalie Kitroeff interviews that doctor, Shannon Dowler.  The story is a very detailed one of how North Carolina eventually came to expand Medicaid, providing health care to many folks who otherwise would not have had access to it.  Many rural characters--you could say stereotypes--are depicted in this story--most of them, I am assuming based on the western North Carolina locale, are white.  

It's only at the end of the half hour interview when you get to the reasons, according to Dr. Dowler, that residents don't or won't blame Trump for their loss of health care.  Here's the exchange between Kitroeff and Dr. Dowler: 

Kitroeff:  

Do you think that your patients, for example, will blame the lawmakers who voted for this bill?

Dowler:   

No.

Kitroeff:  

Why not?

Dowler

There’s just not enough of a direct correlation to people’s health care needs in the moment and what happened in DC 12 months before, 18 months before.natalie kitroeff

So you think there is a chance that the folks who voted for the people who voted for the bill that leads to them potentially losing coverage will not be seeing that those people are really responsible.shannon dowler

No. I had a patient come in the day after the election. And he said, it’s about time. We’ve got to get government out of health care. Well, ironically, he has Medicare. And he just

Kitroeff:  

Wow,

Dowler: 

— doesn’t get it. And so this is not uncommon. This is a super complex system of health care. I was at Medicaid for five years. Every day, I learned something new around how Medicaid worked. It’s very, very complex. I’m not surprised that patients don’t understand all of this.

Kitroeff: 

I’m wondering if you think they will blame anyone for the loss in care. And if so, who would get the blame?

 Dowler: 

It’s hard to know. I think people often would get mad at the hospitals because the hospitals weren’t providing them some service that they felt they were due, not understanding how complex the system of health care is. So I just don’t think based on what I saw before, I don’t think the lawmakers are the ones that are necessarily going to bear the brunt of this, especially with the timeline where they have this stuff rolling out after the midterm elections.

This all reminds me of some of the reasons folks gave for not taking the Covid vaccine back in 2021, even as they came close to dying from the disease.  They nevertheless said that if they survived the disease, they still would not be vaccinated.  

That which sets rural search-and-rescue apart from the urban counterpart

The New York Times reports today from Kerrville, Texas, more than a week after last week's tragic flood.  This story pays attention to how the search and rescue along the Guadalupe River in the "hill country" is different from these processes when they occur in urban areas.  Christopher Maag and Edgar Sandoval write: 

The search for human remains is focused on an area of Texas that is unlike many of the places where recovery professionals are accustomed to looking, several experts said. Most major search operations in recent years have happened in large urban areas hit by hurricanes, said Mr. Koester and Scott Hammond, a professor in the Department of Management at Utah State University who studies search-and-rescue teams.

In the flood plain of Central Texas, by comparison, searchers are dealing with a relatively high number of people who are missing and presumed dead, spread across an expanse of mostly narrow, rural territory, spanning more than a hundred miles of shallow valleys along the river.

* * *

The destructive power arrived with little notice, in a relatively constrained river valley where there are few homes or other buildings to serve as likely search targets. The recovery efforts are therefore focused on the massive piles of debris.

That will continue to make the search especially slow, dangerous, painstaking and long.

Also reflecting this theme, NPR's report this morning observed that the "search area has an enormous footprint." 

Here is a quote in the NYT story from 38-year-old Kerrville resident, Amy Vanlandingham, who has been helping with the search.  Her comment suggests the nature of rural community and lack of anonymity, which fosters a certain solidarity:

It’s overwhelming to see so many people come and help in the search. This is our town. I do it so I can sleep.

Other posts about the Guadalupe River floods are here and here.   

Small-town government run amok (Part XIII): Is Kerr County partly to blame for the high death toll at Camp Mystic?

I've already written this week about the catastrophic flooding in Kerr County, Texas.  What I am going to highlight in this post is recent reporting from the New York Times on the 2019 decision by Kerr County to let Camp Mystic build additional structures--including cabins for campers--in places that were at risk of  flooding.  (This is on top of the county's decision not to invest in a warning system, which is discussed in my prior post).

Why would the county do that when, as one expert suggested, the proposal to construct more buildings was a good time to re-evaluate the risk level associated with the existing structures?  Perhaps what the journalists are suggesting here is Kerr County officials simply trusted the camp as a long-time landowner and patron of the county.  Perhaps what is being suggested is the turning of a blind eye.  I wonder what sort of property taxes and other types of revenues Mystic and the otter camps provided to the county? 

Here's an excerpt from the NYT story: 

In 2019, Camp Mystic...underwent a substantial expansion. Camp owners received approval from local authorities to build a new group of cabins over the hillside to the south, in an area known as Cypress Lake. But even there, flood maps show, some of the new cabins were in areas at risk of flooding.

* * *  

At the same time, Kerr County officials were considering how to manage floodway areas, including those at Camp Mystic.

The county said that floodways were to be considered “an extremely hazardous area due to the velocity of floodwaters which carry debris, potential projectiles and erosion potential.” It adopted rules in 2020 to limit new construction or substantial alterations in floodways to ensure that structures could better survive flood events, and that these buildings would not result in raising floodwater levels in other parts of the river.

This NYTimes piece gives a sense of the local lore around the Eastlands, who owned and ran Camp Mystic.  This New York Times podcast, The Daily, also gives a sense of the beloved status of the camp and its long-time owners; the title says it all, "A Love Letter to Camp Mystic."   

Postscript:  Here is a July 12, 2025 NYT story that suggests FEMA over-rode Kerr County on the designation of parts of Camp Mystic as a flood zone.  An excerpt from Mike Baker's reporting follows: 

In the years before floodwaters killed more than two dozen people at Camp Mystic in Texas, regulators approved a series of appeals that removed many of the camp’s buildings from official federal flood zones, records show.

Flood maps developed by the Federal Emergency Management Agency in 2011 had placed much of the camp within a 100-year flood zone, an area considered to be at high risk of flooding. Camp Mystic successfully challenged those designations, which would limit renovation projects and require flood insurance, citing elevation calculations of a series of buildings that allowed them to be exempted from the federal restrictions.

Sarah Pralle, an associate professor at Syracuse University who has researched federal flood mapping, said she found the exemptions granted to Camp Mystic, a girls’ camp on the Guadalupe River near Hunt, to be “perplexing.” Some of the buildings were still very close to expected flood elevations, she said.

“I think it’s extremely troubling that it’s a camp for children,” Ms. Pralle said. “You’d think you want to be extra cautious — that you’d go beyond the minimum of what’s required for flood protection.”

Here is the Washington Post reporting similar conclusions on the role of FEMA.  

Here is the WSJ reporting on what happened at Camp Mystic, cabin by cabin.   You'll see here featured some aspects of the impulse to secrecy regarding arguable failures of a revered Texas institution.  

My Rural Travelogue (Part XLII): Promoting local food, including wild edibles, in Japan

Ad for ice cream at a Teshikaga (Hokkaido) ramen house
features a photo of the family farm (4 children!) who produce the milk--
and, of course, one of the cows.

During my recent trip to Japan, I noticed a lot of promotion regarding food that played up the origin of food--usually its local origin. In this photo-dense post, I'm going to feature some of what I saw.  (All photos are (c) Lisa R. Pruitt 2025) 

I first noticed the attention to local food in Kanazawa, on the west coast of Honshu, where the breakfast place mats at our Hyatt Centric hotel noted local milk products and featured the label, "Kanazawa Local Style" (lower left quadrant)  

Breakfast placemat Hyatt Centric Kanazawa

Then, in Osaka, which is known as the food capital of the country, the cafe in a private library touted dairy products from Hokkaido, the northernmost island.  When I asked why an establishment in the southern part of the main island, Honshu, was promoting products from the north, I was told that Hokkaido has more space than Honshu--it's less crowded--and thus most of the nation's milk and dairy products are produced there.  Hokkaido seems to be associated with farm-fresh food, especially dairy.

live chickens outside a restaurant in Osaka; 
now that's local food

The next week, I visited northern Hokkaido and saw for myself many dairy farms.  Near Kushiro and the surrounding marshlands, which are habitat for Japanese cranes as well as dairy cows, the two species often share space. 

I also saw, on the northeastern side of the island near Kushiro, greenhouses where strawberries were grown.

To the northwest of the Kushiro area, closer to Shire and en route to Shiretoko National Park, I was driven past fields of yams and sugar beets.  A sugar beet processing facility was also pointed out.  

Then, between Shiretoko and Memanbetsu, I saw apple and cherry orchards, as well as the Okhotsk Bean Factory storage tower/elevator.  

A wild fox crossed my taxi's path very near there, just a few miles from the Memanbetsu airport.  This was striking because I'd not seen one in the far more remote and wild Shiretoko National Park. 

Fried sweet potato balls are associated with Bihoro Pass, above Lake Kussharo, and are sold at the roadside station there.  I can attest to their deliciousness, as well as their greasiness.  

Raised beds for student gardening at a primary school at Wakoto, on the shores of Lake Kussharo, in rural northeastern Hokkaido.
 

Woman preparing bracken, a wild fern-like plant, outside a restaurant at Lake Akan.  I noticed a significant focus on wild edibles, including fiddlehead fern, at restaurants in Japan, especially outside major cities.  I had wild edibles as part of tempura meal sets in Takayama and on Hokkaido.  Hokkaido guides also pointed out to me places (some of them at relatively high elevation) where wild edibles were growing.

Below are a Japanese crane across the road from the cattle pictured in the second photo below, both in/near Tsurui village, in northeastern Hokkaido.  I found that the iconic cranes frequently occupied the same habitat as cattle in the region's marshes.  In fact, a barely visible crane is behind the cattle in the lower photo.  

 

A Sapporo Co-op delivery truck in Utoro, a rural region at the entrance to Shiretoko National Park.  Sapporo is the seat of Hokkaido prefecture and its largest city.  The co-op sells both groceries and daily essentials, e.g., detergents, toiletries.  

I enjoyed a lovely lunch at Heart 'n Tree guest house and restaurant in Tsurui Village, Hokkaido.  I also took a cheese-making class there, where I made string cheese.  The website says it is "a supporter of dairy farmers" and that its "menu lets you enjoy fully the deliciousness of milk and vegetables."   I had a delicious soup curry with shrimp; pizza and a pork stew were also on offer.  Among items you can get for breakfast is "fresh squeezed milk."  

Here is a placard that promotes local dairy products, with Holstein cow stylized art, at ha otel buffet in Utoro, near entrance to Shiretoko National Park, Hokkaido.

Okhotsk Bean Factory products for sale, Utoro, near Shiretoko National Park, Hokkaido.  I saw the storage tower for this company near the Memanbetsu Airport when I was leaving the region. 

Recognizing the barrier of distance, transportation in high school vocational training programs

Kavitha Cardoza reported for the Washington Post a few days ago on an innovative apprenticeship program in Elkhart, Indiana.  An excerpt follows:  

Elkhart County is at the forefront of a movement slowly spreading across Indiana and the nation to make apprenticeships a common offering in high school.

In April, President Donald Trump signed an executive order calling for the creation of 1 million new apprentices, the latest step in a bipartisan push for apprenticeships that began during the Obama administration. The “earn and learn” model is taking hold in more than 30 states alongside growing disillusionment with the concept of the four-year college and the fact that well-paying jobs that don’t require bachelor’s degrees are going unfilled nationally.

But in the United States, the number of apprenticeships for high-schoolers is still tiny, just over one-tenth of a percent of students, according to an estimate by the think tank New America. 

In contrast, 70% of high school students in Switzerland--often held out as a model for such training schemes--participate in these programs. 

What I want to highlight here is the recognition that rural locations pose natural limits to these programs. 

Transportation has been a limiting factor, too. There’s no public transit system, and students who can’t rely on their parents for rides are often out of luck. “We’d love to offer a bus to every kid, to every location, but we don’t have people to run those extra bus routes,” [said a high school principal in Elkhart County].

I also appreciate this comment--not rural specific--from the woman who oversees college and career programs at one Elkhart high school: 

apprenticeships help convince students of the importance of habits such as punctuality, clear communication and regular attendance. “It’s not from a book,” she said. “They’re dealing with real life.”

Risks to rural hospitals grab big headlines in Arkansas

The lead story in today's Arkansas Democrat-Gazette is about the perils that Trump's "One Big, Beautiful Bill Act" poses to rural hospitals in the state.  Here's an excerpt from the feature by Neal Earley, which provides some excellent explanatory reporting: 

Rural hospitals in Arkansas will have to ready themselves for some major changes coming in the next few years that could mean savings for the federal government but fewer people with health care coverage.

The changes are part of the One Big, Beautiful Bill Act the U.S. House of Representatives passed on Thursday. It includes key changes to Medicaid and health care for low-income Americans that are projected to reduce federal spending on the program by $1 trillion over 10 years and lead to an increase in the number of uninsured people...

But some hospital officials worry the work requirements and bi-annual eligibility checks would mean a drop in coverage for many, shifting the cost burden to providers.

“You can take people off the rolls, but they’re still going to come to the (emergency room),” said Shelby Brown, administrator of Southwest Arkansas Regional Medical Center in Hope. “And small rural hospitals like we are in Hope, Arkansas — we don’t have the volume to absorb more people without insurance.”

The Kaiser Family Foundation says 813,000 Arkansans are enrolled in Medicaid, and 41% of those live in rural areas. 

Cuts to Medicaid would be felt more acutely by rural hospitals, as they don’t have the type of patient volume that suburban and urban hospitals have that could help them absorb a drop in revenue, Brown said.

* * *

Arkansas already attempted to implement work requirements in 2018, but it led to about 18,000 Arkansans losing coverage. In 2019, a federal judge struck down the requirement.

While the new requirement is designed to eliminate waste and force those who are able to seek health insurance through their work, Bo Ryall of the Arkansas Hospital Association said prior experience has shown health care providers are the ones who will observe the financial hit, saying, “Arkansas’s prior experience with work requirement enforcement and frequent re-determinations increased uncompensated care in hospitals.”

The story also quotes Stacy Harberson, CEO of Howard Memorial Hospital in Nashville, AR:

[R]ural hospitals (are) already operating at such a thin margin it could be very detrimental.

Deficits in warning systems exacerbate losses as historic floods strike Texas rural hill country

Dozens, including a number of children, were killed on July 4 by a flash flood in central Texas' hill country, primarily due to flooding of the Guadalupe River, whose headwaters are there.  One hard hit area was Camp Mystic, a camp for young and adolescent girls on the river's banks, near Kerrville (population 24,000) in rural Kerr County.  Christopher Flavelle of the New York Times is now reporting on the consequences of the area not having a better early-warning system--and on the fact that local taxpayers are unwilling to pay for that system. Here are salient excerpts: 

Texas officials appeared to blame the Weather Service for issuing forecasts on Wednesday that underestimated how much rain was coming. But former Weather Service officials said the forecasts were as good as could be expected, given the enormous levels of rainfall and the storm’s unusually abrupt escalation.

The staffing shortages suggested a separate problem, those former officials said — the loss of experienced people who would typically have helped communicate with local authorities in the hours after flash flood warnings were issued overnight.

The shortages are among the factors likely to be scrutinized as the death toll climbs from the floods. Separate questions have emerged about the preparedness of local communities, including Kerr County’s apparent lack of a local flood warning system. 

* * * 

In an interview, Rob Kelly, the Kerr County judge and its most senior elected official, said the county did not have a warning system because such systems are expensive, and local residents are resistant to new spending.

“Taxpayers won’t pay for it,” Mr. Kelly said. Asked if people might reconsider in light of the catastrophe, he said, “I don’t know.”  (emphasis added)

The National Weather Service’s San Angelo office, which is responsible for some of the areas hit hardest by Friday’s flooding, was missing a senior hydrologist, staff forecaster and meteorologist in charge.

* * * 

The Weather Service’s nearby San Antonio office, which covers other areas hit by the floods, also had significant vacancies, including a warning coordination meteorologist and science officer, Mr. Fahy said. Staff members in those positions are meant to work with local emergency managers to plan for floods, including when and how to warn local residents and help them evacuate.

That office’s warning coordination meteorologist left on April 30, after taking the early retirement package the Trump administration used to reduce the number of federal employees, according to a person with knowledge of his departure.

The vacancy rate in these federal offices is roughly twice what it was when Trump returned to office earlier this year.

Other posts about rural local governments unwilling to pay for services some might find critical--or at least important--are here and here.   This post discusses how reliant nonmetro counties and rural local governments are on higher scales of government for assistance in financing emergency management.   

Postcript:  This follow up story in the New York Times was published later on July 6, 2025.  

Eight years ago, in the aftermath of yet another river flood in the Texas Hill Country, officials in Kerr County debated whether more needed to be done to build a warning system along the banks of the Guadalupe River.

A series of summer camps along the river were often packed with children. For years, local officials kept them safe with a word-of-mouth system: When floodwaters started raging, upriver camp leaders warned those downriver of the water surge coming their way.

But was that enough? Officials considered supplementing the system with sirens and river gauges, along with other modern communications tools. “We can do all the water-level monitoring we want, but if we don’t get that information to the public in a timely way, then this whole thing is not worth it,” said Tom Moser, a Kerr County commissioner at the time.

In the end, little was done.

And here is coverage of the issue from the Wall Street Journal. 

A former sheriff pushed Kerr County commissioners nearly a decade ago to adopt a more robust flood-warning system, telling government officials how he “spent hours in those helicopters pulling kids out of trees here (in) our summer camps,” according to meeting records.

Then-Sheriff Rusty Hierholzer was a proponent of outdoor sirens, having responded as a deputy to the 1987 floods that killed 10 teenagers at a camp in nearby Kendall County. He made the comments in 2016, after deadly floods ravaged a different part of Texas the year before.

“We were trying to think of, what can we do to make sure that never happens here?” Hierholzer, who served as Kerr County sheriff from 2000 to 2020, recalled in an interview Sunday with The Wall Street Journal. “And that’s why we were looking at everything that we could come up with, whether it be sirens, whether it be any other systems that we could.”

"Minutes of their public meetings showed an inability to get state and federal funds has been a delaying factor," even as other counties on the Guadalupe River have adopted the systems.

P.P.S.  On July 7, Texas Lt. Governor Dan Patrick announced that a warning system would be in place on the Guadalupe River by next summer and that, if the local government cannot afford the system, the state will pay for it.  

P.P.S. on July 11, the Washington Post reports under the headline, "Kerr County did not use its most far-reaching alert system in deadly Texas floods."   The lede follows: 

The Texas county where nearly 100 people were killed and more than 160 remain missing had the technology to turn every cellphone in the river valley into a blaring alarm, but local officials did not do so before or during the early-morning hours of July 4 as river levels rose to record heights, inundating campsites and homes, a Washington Post examination found.

 On July 10, I was listening to a podcast (probably from New York Times or NPR) that mentioned a local Kerr County politician who, a decade ago, railed against an alarm system along the river because of its deleterious impact on the place's tranquility.   The politician got his way, and the system was nixed.  He died a few years ago.  

Wisconsin Supreme Court details rural lawyer shortage in matter where criminal trial delayed 46 months

The Wisconsin Supreme Court decided State v. Ramirez last week, a matter about a criminal defendant who experienced a 46-month delay in being tried for an alleged crime. The court upheld his conviction, in part because he waited 32 months to assert his right to a speedy trial. This is one of the first cases in which I've seen a court acknowledge the legal relevance of the rural lawyer shortage.  Some excerpts follow:

¶1 Our federal and state constitutions guarantee criminal defendants the right to a speedy trial. The Sixth Amendment of the United States Constitution provides, "[i]n all criminal prosecutions, the accused shall enjoy the right to a speedy and public trial," and Article I, Section 7 of the Wisconsin Constitution says, "[i]n all criminal prosecutions the accused shall enjoy the right . . . in prosecutions by indictment, or information, to a speedy public trial." Luis A. Ramirez, as an inmate already serving a lengthy sentence for felony convictions, attacked and injured a corrections officer.  After a series of continuances and rescheduled trial dates, Ramirez was finally tried and convicted by a jury 46 months after he was criminally charged for the attack.

¶2 Ramirez moved for postconviction relief, alleging the 46-month delay violated his constitutional speedy trial right. The postconviction court denied his motion, and Ramirez appealed. The court of appeals reversed and ordered the only remedy available for constitutional speedy trial violations—dismissal of the charges. The State sought this court's review of a single issue: Whether Ramirez's constitutional right to a speedy trial was violated. We conclude it was not and reverse the court of appeals.

What follows is an excerpt from the concurrence by Chief Justice Ann Walsk Bradley, with whom Judge Janet Protasiewicz joined.  

¶80 In this case Ramirez's claim was doomed by his 32-month delay in asserting his speedy trial right and his failure to persuade that the 14-month duration from his assertion of the right to his trial violates the constitution. However, I cannot join the majority's approach because it could give the State a pass in cases involving delays even longer than the 46 months at issue here.

¶81 At a time where defendants are experiencing significant delays in appointment of counsel, this concern is especially acute.[5] Delays due to the lack of available attorneys can stretch into the triple digits. See Lee, 401 Wis. 2d 593, ¶6 (Dallet, J., dissenting) (setting forth that the defendant was held in custody "for 113 days before a preliminary examination, 101 of which were prior to the appointment of counsel").[6] In 2022, the state public defender opined that it would "take several years to clear a backlog of roughly 35,000 cases because of a shortage of public defenders."[7]

¶82 In Wisconsin's vast rural areas, especially in the northern part of the state, the problem has reached crisis levels. Although the data is admittedly at least seven years old, an article published in 2018 describes how "[o]ver 60% of the state's attorneys practice law in major urban areas, leaving some counties in rural Wisconsin with attorney-to-resident ratios as high as 1:4,452." Lisa R. Pruitt et al., Legal Deserts: A Multi-State Perspective on Rural Access to Justice, 13 HARV. L. & POL'Y REV. 15, 81 (2018) (footnotes omitted). In comparison, the statewide ratio is about 1:389.[8]

¶83 Additionally, the population that is practicing law in the rural north is rapidly aging. As of 2018, "[a]cross the northern half of the state, only six of the forty attorneys in Vilas County are under the age of fifty, and Florence and Pepin counties have no lawyers under fifty. Oconto County has two, and no new attorneys have moved into the county in the last decade." Id. at 81-82 (footnotes omitted). In total, as of that time, "[n]ine counties in northern Wisconsin ha[d] ten or fewer active attorneys." Id. at 82 (footnote omitted). Although this data is now seven years old,[9] the problem has certainly not abated. In fact, it has only worsened.[10]

¶84 As of 2024, the number of active attorneys in Wisconsin had dropped four percent over the last four years, while the number of attorneys in rural Wisconsin had plummeted by seven percent.[11] Eight counties have no certified private bar attorneys to take cases when the state public defender cannot represent a defendant.[12] Such a shortage "not only impacts the constitutional rights of defendants—it also affects victims and our communities."[13] Despite intervening attempts to address the root causes of the shortage, the problem persists.[14]

¶85 The shortage of lawyers in rural areas is a systemic problem, not an intentional one, putting it at risk of being termed "neutral" in the parlance of the majority's speedy trial analysis.[15] It is possible that a defendant could spend months or even years awaiting the appointment of an attorney, a necessity for any trial, much less a speedy one. And as the majority opinion demonstrates, when a delay is termed neutral, good luck to a defendant in succeeding on a speedy trial claim.

¶86 This court should not give its seal of approval to such an approach. Rather, the court of appeals approached this case the right way by breaking down the periods of delay and determining the reasons behind them and the weight to be given in the Barker analysis. The analysis conducted by the court of appeals represents a more nuanced approach that is better suited to the fact-specific nature of a speedy trial determination. See Urdahl, 286 Wis. 2d 476, ¶11.

"Rural" all over the news as Senate passes "Big Beautiful Bill" that will undermine rural services, especially health care

Analysis of what Trump's "Big Beautiful Bill" would do to rural health care has been in the news for several weeks, and it stayed there today as the Senate passed the Bill by a vote of 50-50, with Vice President J.D. Vance breaking the tie.  

What follows appeared on the Ezra Klein Show today, July 1, but much of it was recorded in advance in anticipation that the bill would pass.  Here, I'm just going to highlight the bits about rural health care, including as they relate to "red state" voters: 

Klein: [T]hey are very substantially cuts to the Republican Party’s voters. They’re cuts to Republican states. They’re cuts to Republican hospitals — rural hospitals in areas that vote for Republicans and are very dependent on the care that gets financed by Medicaid in order to stay open.  (emphasis added)

This is the Republicans’ old ideology coming into conflict with their new coalition.

Yglesias:  Absolutely. If you look at the share of people who are on Medicaid by state, there are seven states where more than a quarter of the population is on Medicaid.

One of them is New York, and one of them is California. But the other five are New Mexico, Louisiana, Arkansas, Kentucky and West Virginia.

And then you look at states like Mississippi and Alabama: If they would accept Medicaid expansion funding, there’s a huge, potentially eligible population share in those states.

It’s a big conflict inside the heart of Republican politics. [Details about Mitch McConnell and Kentucky] 

There’s just a conflict between the Republican Party electorate and their ideology, which has shifted in some ways but really remains focused on low taxes, on investment income, low corporate taxes and wanting to cut spending on programs for the poor.

About work requirements and how they've worked out so far, Klein and Yglesias shared this conversation:

The most conservative states don’t accept Medicaid expansion funds. They have tried to impose work requirements in Arkansas, for example.

(Read more about the Arkansas experiment here and here.) 

So we ran the experiment: Does putting work requirements on Medicaid increase employment? And the answer was no. When they did it, employment didn’t go up. People did lose coverage, but employment didn’t go up.

And Republicans didn’t reverse course after that. They didn’t say to themselves: Oh, our goal here was to get more people working, but we didn’t succeed at that. They said: You know what? This cut the rolls. It cut spending. We’re happy with that.

That’s a free market view: If you want a television, you’ve got to pay for it yourself. If you want chemotherapy, you’ve got to pay for it yourself.

On work requirements, I published this three years ago in Politico.   

Here's more from Yglesias, on perverse incentives: 

There’s this threat that hospitals will go out of business. I’m in Maine right now in a very rural area, and hospitals don’t have a ton of customers here. If they lose let’s say 10 percent or 15 percent of their customer base and have higher uncompensated care burdens — some of the facilities will just close.

Senate Republicans have discussed creating a hospital bailout fund to prevent this, but it seems crazy to me to address hospitals’ business model problems by giving them direct payments to stay in business even though they’re not treating patients, rather than just letting people get the treatment they need.  (emphasis added)

Senator Lisa Murkowski of Alaska ultimately voted for the bill, but only after she was offered big concessions for her state.  Read more about those here.  Apparently, one of those concessions was to double to $50 billion (from an initial $25 billion) the amount in a fund that would support rural hospitals.  Another related to how SNAP will be administered in Alaksa. 

Also instructive is this interview by NPR with Kaiser Health News reporter Sarah Jane Tribble, published yesterday, leading with Juana Summers questioning Tribble: 

SUMMERS: Rural America is poised to be greatly impacted by these proposed cuts. Roughly 20% of the U.S. population lives in rural areas where Medicaid covers 1 in 4 adults. Here to talk about what could be at stake for those communities is Sarah Jane Tribble. She's the chief rural correspondent for KFF Health News. ...

Sarah, just start if you can by telling us a bit about what you have been hearing from people in rural communities across this country about these proposed cuts.

TRIBBLE: Yeah, I'm not hearing good things. They're very concerned, because Medicaid rates are so high in rural America, that these cuts will be very detrimental, they'll cause more hospitals to close, they'll tax rural health clinics. I was sitting next to a CEO of a rural hospital from Colorado. He has a 25-bed critical access hospital, the only hospital between the Kansas border and Denver on the Colorado I-70 corridor. And he had been talking about the cuts and not happy about them. And then we heard about the rural transformation fund that the Senate has been working on to sort of help offset the cuts. And he leaned over and he just scoffed. He just said, that's just not going to be enough. So I think that there's a lot of concern out there in rural America.  (emphasis added) 

Here's a late June NPR story about the ripple effects the cuts are likely to have on hospitals in rural Colorado, this one focused on the San Luis Valley in the southwest part of the state.  Here is a key excerpt from the story by John Daley: 

"I'm trying to be worried — and optimistic," said Konnie Martin, CEO of San Luis Valley Health in Alamosa. It's the flagship health care facility for 50,000 people in six agricultural counties — Alamosa, Conejos, Costilla, Mineral, Rio Grande and Saguache.

The numbers out of the bill about deep Medicaid cuts were "incredibly frightening," Martin said, "because Medicaid is such a vital program to rural health care."

Martin's hospital is not alone. "I think in Colorado right now, nearly 70 percent of rural hospitals are operating in a negative margin," in the red, Martin said.

Here's a late June Washington Post story about Medicaid as a "lifeline" in West Virginia.  

iPhone factory rises in rural India. Does it provide rural development lessons for the United States?

Alex Travelli and Hari Kumar report from Devanahalli, India in yesterday's New York Times on the pending opening of an iPhone factory.  The story features many descriptors suggesting the remoteness and rurality of the place and concludes with a brief comparison to rural development efforts in the United States.  The plant, which will be fully functioning and employing 40,000 people by the end of this calendar year, responds to Prime Minister Narendra Modi's “Make in India” policy, announced in 2015.  The Modi government has committed $26 billion to subsidizing strategic manufacturing goals since 2020. 

A new iPhone factory in an out-of-the-way corner of India looks like a spaceship from another planet. Foxconn, the Taiwanese company that assembles most of the world’s iPhones for Apple, has landed amid the boulders and millet fields of Devanahalli. 

* * *

By the end of 2025, with the Devanahalli plant fully online, Foxconn is expected to be assembling between 25 and 30 percent of iPhones in India.

* * *

The effects on the region are transformative. It’s a field day for job-seekers and landowners. And the kind of crazy-quilt supply chain of smaller industries that feeds Apple’s factory towns in China is coalescing in India’s heartland. 

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India’s most urgent reason for developing industry is to create jobs. Unlike the United States, it does not have enough: not in services, manufacturing or anything else. Nearly half its workers are involved in farming.

* * *

India is thick with people. A five-minute walk away, a village called Doddagollahalli looks the same as it did before Foxconn landed. Nearly all the houses clustered around a sacred grove belong to farming families growing millet, grapes and vegetables.

Some villagers are renting rooms to Foxconn workers. Many more are trying to sell their land. But Sneha, who goes by a single name, has found a job on the Foxconn factory’s day shift. She holds a master’s degree in mathematics. She can walk home for lunch every day, a corporate lanyard swinging from her neck.

It is people like Sneha, and the thousands of her new colleagues piling into her ancestral place, who make Foxconn’s ambitions for India possible. Mr. Trump wants to revive the fortunes of left-behind American factory towns, but the pipeline of qualified young graduates is not there.

Thus, while Trump wants this to happen in the United States, it probably won't, "without sustained government financial support to revive U.S. manufacturing and training to expand the pool of qualified factory workers."   

Op-ed by Alaska legislators decries likely effect of "Big Beautiful Bill, "especially in rural areas

Bryce Edgmon and Cathy Giessel of the Alaska legislature have published an op-ed in today's New York Times, "Our State Cannot Survive this Bill:"  One of the legislators is a Republican and the other an Independent, and they focus on their bipartisanship.  In some ways, this piece echoes analysis we are seeing about how many "red states" will suffer particularly under Trump's "big beautiful bill," but it also features some Alaska specifics.

Here's the lede: 

Across the country, state lawmakers like us are bracing as the federal government considers a bill that will throw state budgets into chaos and add red tape that our social service agencies do not have the capacity to administer. If the budget reconciliation bill passes Congress in anything like its current form, we will be left to deal with the fallout.

The likely impacts from the “big, beautiful bill” are particularly ugly for our home state, Alaska: Nearly 40,000 Alaskans could lose health care coverage, thousands of families will go hungry through loss of benefits from the Supplemental Nutrition Assistance Program, or SNAP, and the shift in costs from the federal government to the state will plunge our budget into a severe deficit, cripple our state economy and make it harder to provide basic services.

And in these paragraphs, the writers get around to the rural angle: 

The benefits of Medicaid and the SNAP program permeate the entire fabric of the Alaska economy, with one in three Alaskans receiving Medicaid, including more than half of the children. In remote Arctic communities, Medicaid dollars make medical travel possible for residents from the hundreds of roadless villages to the communities where they are able to receive proper medical treatments.

We fear that if this bill passes, a village in rural Alaska might lose its one and only grocery store because of a drastic decline in SNAP dollars. It might also lose its sole health care clinic or hospital because it cannot sustain its services with decreased Medicaid reimbursements. The reconciliation bill does not take into account the uniqueness of Alaskan lifestyles and geographic remoteness.

The legislators explain that the federal cuts will cause costs for many services to be shifted to the state budget, which will cause great strain.  It also takes up the fact that work requirements for public benefits are an ill fit for rural Americans.

Alaska cannot afford to lose health care funding. Our state is near the top of the list for the highest rates of suicide, tuberculosis and sexually transmitted infections in the nation. It is also severely lacking in adequate behavioral health services. The cuts will only make these problems worse.

Work requirements instituted in Medicaid are untenable for rural Alaska, with many communities facing limited broadband access and job opportunities.

Here's a piece in The Atlantic, by Russell Berman, suggesting that Kentucky Republicans are not afraid to stand up to Trump.