Wednesday, March 22, 2017

The farmer's fight for the "right to repair"

Corporate giants like Apple, AT&T, and John Deere are up in arms about proposed legislation in eight states this year - legislation commonly known as the "Right to Repair" or "Fair Repair" bills. If passed, these laws will allow consumers and independent repair shops to fix equipment, like iPhones, without being forced to go through the manufacturer. It will also make the diagnostic and service manuals available to the public. And farmers are leading the charge. 

When I think about a farmer, I envision a self-sufficient businessman who leads a rural lifestyle. Someone who will find a way to make ends meet using the resources at their disposal and fixing things when they are broken - like their own farm equipment. But thanks to intellectual property law, there is at least one piece of equipment a farmer can't fix...a tractor.

If you are not mechanically inclined, or even if you are, you might assume that today's tractors can be fixed by using the correct combination of wrenches and screwdrivers. But actually they can't. Today's tractors are filled with sensors, wires, and complex computer software (some even have satellite radio!) that require factory passwords and special diagnostic tools to repair them. Because of the Digital Millennium Copyright Act (DMCA), famers cannot access these passwords or tools without the manufacturer's permission.

The DMCA, which is designed to prevent digital piracy, classifies breaking a technological protection on a device's programming as a copyright breach. So if a person changed or modified that programming to fix the equipment, they would be in violation of the DMCA.

Kyle Wiens has written about the difficulties of modern tractor repair and its effect on farming. Wiens is a strong voice for the "Right to Repair" movement and self-identifies as a "computer programmer by training and repairman by trade." In a Wired article, he recounts the experience of trying to help his farmer friend repair a tractor. Wiens continues: 
Over my left shoulder a massive John Deere tractor loomed…Repair is what I do...being rebuffed by a tractor was incredibly frustrating. 
Wiens continues:
I tossed my wrenches and screwdrivers. The conventional tools of my trade had no power here....Armed with wire, alligator clips, a handful of connectors, and a CANbus reader, I launched myself back into the cab....One hour later, I hopped back out...Defeated…I couldn’t even connect to the computer. Because John Deere says I can’t.
Even with this knowledge, you might think, so what? I would never attempt to fix my car, my computer, or my iPhone for that matter, on my own. Those repairs should be left to a professional - someone who has training in complex electronic systems. This is the type of argument that manufacturers hope will persuade politicians as they prepare to fight in the Nebraska, Minnesota, New York, Massachusetts, Illinois, Wyoming, Tennessee and Kansas legislatures. 

Before "Right to Repair" bills were introduced, activist farmers and repairmen like Wiens worked with nonprofit legal groups like the Electronic Frontier Foundation to get a DMCA exemption from the U.S. Copyright Office for agricultural machinery owners. The limited exemption grants owners access to the software to assess, repair, or modify tractor systems. But there is a catch: the exemption only lasts until the next rule-making in two years.

The main thrust of John Deere's argument is that people who buy tractors do not actually own them. Instead, they are buying an "implied operate the vehicle[.]" (see their opposition letter to a Kansas bill here). Apple and AT&T's arguments list the myriad of safety risks to consumers if they are allowed to fix their own devices. It will be a difficult fight: last year a similar New York bill was killed by Apple and IBM's aggressive lobbying.

But farmers are not giving up easily. The farming community has been making, building, repairing and tinkering with their equipment for centuries and they would like to keep it that way. Farming equipment is extremely expensive (a new tractor might cost $100,000 to $250,000 or more), and unlike tractors of the past, when a modern tractor breaks down farmers are dependent on dealers and technicians to repair them. The added costs of hiring a technician, as well as the time lost waiting for the repairs, can have a real economic impact on a farmer's livelihood.

The realities of a rural lifestyle exacerbate this problem. As I speculated earlier, farmers value their ability to fix things themselves without relying on or paying for outside assistance. But the repairs can be costly and most American farms are quite small. According to the Census of Agriculture, in 2012, 75% of American farms grossed less than $50,000. 

Additionally, many farmers live in small communities where the nearest dealer or technician may be hours away. It could take days for a technician to order the part, get out to the farm, and make the necessary repairs. Some farmers are so fed up with the hassle of repairing modern tractors that they are turning back to older models. 

The biggest issue with the legal restriction is probably the effect it can have on a farmer's crops. A crop's viability depends on the weather. Farmers work when the weather conditions are right, so an equipment malfunction during a crucial time, like planting or harvest, could be disastrous.

Farmers also argue that tractors are being treated differently from cars and trucks. In 2012, Massachusetts passed a law guaranteeing the right to repair automobiles and trucks, which became national legislation after manufacturers gave up the fight in other states. 

Nebraska activist Kevin Kenny makes a compelling argument from a different lens. He argues that allowing farmers to repair this equipment will promote ag-tech innovation in "Silicon Prairie," a term used to describe the growing tech industry in the Midwest. 

I argue that farmers and mechanics who enjoy "tinkering" and fixing their own equipment should have the right to modify their property as they see fit. The agricultural industry faces unique challenges, as I mentioned earlier, and laws like the DMCA only frustrate a farmer's ability to do their job and maintain their independence - something that is highly valued in the profession. 

Nebraska is the first state to consider the bill this year and the outcome is especially important because they have a unicameral legislature, which makes it easier for proposed legislation to move quickly. Hearings have already begun, but whether the farmers will prevail remains to be seen. 

Tuesday, March 21, 2017

The "neo-rural" Part I: the new generation moving into the hinterlands

I have a person very near and dear to me. Let's call him my kin. He is a prime example of what can be called the "neo-rural". A few have made attempts at defining the neo-rural, but I'd like to broaden the scope of those definitions a bit. I think we are on the cusp of a whole new generation of folks who are moving to rurality. I'd love to know exactly who these people are, and what inspires their love of the country. This post is a modest beginning to this inquiry.

One of the groups of people who fit into the "neo-rural" are "modern homesteaders," which my kin most certainly is. I recently interviewed him, during which he decided to go by the pseudonym Bill (or, sardonically, "Bill Damn", when he has to throw down). He wants to keep his rural home and his name unpublicized because there are some grey areas with regard to legality where he lives, and honestly, he'd like to keep it that way. Bill's rural reflections on the law will be the majority of Part II of this post.

To get to where Bill lives, you drive a few miles out of a lovely small town with a population less than 6,000. The town is a tourist destination, but remains remote. Then, you go over a bridge, take a sharp turn and brace yourself for more than six miles of dirt roads that are unmaintained with the exception of the maintenance that local homesteaders do. Bill doesn't feel that far out. He told me:
Where I’m at is kind of a nice position to be in because it’s extremely rural and out miles of dirt roads and beyond the reach of the power lines but I’m still only, like 30 minutes from a grocery store, which is nice.
Thirty minutes from the grocery store sounds pretty far-flung, in my opinion. I asked Bill if he lacked services way out there, and he said that was definitely a factor of his life. When a friend got injured once on his property, Bill had to lift her into his truck and haul-ass over the dirt and gravel out to the paved road - the ambulance wasn't coming anywhere near the acres he owns. It sounded harrowing.

However, that bit about the land is one that deserves some underscoring: Bill owns land. Acres of it. He owns several parcels around where he built his house (with his own hands), and several parcels in various other places down the dirt road where he lives. Bill is just 31, and he owns more land than I will likely ever own in my life. He is part of a movement around sustainable off-the-grid houses. He built his house (and many others) from the ground up. House-building is both Bill's passion and his livelihood. He flies all over the world building sustainable housing, and has built houses and structures in Thailand, Cambodia, Australia, South America, Canada, and more.

The desire to move out into rurality isn't new, but living and building like Bill "homesteading"-- has been gaining traction in pop-culture circles lately. For two examples, check out recent books "The Unsettlers" and "Modern Homesteading". People who have gotten tired of relying on corporations and government entities for services can find a myriad of articles that offer "21 Tips For Quitting Your Job, Going Off Grid and Living The Dream""The Secrets of Living with No Money""Lessons from Off-Grid Living" and more.

There is a lot of overlap with Bill's work and the tiny house movement, and he's also involved in the straw-bale house and pounded-tire construction communities. The electricity at his own house comes from his solar panels, which give him what he considers "oodles of power" to run his wifi, laptop, lamps, blender and bass-amplifier-doubling-as-sound-system. However, his solar panel-and-battery setup slightly limit his ability to live a "modern" technological lifestyle. No hairdryers allowed at Bill's, and you can't use all of the above at once. Bill Damn's house has a composting toilet, makes its own heat through passive solar heating, and all the water is harvested rain from the house's ingenious roof. Thus, the house entirely takes care of itself.

With the rise of AirBnB in rural places and the concept of "glamping," Bill's house now also pays for itself. If you ask him, Bill'd tell you that he feels his house actually takes care of him better than many humans in his life have. He says this with love in his heart, and when you listen to him, you realize how much of a modern cowboy he is: in his solitude, in his love of the land, and in his powerful self-sufficiency. This romanticism might seem a little gauche (especially since some urban circles have "practically fetishized the idea of building humble rural retreats"), but you can't argue that it is a remarkable life he leads.

Of course there are tough aspects about living as far out as Bill lives. As indicated above, getting services is a struggle: ambulance service has been a challenge for several small towns across the nation recently (examples here and here). In addition, the struggles of community-building in rurality and the dangers of substance abuse have become sticks in Bill's craw, so-to-speak. I asked him about this, to which he responded:
I sort of struggle sometimes because I feel like I’m one of the only ones out there who really wants [community] and wants to make it a better place, and a lot of people kind of go out there and settle for less. They’re comfortable being more cutoff and reclusive and, you know, there’s a lot of alcoholism, and some . . . heavier stuff as well.
The "heavier stuff" that Bill mentions might be a reference to rising methamphetamine use in rural communities (noted on this blog here, and here). He might also be intimating the rural opioid epidemic, which has recently been called "this generation's AIDS crisis." Fellow bloggers have also drawn attention to this heartbreaking issue's impact on rurality here and here. This upsets Bill, but the best he can do is look for other folk who are not part of that lifestyle -- who are more onboard with his goals for country living. The struggle of building community in rurality is an age-old one, but Bill has begun to discover new ways to create a network due to the house-building and subsistence-living communities that he has developed. He says that in recent years, community is improving out where he lives. He notes that "there’s starting to be some more younger folk coming out and building structures instead of dragging out trailers and starting junk yards."

Despite all the challenges of living in rurality, Bill Damn represents a growing contingent of Americans who find it to be the only way to live. Indeed, as of 2013, over 180,000 families lived off the grid in the US, and it appears that due to revolutions in battery technology and solar energy, it will only get easier to do so in the next quarter-century.

I asked Bill exactly what kept him out in the "hinterlands," and he said that rurality is where he feels closest to home. He observed that in the beginning, striving for his rural life was a reaction against some aspects of modern urban life that he felt were unhealthy:
We’re constantly surrounded with a whole lot of distractions these days that kind of keep us separated from nature – speaking in a cliché, but it’s true, you know? Our existence is extremely disconnected from nature and from the natural phenomenon of the earth. We’re constantly sheltering ourselves from it and finding other things to look at, and even just finding things that keep us from connecting with one another.
Instead, Bill Damn lives deeply rooted in the earth, and he constantly strives to find new ways to connect to his rural livelihood and to reduce distraction. His life is built on finding more peace and harmony despite the craziness that he sees in modern society. "I guess I just feel more at peace when there’s less going on around me", he mused. It seems to me that he represents thousands of others in our nation who live by exactly the same sentiment.

The rural health landscape (Part IB): Rural midwifery—Origins

Recently, during a dinnertime discussion punctuated by a phone call from my mother—“Call the Midwife is airing on April 2nd! What is the Netflix password?”—my boyfriend raised a bemused eyebrow and commented, “Aren’t midwives like witch doctors?”

No, no they are not—but surprisingly, my boyfriend is apparently not alone in his misconception. According to a 2015 article published by NPR, many people continue to imagine midwives as, at worst, “old ladies with potions and herbs,” and, at best, as “untrained labour coach[es]” adverse to modern medicine. Indeed, the prevailing myths about midwifery (see below) seem to position midwives as anti-establishment, anti-western and anti-modernity. It is possible these misconceptions are rooted in the profession’s historical underpinnings.

The midwifery origins story is steeped in rurality. In the late 19th century, two concerns preoccupied physicians: overcrowding and competition. An influx of practitioners into the medical market in the 1820s and 1830s prompted a new professional self-consciousness and a desire on the part of “learned gentlemen” to distinguish themselves from the “quacks.” In the Age of Reform that followed, qualified practitioners increasingly relied on “appeals to science as the justification for professional prerogative”—though, it must be noted, such appeals “took place well before medicine could demonstrate the efficacy of its science.” In obstetrics, especially, the effects of medical professionalization were severe. Before 1900, midwives and physicians attended births in roughly equal proportions, and less than five percent of women gave birth in hospitals. Then, in the first decades of the new century, Dr. Joseph DeLee, now considered the father of modern obstetrics, published a series of influential articles and textbooks on the practice of obstetrics. In The Prophylactic Forceps Operation, Dr. DeLee described labor as “a painful and terrifying experience,” resulting in “much morbidity that leaves permanent invalidism.” He concluded that professional medical intervention was the means by which to protect mothers from Nature’s pathogenic process. In 1915, Dr. DeLee spoke at the Sixth Annual Meeting of the American Association for the Study and Prevention of Infant Mortality. According to Volume 88 of the Medical Record:
Dr. Joseph B. DeLee of Chicago asserted his opposition to every movement to perpetuate the midwife, declaring her to be a relic of barbarism . . . He regarded her as a drag upon the progress of the science and art of obstetrics, her existence stunting the one and degrading the other. . . . In educating the midwife he felt that the profession assumed the responsibility for her, lowered the standards and compromised with wrong, and personally he refused to be particeps criminis.
Dr. DeLee was not alone in his opinion; even those “who had favored the midwife now admitted that she must be eliminated,” and that “she should never be regarded as a practitioner.” Notably, even amidst these avowed renunciations of midwifery as a professional practice, numerous physicians acknowledged that “in rural districts there was no demand for obstetric hospitals and dispensaries, but that there was a demand for good midwives.” Dr. J. Whitridge Williams of Baltimore voiced his belief that absent midwives, the “farmer’s wife” would have only the “neighboring farmer’s wife to look after her confinement.”

The obstetrical restructuring sought by Dr. DeLee and his contemporaries had a disparate impact. “For example, as physicians became the provider of choice for the affluent woman, midwives cared for an increasing number of poor women. These midwifery clients usually lived in either rural areas of the country, or in immigrant areas of large urban cities[.]

By 1935, midwives attended less than 15 percent of births. By 1939, over 50 percent of all women and 75 percent of all urban women gave birth in hospitals; by 1950, the percentage was 88; by 1960, it was 97. By the 1960s, fewer than 70 midwives were practicing in the United States, and the infant mortality rate had increased by 41 percent.

Today, many of the myths perpetuated during the period of medical professionalization remain entrenched in the popular imagination. Many Americans continue to believe that delivering with an obstetrician is safer than delivering with a midwife. In reality, studies show that “mothers whose care was led by a nurse-midwife had lower rates of episiotomies, drug-induced labor, and vaginal tearing during delivery.” Many Americans think that opting for midwifery care precludes a woman from giving birth in a hospital. In reality, “[m]ost births with midwives occur in hospitals, with relatively small percentages at free-standing birth centers or at home.” Many Americans continue to typecast midwives as naturopathic providers who lack formal training. In reality, “[t]he vast majority of midwives in the United States are certified nurse-midwives (CNMs) and certified midwives (CMs).” Typically, CNMs have earned at least a master’s degree from an accredited college, in addition to clinical training and certification from a national board. They have prescriptive authority in every state. Perhaps the most common myth is that midwives provide only maternal care. In fact, “CNMs and CMs provide health care services to women in all stages of life, from the teenage years through menopause, including general health check-ups, screenings and vaccinations; pregnancy, birth, and postpartum care; well woman gynecologic care; treatment of sexually transmitted infections; and prescribing medications, including all forms of pain control medications and birth control.

That said, some of the midwifery stereotypes ring true. Historically, midwifery shared a special affinity with rural America. Around the same time obstetrical medicine was organizing, Mary Breckinridge founded the Frontier Nursing Service (FNS) in Kentucky’s Appalachian Mountains. According to the National Museum of American History:
Serving families in a 700-mile area extending into four southeastern Kentucky counties, FNS had, by 1930, six outpost centers, with two nurse-midwives at each responsible for both the general health of all of the families as well as prenatal, labor and delivery, and postnatal care for women in their district.

The narrow winding roads of Appalachia meant that nurse-midwives might have to ride for up to an hour on horseback to help a woman in labor. Though supervised by physicians, the isolated nature of rural Kentucky meant that these midwives often worked independently, carrying supplies with them.
Today, FNS remains a bastion of midwifery, operating a hospital in Hyden, Kentucky, four rural health clinics, a home health agency, and the FNS School of Midwifery and Family Nursing. FNS, as well as many other midwifery educational programs, continue to emphasize rural outreach. Indeed, “[t]o increase the number of rural midwives, several programs are providing long-distance courses to nurses already practicing in rural areas. Some ensure that their students take part in rural rotations, as well.” Over 80 percent of FNS graduates work in areas HRSA has designated as rural or underserved.

Part IA of this series provided a snapshot of women's health in rural areas.  In the interview that follows in Part IC, a recent graduate of Columbia’s University’s Nurse Midwifery Program gives us a glimpse of modern midwifery and its intersection with rural populations.

Monday, March 20, 2017

Oroville Dam crisis is not urban v. rural policy making

Victor Davis Hanson, a self-described "fifth-generation rural Californian" wrote an Op-Ed in the LA Times titled "The Oroville Dam disaster is yet another example of California's decline." Hanson frames the imminent failure of the Dam as a failure of the state legislature and state planners to provide funding for infrastructure in rural areas.
State lawmakers spend their time obsessing over minutia: a prohibition against free grocery bags and rules against disturbing bobcats. When they do turn their attention to development, they tend to pick projects that serve urban rather than rural populations — for example, that boondoggle of a bullet train whose costs keep climbing even as the project falls years behind schedule.
He may be correct to say that California's infrastructure as a whole has fallen into a state of disrepair. It misrepresents the issue to frame it as an urban versus rural issue for a number of reasons. At the very least it oversimplifies the issue and ultimately suggests that rural and urban concerns can never be aligned.

Oroville Dam Background
Oroville Dam stands at 770 feet, the tallest dam in the United States, and provides water storage, hydroelectricity generation, and flood control for the state. Since 1968, the dam has held flow from the Feather River to create Lake Oroville Reservoir with a total capacity of 3.5million acre feet.

In early February 2017, following a period of heavy rain, Lake Oroville was well over capacity. The overflow water eroded the land faster than predicted and broke a hole in the spillway, eroding land to the side. Structural managers instead opened the emergency spillway, causing additional erosion and damage around the damn. While the main damn is not threatened, if the erosion on either spillway reaches the top, it would cause the gate to collapse, releasing uncontrolled, life-threatening floods. The water is currently under control.

Dam Infrastructure Monitoring
First, the dam is not an overlooked infrastructure project. It has to be checked every year by state and Federal agency specialists.

The Bureau of Reclamation operates Safety Evaluation of Existing Dams (SEED) program under the Safety of Dams Act. This risk assessment integrates engineering analyses and the consensus of a specialized review board to meet the SEED program objectives: assess safety of damns, protect potentially affected public safety, and allocate resources efficiently.

The California Department of Water Resources, Division of Safety of Dams monitors dams and dam proposals in the state. This monitoring and risk assessment role is identical to that of the Bureau of Reclamation.

Further, the Federal Energy Regulatory Commission (FERC) regulates dam safety at hydropower plants. FERC was active in the dam' building before and during construction. Commission engineers continue to inspect it on a regular basis.

Note that there are reports that Oroville Dam's last inspection was done at a distance rather than undergoing a close visual inspection. It is unclear why. There are parties that claim that this could have been an avoidable emergency. However the cause is still undetermined and the state has not neglected their responsibilities to keep the dam.

Dam Urban/Rural Interconnectedness 
Second, Oroville Dam is not only responsible to rural populations. It is a core facet of the California State Water Project (SWP), the statewide water system. The SWP is the largest public water and power utilities project in the world and provides drinking water to more than 23 million people. This system redistributes water from Northern California to the San Francisco Bay Area, Greater Los Angeles, Greater San Diego, Inland Empire, Santa Clara Valley, San Joaquin Valley, and the Central Coast, among other urban and rural populations.

While Hanson paints Oroville Dam as being in a rural area, the dam's failure is not a rural issue. (Note: Oroville has a population of 18,000, hardly rural if measured in terms of low population. In social prestige, it is the county seat of Butte County and it hosts Butte Community College. This author would not support an argument that Oroville is especially rural.)

Oroville Dam main spillway erosion William Croyle, California DWR
A Misplaced Issue Framing
Third, there is no utility in this misplaced framing. No one doubts that the dam's safety is a major concern. However, it is an insult to genuine rural issues such as access to healthcare, drug abuse, and employment opportunities to say that its impending failure is at the cost of urban social programs. This is something that effects all Californians. 

Sunday, March 19, 2017

From Reagan to Trump: The battle for civil legal aid

As many of you may be aware, the White House recently unveiled the blueprint for President Donald Trump's first budget. The budget calls for dramatic cuts to some programs and the complete elimination of funding for others (some are perhaps most familiar with the elimination of federal funding for the Corporation for Public Broadcasting and Meals on Wheels). One of the other programs that the Trump Administration wants to withdraw funding from is the Legal Services Corporation, a non-profit entity that provides funding to organizations that provide civil legal services to indigent populations. President Trump's decision to propose the elimination of funding for the Legal Services Corporation is sadly representative of a pattern that goes back to Ronald Reagan. In 1981, President Ronald Reagan called for the elimination of the program and in 1995, House Speaker Newt Gingrich, future House Speaker John Boehner, and future Ohio Governor, Rep. John Kasich were vocal proponents of the program's elimination. The Legal Services Corporation and the legal aid movement more broadly have long been accused of being a front for a "liberal" agenda, sentiments echoed in both Reagan's earliest attempts to eliminate it and the most recent attempts in 1995. The Trump Administration has yet to give a reason for their attempts to eliminate the LSC.

Rural legal services organizations are perhaps the most vulnerable to these proposed cuts. Owing to spatial isolation and historically entrenched poverty, the rural impoverished are incredibly reliant on the services of lawyers who can provide them with a voice in a community where they are marginalized and help them obtain access to resources that may not otherwise be available to them. For many agencies, LSC funding makes up the majority of their funding and when funding is cut, rural offices are often the first to close. If enacted, President Trump's cuts would be devastating to the rural impoverished.

The creation of the LSC

The LSC has its roots as the "Legal Services Program" within the Office of Economic Opportunity, created by President Lyndon Johnson in 1965 as part of the War on Poverty. The creation of the LSP is important for rural legal services, if only because the Legal Aid movement had historically been a predominantly urban phenomena. In his 1919 writing, Justice and the Poor, Reginald Heber Smith wrote, "[i]n the country towns and smaller cities this difficulty [in obtaining legal services] is overcome by the charity work of the lawyers. It is the general opinion that it is rare indeed for an inhabitant of a small town to be denied legal assistance even if he is unable to pay for it. Just where the line of demarcation is to be drawn is not certain, but there is good authority for fixing it at cities with a population of one hundred thousand." Smith postulated that only cities of 100,000 or more even needed a civil legal aid society, an assumption that we know today to be false.

On July 25, 1974, President Richard Nixon signed the LSC Act, creating the Legal Services Corporation as an independent non-profit agency. Despite its independence, the President retained the power to appoint, with the approval of the United States Senate, the board of the LSC.

Reagan's crusade

The creation of the Legal Services Program saw the creation of what may perhaps be the first successful rural legal services organization, California Rural Legal Assistance (CRLA). California Rural Legal Assistance quickly proved the potency of an organization that actively advocated for the rights of rural citizens. As one of the first rural legal assistance programs in the country, CRLA sought to change the distrust that many of the rural poor in California had for the legal system. While the vast majority of the cases that CRLA took were service cases, which dealt primarily with only remedying the problems of the individual, they did often take cases that were designed to set precedent and reform the legal system. 

The CRLA would directly clash with then-Governor Ronald Reagan, often taking cases that sought to overturn the policies of the Reagan Administration. As governor, Reagan had the ability to veto funding for the CRLA, but his veto was subject to approval by the director of the OEO. Knowing that he lacked the political will to have his veto upheld, Reagan appointed a new director for the California OEO and commissioned a study into the activities of the CRLA. The study alleged that the CRLA was connected to unions, racial violence and had allegedly exploited the poor by refusing to simply settle their cases. In December of 1970, Reagan vetoed funding for the CRLA. The federal OEO did not immediately overturn Reagan’s veto, but instead funded CRLA for six months while they investigated the report itself. The OEO found that many of the allegations made in the report were without merit and overturned Reagan’s veto.

Reagan also tried to use his relationship with Republican Senator George Murphy of California to amend the OEO's enabling legislation as a means of weakening the CRLA. Murphy first tried to achieve this by introducing legislation that would bar Legal Aid organizations from suing federal, state and local agencies. When that failed to pass in the Senate, Murphy introduced legislation to give governors the absolute power to veto funding for OEO programs, a measure which also failed to pass.

During the period following President Nixon's signing of the legislation that created the Legal Services Corporation and the inauguration of President Reagan, the LSC's budget had grown from $11.7 million to $321.3 million. The program had successfully expanded to such a point that it had representation in every county in the United States. Upon taking office however, Reagan immediately called for the abolishment of the LSC, an action that was immediately rebuffed by a bipartisan coalition in Congress. Funding for the LSC for the 1981-1982 fiscal year was reduced however to $260 million. Reagan also tried to weaken the LSC by appointing people to its board that were hostile to its mission and it was because of his failure to get these appointees approved by the Senate that the LSC was essentially governed by a series of recess appointments for the duration of Reagan's presidency. In an article in the June 8, 1984 edition of the New York Times, Senator Tom Eagleton of Missouri described Reagan's efforts by saying, "[t]here are three ways to kill a federal program, and the President with respect to legal services has tried all three. One way is to kill it outright. That didn't succeed. Another is to fund it at such a low level as to make it inoperative. From Reagan's point of view, he made a little progress on that, he got a budget cut. And the third way is to put management and oversight of the program in unfriendly hands." 

Reagan ultimately failed to kill the LSC but did succeed in weakening it. During the Reagan years,  restrictions were put on the activities of LSC grantees (including limitations on class action lawsuits) that severely limited what they could accomplish for the indigent. As the below chart shows, the Reagan Administration did succeed in cutting funding for the organization. 

Under fire again: The new Republican majority

In 1994, the Republican Party took back control of the United States House of Representatives for the first time since 1955 and as a result, the LSC again faced a threat to its existence. Continuing with the Reagan-esque tactic of painting the LSC as a funder of "liberal causes," they sought to eliminate it and turn legal services into a block grant that would be given to the states. As an example of the rhetoric surrounding this attempt to end the LSC, we can look to Rep. Charles Taylor of North Carolina who was quoted in an article published in June 1, 1996 edition of the New York Times as saying, "[o]f the 1.6 million legal matters they say they handled last year, at our request, they could not find one case where they helped throw a drug dealer out of public housing or helped protect a home schooler ... [t]hey have never stepped forward to help on the moderate or conservative front." Like President Reagan, a decade earlier, the Republicans had politicized the mission of the LSC.

A plan was devised that would lower funding of the LSC incrementally until 1998 when the program would then be eliminated all together. To begin the implementation of this plan, the House Republicans implemented a 31% cut in LSC funding in FY1996. Like with President Reagan's plans to eliminate the LSC in 1980s, the House Republican plan of the 90s ran into bipartisan opposition

Like President Reagan, the House Republicans failed to eliminate the LSC but they were successful in enacting reforms that severely limited the scope of representation that LSC attorneys could provide. Legislation was enacted that banned LSC grant recipients from representing clients in class action suits against federal state, and local governments and trying to influence the passage of legislation. As with President Reagan's attempts, the House Republicans succeeded in severely reducing funding afforded to the Legal Services Corporation.

Legal aid: a lifeline for the rural poor

There is perhaps no population that benefits more from civil legal aid than the rural poor. Rural poverty is defined largely by spatial isolation and is also deep rooted and multigenerational. Every single "persistent poverty" county in this country is rural. When rural people are in poverty, it's often because their grandparents and their grandparents were in poverty and it is also likely that their grandchildren will be in poverty (this interactive map from the New York Times shows that the issue is particularly pervasive in the rural South). Poor rural people are often forced into substandard school districts and given substandard opportunities. They are trapped in a power structure that leaves them vulnerable to manipulation by unscrupulous slumlords, employers, and even domestic partners. To someone who has no money and no resources, a lawyer is often the only person who can help them assert themselves and their rights. Due to the relative isolation of many rural communities, lawyers may also represent the only help that they can get for other issues. As Tom Weeks, executive director of the Ohio State Legal Services Association, noted in a recent article in The Atlantic“[i]n the cities, you're more likely to have some other organizations, for example, that are doing domestic-violence protection work .... In southeastern Ohio, we're basically pretty much the only lawyers who are representing poor people in domestic-violence and other family cases.” 

Impoverished rural citizens have long suffered from a lack of attorneys who can represent them. When the LSC faced being cut in 1995, Richard M. Taylor of Legal Services of North Carolina noted that "there are broad areas where there is great poverty and very few lawyers. The poverty is not distributed where the lawyers are." I also wrote about the issue of the misdistribution of lawyers here. In 1990, the Maine Commission on Legal Needs (chaired by Senator Edmund Muskie) issued a report that found that available legal services in Maine (an almost entirely rural state) were inadequate to fully address the needs of the poor. The report further found that, "[p]oor people living in a city in which a legal service office is located were nearly two times more likely to obtain legal assistance, and six times more likely to have obtained free legal service, than those not living in such a location. Residents of these cities were also twice as likely to be aware of the availability of free legal services." The findings of the Muskie report are particularly troubling when you consider that rural legal aid offices are perhaps the most vulnerable when funding gets cut. In 2011, Legal Aid of North Carolina lost $2 million in state funding. They responded by closing three rural offices, a decision that Executive Director George Hausen defended by saying, "[b]ecause those offices, because they cover so much geographic territory, don't serve as many clients. So if the issue is serving as many clients as possible with the same amount of money, we have to cut down on the travel and the time and kind of circle the wagons in the larger urban offices." In 2016, Legal Aid of North Carolina once again responded to budget cuts by closing yet another rural office. As with many issues of rural poverty, spatial isolation is the key barrier preventing a person from accessing the resources that they need. 

As Gene Nichol of the UNC School of Law noted in an October 2013 article in the Raleigh News & Observer, eighty percent of North Carolina's poor are unable to access legal representation. President Trump's proposal would only serve to exacerbate this problem. For many predominantly rural states, funding from the Legal Services Corporation represents the majority of their funding. According to Jim Sandman, President of the Legal Services Corporation, the organization provides the majority of funding for legal services provided in 12 states: Alabama, Arizona, Idaho, Indiana, Kansas, Mississippi, Nevada, New Mexico, South Carolina, South Dakota, Texas and Utah. When funding is cut from legal services, rural citizens are the among the first to suffer.

The scars remain

The below charts are visual representations of the cuts enacted by the Reagan Administration and Gingrich led House of Representatives.

Credit: Center for Law and Social Policy

Credit: Center for Law and Social Policy
As you can see, there is a marked decrease in funding in both 1982 and 1995, a legacy of these attempts to weaken the Legal Services Corporation. While it is incredibly likely that Donald Trump's budget will not pass, presidential budgets rarely do, it is likely that Trump's attempts will result in yet another weakening of the Legal Services Corporation. While Reagan and Gingrich failed to strike a fatal blow to the LSC, the scars from their attempts to do so remain. 

What will be the effects of President Trump's attempts to abolish the LSC and what resistance will be mounted against it? That remains to be seen. 

Saturday, March 18, 2017

New writer joining the fray

Me (left) with NC Governor Roy Cooper
Hi everyone!

My name is Christopher Chavis and I am deeply honored to have the opportunity write here and share my love of rural issues with you all. I am a native of Rowland, North Carolina, current resident of Battleboro, North Carolina, and a member of the Lumbee Tribe of North Carolina. I have a bachelor’s degree in Native American Studies and Sociology (modified with Public Policy) from Dartmouth College, a Juris Doctor from Michigan State University College of Law, and I am currently a part-time MPA candidate at the University of North Carolina at Chapel Hill where I am focusing on Community and Economic Development as a North Carolina Public Service Fellow. In my full time work, I am a Program Officer at Single Stop, an anti-poverty non-profit, where I get to work with colleges around North Carolina to help them connect students to local resources and programs that will help them graduate and hopefully break the cycle of poverty.

I have a deep passion for addressing resource scarcity in rural communities and have pursued this interest in a variety of ways. I have interned for the governor of New Hampshire, interned for Legal Aid of North Carolina, done grassroots organizing in rural New Hampshire and North Carolina, and worked as a disability rights advocate in rural Maine. I have written papers on the shortage of rural lawyers, both broadly and focusing on Indian Country. I have worked with classmates to do an economic analysis of a former mill town in New Hampshire, analyzed funding disparities and the resulting achievement gap between rural and metropolitan school districts, studied the correlation between rurality (and parental income) and college achievement, and even worked with a group to analyze how Alaskan villages can address water scarcity. Through my MPA program, I am currently working on a quantitative analysis of the rural lawyer shortage. 

This issue is also personal to me. I grew up in an impoverished rural community in Southeastern North Carolina and was the first in my family to not only attend college but also graduate high school. I grew up experiencing the results of the resource gap that many rural communities face and that drives my passion for addressing it. 

Prior to this, I wrote a blog for the Bangor Daily News in Maine where I also focused on rural issues. My research and writing are heavily focused on New England, Appalachia and the Southeastern United States. 

Aside from my passion for addressing rural poverty, I am also a huge Boston Red Sox fan, a passion that I picked up in college. Despite growing up in a coastal Southern region, I also feel most at home in the mountains and feel that there is nothing more relaxing than a calming drive through the Northern New England countryside.

Thursday, March 16, 2017

The GOP health plan would disproportionately hurt rural Trump voters

On Monday March 6, 2017 the GOP released its proposal to repeal and replace the Affordable Care Act. The proposed American Health Care Act (AHCA) would end or radically changed aspects of the ACA, while keeping some of its more popular provisions. For instance, it will terminate the individual mandate, taxes on the wealthy, change the way Medicaid is funded, change the subsidies, change the employer mandate, and much more.

A report published by the Congressional BudgetOffice (CBO) on Monday revealed the deep flaws in this proposal, including the possible negative effects on many rural Americans. According to the CBO report, the GOP proposal would cause 14 million people to lose health insurance in the first year and 24 million people by 2026 will lose health insurance. This immediate spike in uninsured Americans will result from higher premiums due to changes in subsidies and healthy people dropping insurance without the individual mandate. Rural states are expected to be disproportionately negatively impacted by these changes.

One of the most dramatic changes under the AHCA are the federal subsidies for health insurance. The AHCA would give Americans on average $1,700 less in subsidies in 2020 compared to the ACA. The subsidies proposed by the AHCA are refundable tax credits which phase-out for higher-income individuals, vary with age, and grow annually with inflation. These tax credits range from between $500 and $4,000 per year. The AHCA tax credits are refundable which means that they reduce the amount a taxpayer owes on their federal income tax, but means that poor families must pay their premiums out of pocket up front. Under the ACA, the tax credits vary with family income, cost of insurance where people live, age, etc. These credits also increase annually along with premiums. The ACA also offers advanceable tax credits, meaning that they are available when the premium payment is owed and are reconciled based on actual income when a person files their income taxes. This benefits lower-income families who may not be able to pay for their premiums up front and wait for their tax refund. The differences in these tax credits are compared by the Kaiser Family Foundation in an interactive coverage map.

Credit: Kaiser Family Foundation
This chart illustrates the basic coverage differences by income and age between the ACA and the AHCA. Younger and wealthier Americans benefit from the new subsidies, while older and poorer Americas do not. Rural areas often have larger populations of poor and older individuals, meaning that they receive less subidies under the AHCA. However, this disparity only increases when the higher premiums that exist in many rural areas are accounted for. Rural regions have higher premiums in part because their populations are sicker and need more care on average, with higher rates of chronic conditions like heart disease and diabetes. As discussed in a previous blog post rural populations also have higher mortality rates, especially among women. Rural areas are experiencing higher rates of insurer drop outs and poorly drawn rating areas, which are also contributing to higher premiums. For more information on the Affordable Care Act in rural areas see this previous blog post.

The 11 states whose residents would lose the most in tax subsidies under the AHCA all voted for Trump in the 2016 election. The Center on Budget and Policy Priorities found that the average tax credits for marketplace consumers in these 11 states would decrease by over 50% under the AHCA. Ten of those eleven states have significant rural populations in their health insurance marketplaces of at least 25%. The average tax credits in these high-cost rural states would fall sharply under the AHCA, between $3,160 and $10,243 in 2020.

Credit: CNBC
In Alaska, a state with high health care costs, the premiums for a 45-year old with an income of $22,000 per year would increase by 1408%. The 45-year old would pay $784 for healthcare under the ACA and $11,820 for healthcare under the AHCA. This would likely mean that this person would not be able to afford health insurance since their premiums would be almost 54% of their income. The income cutoff for Medicaid in Alaska in 2020 would be $20,000 a year, so the 45-year old would likely be uninsured. Trump won Alaska by 14.7 percentage points.

In 27 Nebraska counties, a 60 year-old with an income of $30,000 would lose $12,950 in subsidies a year under the AHCA. All of these counties voted for Trump in the 2016 election. 51% of consumers in Nebraska's health insurance marketplace live in rural areas.

In 22 Oklahoma counties, a 60 year-old with an income of $30,000 would lose $11,970 in subsidies a year under the AHCA. These counties also voted for Trump, who won Okaloma by 36.4 percentage points. 37% of consumers in Okalahoma's health insurance marketplace live in rural areas.

In Pennsylvannia and North Carolina, two swing states that helped Trump win the election, the subsidies would also decrease. In Berks and Lancaster counties in Western Pennsylvania, the subsidies would decrease by $9,500. Trump won those counties by 9.9 and 19. 1 percentage points respectively. In Western North Carolina, the subsidies would plummet by over $10,000. 25% of consumers in North Carolina's health insurance marketplace live in rural areas.

Despite these statistics, Trump and the GOP still claim that the AHCA will benefit all Americans. However, Trump did admit in an interview with Fox News last night that his working and middle-class supporters will not fare as well under the AHCA. Trump still claims that this is only the preliminary draft and that there will be negotiation in the Senate. 

Monday, March 13, 2017

Living with a disability in rural America (Part II): adults and employment

As a follow up to my last blog post on children with disabilities in rural America, I decided to explore some of the employment challenges faced by adults with disabilities in rural areas.

This is not the first time disability and employment have been discussed on this blog. Some of you may have read Lisa Pruitt's 2013 post discussing NPR's "Unfit for Work," a piece that explored being "on disability," as the phrase is often used. Being "on disability" means that the individual no longer works, but instead, receives a monthly payment from the federal government in lieu of a paycheck. In NPR's story the reporter highlights Hale County, Alabama, a rural area where (at the time of this story) nearly 1 in 4 working-age adults received federal disability assistance.

A more recent article from Bloomberg Businessweek highlights the current geographic distribution of people receiving disability benefits. This map (shown below) notes the emergence of "disability belts" in rural areas that include: Appalachia, the Deep South, and the Arkansas-Missouri border.

Credit: Bloomberg Businessweek
Another visual provided by the American Community Survey reports that for people who self-identify as having a disability (not necessarily those who receive federal disability assistance) the national disability rate is estimated to be 12.4%, while the rate in rural counties is estimated at 17.7%.
Credit: University of Montana Rural Institute 
Although an aging population may partially explain the higher disability rate in rural counties, the University of Montana's Rural Institute notes that disability rates are generally higher in rural areas across all ages and impairment types. One researcher posits that these numbers may be explained by the higher rates of injuries, limited emergency responses, and less access to preventative and primary health care in rural settings.

After reviewing these statistics, I wondered: what barriers do adults with disabilities and transitioning adults (those leaving high school) encounter in seeking employment? For some people with disabilities finding employment can be a challenging and frustrating task, but for people in rural areas, this challenge is even greater. Generally speaking, rural students transitioning from school fall behind their urban peers in rates of employment and postsecondary education after graduation. So are transitioning students with disabilities in rural areas destined to be "on disability" when they reach 18?

When a student transitions from school, there are a variety of routes the student might take. These options (which are not exhaustive) can include: post-secondary education, vocational training, independent employment, supported employment, or unemployment. For this post, I am only going to focus on employment.

Vocational rehabilitation agencies (VR agencies) are the state-supported offices charged with helping people with disabilities find employment. VR agencies often work with vendors to provide rural job services. Vendors are the individuals, private agencies, or community programs who connect people with disabilities to employment opportunities. Depending on the state and the contract, a vendor might be paid in different ways, depending on whether their consumers (people with disabilities) meet certain milestones or benchmarks in their employment plans. A milestone, for example, might include getting placed with an employer or reaching 90 days on the job.

But according to the Rural Institute, in rural areas the vendor options are typically limited and some rural regions are not served by any vendors. Another common problem in rural areas is that vendors may have to work with "mom and pop" establishments that hire few employees. Securing these job opportunities can also be a longer process because the vendor will need to establish a relationship with the employer and there may be fewer job openings. In contrast, vendors who work in urban settings have access to larger businesses, so once they establish a relationship with an employer they can secure more job placements for people with disabilities, which makes urban areas easier and cheaper to serve.

For students transitioning out of school, VR agencies report that maintaining connections with rural schools can be difficult because of the variation in the eligible student population and the large service areas of rural communities. Some VR employees may serve between 8-22 counties, limiting the amount of contact with each transitioning student. But supported career counseling between a school and VR agency might be more effective in rural areas where a full-time VR counselor is not available.

A lack of access or limited access to technology - like email - can impact communication between a VR worker and a person with a disability in a rural area. In some instances, the individual may not even be capable of using email, depending on the level and type of disability.

And finally, the absence of available and affordable transportation is a huge barrier for people with disabilities who work in rural areas. Support from family, friends, and other co-workers is most frequently cited as the primary transportation option for people with disabilities who do not have their own vehicle. Without this support system in place, it can be difficult or even impossible for a person with a disability to reach their employer.

Sunday, March 12, 2017

Connectedness in California communities may determine well-being

The 2016 Community Well-Being Rankings may compel people to reevaluate their commitment to California dreaming, or at least narrow their focus to only the coastal communities.

One hundred and eighty-nine communities across the United States were evaluated through telephone interviews. The five elements of well-being assessed by the surveys were sense of purpose, social well-being, financial well-being, community well-being, and physical well-being. The most powerful predictor of overall well-being is purpose, meaning "liking what you do each day and being motivated to achieve your goals." The pollsters completed over 354,000 interviews, nearly 2,000 from each community. Each tele-responder focused on their personal experience in the community.

The study's color-coded map of community well-being shows California coastal communities as bright blue, in the highest quintile. Communities in the spine of California, nestled between the western coastal ranges and eastern Sierra Nevada mountain range, are predominantly moss green. This signifies they are in the fourth and fifth quintile.

Top Quintile Communities based on Well-Being
In the top quintile are the California communities of Santa Cruz (3), San Luis Obispo (7), Santa Barbara (12), Santa Rosa (17), Salinas (19), San Diego (22), San Francisco (31), and Thousand Oaks (33). All but three of these communities, Santa Rosa, Salinas and Thousand Oaks, have a local major university. Most have multiple institutions of continuing education. Indeed, San Francisco and San Diego have multiple universities. Universities provide an energetic student population, diverse art and culture venues, and continuing education courses. These contribute to unique opportunities to interact with interesting people and engage in intellectual experiences. This finding may be reflected on the poll in the high purpose and social rank for these communities.

All of these top quintile California communities are near the beach. Besides being temperate climates, California beaches are recreational space. Beaches in the state are public property under the public trust doctrine meaning that all beaches are accessible for the "benefit, use and enjoyment of the public." This provides communities opportunities to exercise outdoors and experience nature. This may be reflected on the poll in community well-being, "liking where you live, feeling safe and having pride in your community," or in community physical well-being, "having good health and enough energy to get things done daily."

According to US Census Bureau data, all of these coastal communities are above the national mean household income ($53,889) except for Salinas ($49,840). This shows that the communities live comfortably but that wealth is not a clear indicator of well-being. San Francisco is the only community whose residents median income is more than $15,000 over the national median. This is reflected in its thirteenth place ranking for financial well-being, "managing your economic life to reduce stress and increase security."

This is all to say that it is not surprising that these communities ranked high in well-being.

An outlier to the top quintile California communities is Visalia, a community south of Fresno in the San Joaquin Valley. Compared to national averages, the community is only noteworthy for having about three times the national average Hispanic population. Given this high ranking, it is also surprising that the community has a higher poverty rate (21.3%) than the national average (13.5%).

The community ranks second of the 189 communities in purpose well-being. This may be due to the prevalence and success of agricultural ventures in the area. This theory is problematic where the California communities of the bottom quintile like Stockton, Bakersfield, and Fresno are mostly agriculture-based. Visalia is a much smaller in population than Stockton, Bakersfield, and Fresno but very similar to Chico. The top-ranked community has a population under 130,000 where the other farm communities are near or above 300,000. Chico is not as agriculturally successful. Visalia may rank high in "well-being" for having the ideal balance of size and success in the agriculture industry.

Bottom Quintile Communities based on Well-Being
Three California cities are in the bottom quintile of the study results: Chico (183), Bakersfield (172), and Stockton (166). Other cities in the spine of California escape the bottom quintile by 0.5 of an index point: Fresno (137), Fairfield (125), and Modesto (114).

Chico's ranking is especially shocking because it falls 0.8 ranking points behind Bakersfield, the next-closest California community.  It scored in the lowest quintile for all five indicators of well-being.

Chico is an urban epicenter of Northern California but ranked just above Flint, Michigan. The city boasts industry backbones like Sierra Nevada Brewing Co., Klean Kanteen, Lulu's Fashion, and Chico Bag, the original reusable grocery bag. California State University, Chico, is among the top 25 universities in California. Butte Community College has the most accomplished community college football program in the nation. Its most notable alum is Aaron Rodgers, star quarterback to the Green Bay Packers and winner and MVP of Super Bowl XLV. Bidwell Park is the third largest municipal park in the California with swimming holes, hiking paths, and wild bike routes.

Chico's Upper Bidwell Park by OFilbrandt
Why Chico?
The survey's research director reported that Chico community members report the highest rate of stress in the nation that "the negative emotions are really crummy in Chico." Chico has educational opportunities and convenient outdoor space. What it does not have is obvious and available connectivity to other communities. Though an intellectual destination in the region, Chico is surrounded by small towns that struggle to keep the only cafe in Richvale open, the only stop light in Durham working, and the water for Southern municipalities from drowning their town. (While I cannot find a reporting source for the first two points, this is common knowledge to Chico natives like me)

Indeed, the nearest international airport is in Sacramento, about two hours' drive. The nearest community of comparable size is about an hour south, Marysville-Yuba City. The closest northern community is Redding, about two hours away. No California community north of Redding is of comparable size. The closest community in the highest quintile, San Francisco, is about three hours away.

Essentially, a city with high well-being does not only need, as one writer read the study saying, "beaches, prosperity, and an intellectual zest" but also proximity to other communities marked by well-being. Bidwell Park provides outdoor adventure comparable to any beach. Lack of ocean views can hardly justify the low ranking when a handful of Colorado cities are in the top quintile.  Indeed, it may be an inability to enjoy the more unique Chico community aspects that hinders survey takers' perception of well-being. To correct for such a variable would require consideration of physical health, intellectual achievements, and individual participation in the community rather than self-reported well-being.

Disclaimer: the writer is from Chico, CA and shocked at the study's findings, especially that her unremarkable birthplace, Toledo, OH scored higher. 

Immigration policy adds a bitter taste to Trump's healthcare gumbo

Last week Republicans in the House of Representatives introduced their latest attempt to dismantle the Affordable Care Act (ACA). Appropriate for the hydra-headed problem of healthcare coverage, the American Health Care Act is currently proceeding in two bills and will likely have to merge with a divergent Senate proposal if it passes the House.

Previous blog posts have unpacked various dimensions of the ACA's effects in rural areas. A few years into its tenure, the results in rural areas were mixed; this remains the case today. Seven years after its implementation, rural hospitals are bracing for its repeal. One of the ACA's wonkiest features is its push for data-driven healthcare, which can pay big dividends in rural communities by improving and standardizing outcomes. And as the opioid epidemic has seized many rural Americans, including newborns, the repeal effort seems ill-timed in light of rural needs. The Trump Administration, "establishment" Republicans like Paul Ryan, and the nihilistic Freedom Caucus are among the cooks in the Obamacare-abolishment kitchen, and if they find a way to coordinate their efforts the resulting gumbo is likely to leave a bad aftertaste in rural America.

This blog has documented the lack of rural doctors; in California, the people-to-doctor ratio in rural counties is more than twice that of urban ones. Many rural communities carry the government imprimatur of a "shortage designation," which permits special treatment of foreign medical graduates (FMGs). Doctors trained abroad often enter the United States on J-1 visas to complete additional training, but in most cases they are required to return to their home countries. (Section 212(e) of the Immigration and Nationality Act is meant to prevent brain-drain.) However, waivers are available for FMGs that commit to practicing in parts of the United States carrying the Health Professional Shortage Area (HPSA) designation. These practitioners comprise approximately one-quarter of all U.S. physicians.

When the current president imposed the first version of his travel ban affecting seven majority-Muslim countries, some observers (CNN, Forbes, NPR, and Scientific American among them) wondered what the implications for HPSAs would be. These reports overstated the impact, but they also predicted the trouble that the Trump Administration's immigration policy portends.
Green areas indicate a designated primary-care HPSA. Source:
As the map above indicates, HPSAs are widespread and do not track the distribution of metropolitan and non-metropolitan counties. (See below).
Furthermore, the share of FMGs coming from the affected countries is small. The Educational Commission for Foreign Medical Graduates, a leading certifying body, processed 10,000 FMGs in 2015. Some 3,100 of these were U.S. citizens -- some aspiring doctors complete their studies abroad for academic, financial, and other reasons. Of the 6,900 foreign nationals, four countries subject to the travel ban contributed 571 FMGs. This does not include possible ban-affected individuals among the 1,100 doctors from countries with fewer than 50 FMGs, but it does include Iraq (118), which is not subject to the ban's second iteration. The Scientific American piece (above) notes that 8,400 FMGs from Iran and Syria are currently working in the United States, but this figure is eclipsed by India's 50,000 doctors.

As a statistical matter, it overstates the case to draw a direct line from Trump's travel ban(s) to worsening rural doctor shortages. But there are many reasons to predict that the Trump Administration has more bad news in store for patients in rural places.

The travel ban is thought to be the brainchild of Trump advisors Stephen Bannon and Stephen Miller. Both men are key advisors to Trump, and Bannon espouses a "clash of civilizations" view toward the Muslim world. In a Bannon-Trump interview from November 2015, Bannon expressed alarm that "two-thirds or three-quarters" of Silicon Valley CEOs were from South Asia; the real figure is closer to one-seventh, but the trend is clearly troublesome in Bannon's view. To him, legal immigration is a scourge as bad as unauthorized immigration, and Trump appears to be coming around to that view. If "version 2.0" of the travel ban is upheld by the courts, the list of barred countries may expand and affect major FMG-sending countries like India or Pakistan. The "Conrad 30" program that permits FMGs to avoid returning home after their J-1 programs lapse is temporary. In 2012, President Obama signed a three-year extension; since then the program has been kept afloat through "Continuing Resolution" legislation and could expire as soon as April 2017. And while some have advocated for expanding the number of waivers beyond 30 per state (1,500 nationally per year), there's little reason to think that such proposals will become law under this administration.

Thus, the travel ban is not as grave a threat to FMGs as is the pervasive ring of anti-immigrant voices within the Trump Administration. Even if the legal status quo prevails, predictions that FMGs from will eschew the U.S. for friendlier climates (or in solidarity, or from fear) may be proved right. In these ways, Trump's immigration policies may affect the health of his rural supporters while up-ending the economies where they live. If these policies unfold as predicted, rural voters will decide if Trump's strongman saccharine is enough to mask the bitter taste of his cooking.