Friday, June 16, 2017

WSJ on the digital divide between rural and urban

The Wall Street Journal's  Jennifer Levitz and Valerie Bauerlein reported yesterday from Caledonia, Missouri on the state of broadband in rural America.  The story, part of the WSJ's "One Nation, Divisible" series, is headlined, "Rural America is Stranded in the Dial-Up Age." The story is chock-full of data points about the consequences of lack of broadband in rural places, including these:
  • Rural counties with more households connected to broadband had higher incomes and lower unemployment than those with fewer (based on a 2015 study)
  • In St. Louis, speeds as fast as 100 Mbps start at about $45 a month, according to BroadbandNow, a data research company. Statewide, an estimated 61% of rural residents lack broadband access.
  • About 39% of the U.S. rural population, or 23 million people, lack access to broadband internet service—defined as “fast” by the Federal Communications Commission—compared with 4% of the urban residents. 
It also features lots of anecdotes about how the lack of broadband is holding rural folks back in the digital era.  Here's one of my favorites, which features an agricultural issue.  Indeed, one Caledonia resident who the authors keep returning to is a goat and sheep farmer named Jeanne Wilson Johnson.  She regularly drives four miles to a gas station for better Internet connectivity:
Counties without modern internet connections can’t attract new firms, and their isolation discourages the enterprises they have: ranchers who want to buy and sell cattle in online auctions or farmers who could use the internet to monitor crops. 
The story also features an anecdote regarding public safety:  
At the county’s 911 center, dispatch director William Goad sometimes loses his connection to the state emergency system. That means dispatchers can’t check license plates for police or relay arrest-warrant information.

As severe thunderstorms approached in late February, Mr. Goad tried to keep watch using an internet connection sputtering at speeds too slow to reliably map a tornado touchdown or track weather patterns.
Other illustrations are about other businesses (a boot factory) and healthcare and hospitals.  Given these illustrations of the need, why--as Mr. Goad asks--we have not solved this problem:
We drill for oil above the Arctic Circle in some of the worst conditions known to man.  Surely we can drop broadband across the rural areas in the Midwest.
The journalists who wrote this story explain what is probably obvious:
Rural America can’t seem to afford broadband: Too few customers are spread over too great a distance. The gold standard is fiber-optic service, but rural internet providers say they can’t invest in door-to-door connections with such a limited number of subscribers.
And this reminds me of a statement by former FCC economist Michael Katz back in 2009:
Other people don't like to say bad things about rural areas. So I will. 
The notion that we should be helping people who live in rural areas avoid the costs that they impose on society … is misguided, from an efficiency point of view and an equity one.
At stake then was $7.2 billion investment (as part of Obama's stimulus package) in broadband access for "underserved" and rural areas.

This story is well worth a read in its entirety, and I'm happy to see a national newspaper attending to these issues.

Monday, June 5, 2017

So much rural news (most of it depressing), so little time to blog

National media have featured some big rural headlines in recent weeks, including the one from the Wall Street Journal that I highlighted in my last post.  Since then, the Washington Post published this piece a few days ago on intergenerational disability and intergenerational poverty.  It is part of a series by journalist Terrence McCoy on disability in rural America.  The first installment of the series is here, and in it McCoy observes:
The rise in disability has emerged as yet another indicator of a widening political, cultural and economic chasm between urban and rural America.
The family featured in this most recent piece about the intergenerational nature of the disability designation (for SSI purposes) is in rural southeast Missouri, in Pemiscot County.  The headline is "Generations, Disabled."  One compelling blurb is "a family on the fringes prays for the 'right diagnoses.'"  Indeed, in the family that McCoy depicts, the 10-year-old twins' diagnosis as disabled--or, more precisely, their retention of that diagnosis--is what will permit the family to pay the bills, which McCoy itemizes in excruciating detail (and with an implicit invitation to judgment?).   

I want to note that while McCoy suggests that academics don't pay attention to the intergenerational nature of disability, I would say it often accompanies persistent poverty (as is the case with Pemiscot County), and a number of  rural sociologists, demographers and economists do attend to those places marked by intergenerational poverty as a particular phenomenon--and, of course, a particular challenge for policy makers.  (This blog features lots of entries about persistent poverty counties, not least because my home county is one such place).   I would be interested to see a persistent poverty map overlaid by a map showing the counties with the highest rates of disability.  I suspect it would reveal a great deal of overlap.

Among many observations I might offer about McCoy's Pemiscot County piece is that it reminds me of the character Pennsatucky in "Orange is the New Black," whose childhood was depicted as one in which her mother would get her jacked up on Mountain Dew before taking her into the social services office, with the goal of getting more money for a child "with issues." Indeed, McCoy's earlier installment on disability has a Mountain Dew angle (look for it in one of the photos, as well as in the text).  

This latest disability piece (the one set in the Missouri boot-heel) is classic Terrence McCoy, who last year published this much-read and lauded piece about a child who accidentally shot his sibling in rural Alabama--but also about how the family was getting by in the aftermath.  McCoy's stories typically include lots of dialogue between/among family members (less, if any, of what they say directly to McCoy), which essentially permits them to tell their own story.  In some ways, that's a good thing, but I'm not sure the average reader is well positioned to put the dialogue in context, and I can't help wonder if McCoy's style actually invites harsher judgments from readers than if he synthesized and paraphrased more.  He certainly has an uncanny ability to get the subjects of his stories to trust him with theirs.  The end products are these raw, open books on the lives of people living tragedy, which is akin to what I recently saw referred to as "decline porn." But McCoy's revelations are at the individual and family levels, less at the community level.  Indeed, you could say these stories constitute what I've seen referred to as poverty porn.  Speaking of poverty porn, the photographer who has worked with McCoy on these disability stories, Bonnie Jo Mount, has an incredible eye; her images are noting short of searing (though, again, I fear also damning).  The combination of McCoy's prose and Mount's photos is like taking in a documentary film.  (Indeed, this piece about inter-generational disability reminded me of the 2014 documentary, Rich Hill, set in Southwest Missouri). 

The details of the Missouri family aside, McCoy provides hard data, too, on disability as a rural phenomenon:
How to visualize the growth in disability in the United States? One way is to think of a map. Rural communities, where on average 9.1 percent of working-age people are on disability — nearly twice the urban rate and 40 percent higher than the national average — are in a brighter shade than cities. An even brighter hue then spreads from Appalachia into the Deep South and out into Missouri, where rates are higher yet, places economists have called “disability belts.” The brightest color of all can be found in 102 counties, mostly within these belts, where a Washington Post analysis of federal statistics estimates that, at minimum, about 1 in 6 working-age residents draw disability checks.
Meanwhile, on other rural fronts, I've continued to blog about rural disadvantage and rural poverty (among other issues) as a guest blogger over at Concurring Opinions.  This post over the week-end discusses rural-proofing laws in relation to rural labor markets, with embedded links to stories about proposals in Arkansas and Maine to make receipt of Medicaid contingent on work.  As I have highlighted on numerous occasions, such programs do not tend to work well in rural places, where labor markets are typically weak and the lack of economic diversification results in a narrow range of available jobs, and where child care and transportation infrastructure are inadequate to support would-be workers.  See more details in the Concurring Opinions post.  

On a more optimistic note, the New York Times published this piece by Patricia Cohen last week, "Immigrants Keep an Iowa Meatpacking Town Alive and Growing."  The story is about how immigration is remaking--and in so doing, also saving--places like this corner of northwest Iowa.  The dateline is Storm Lake, population 11,000, and here's an excerpt:  
The union is long gone, and so are most of the white faces of men who once labored in the broiling heat of the killing floor and the icy chill of the production lines. What hasn’t changed much is Mr. Smith’s hourly wage, which is still about $16 an hour, the same as when he started 37 years ago. 
* * *
Fierce global competition, agricultural automation and plant closures have left many rural towns struggling for survival. In areas stripped of the farm and union jobs that paid middle-class wages and tempted the next generation to stay put and raise a family, young people are more likely to move on to college or urban centers like Des Moines. Left behind are an aging population, abandoned storefronts and shrinking economic prospects.
So, this overview excerpt is not about Storm Lake, but rather about the rural America that is  suffering these ills.  Storm Lake has been kept bustling by several generations of migrant streams not only from Latin America, but from around the world. Less than half of Storm Lake's population is non-Hispanic white, though 88% of Iowa's is.

This story, too, is accompanied by some fabulous photographs, including one of the high school soccer team, a veritable human rainbow.  Cohen notes that 18 different languages are spoken among those who attend Storm Lake High.
Storm Lake, by the way, is the home of the Storm Lake Times and Art Cullen, who won this year's Pulitzer Prize for Editorial writing.  Read more here.  I wonder if that is how Cohen "found" or identified it as the subject of her story.

These offerings all represent really strong reporting on rural America from some of our most important national media outlets.  

Friday, May 26, 2017

Wall Street Journal: "Rural America Is the New 'Inner City'"

Janet Adamy and Paul Overberg report in today's Wall Street Journal under that very sobering headline.  Further, here's the most sobering excerpt from the story (in bold below), IMHO, in some historical perspective:  
For more than a century, rural towns sustained themselves, and often thrived, through a mix of agriculture and light manufacturing. Until recently, programs funded by counties and townships, combined with the charitable efforts of churches and community groups, provided a viable social safety net in lean times.

Starting in the 1980s, the nation’s basket cases were its urban areas—where a toxic stew of crime, drugs and suburban flight conspired to make large cities the slowest-growing and most troubled places.

Today, however, a Wall Street Journal analysis shows that by many key measures of socioeconomic well-being, those charts have flipped. In terms of poverty, college attainment, teenage births, divorce, death rates from heart disease and cancer, reliance on federal disability insurance and male labor-force participation, rural counties now rank the worst among the four major U.S. population groupings (the others are big cities, suburbs and medium or small metro areas). 
In fact, the total rural population—accounting for births, deaths and migration—has declined for five straight years.
The story quotes--well, paraphrases--me:
Although federal and state antipoverty programs were not limited to urban areas, they often failed to address the realities of the rural poor. The 1996 welfare overhaul put more city dwellers back to work, for example, but didn’t take into account the lack of public transportation and child care that made it difficult for people in small towns to hold down jobs, said Lisa Pruitt, a professor at the University of California, Davis School of Law.
To some extent, I'm referring to my 2007 article on how welfare reform was not a good fit for rural America because of poor transportation infrastructure and lack of child care, in addition to limited labor markets that leave few places for would-be welfare recipients to "work" (or even volunteer) to earn their TANF.

On the decline of the family (high divorce rates) in rural America, see this report from the NY Times in 2011.  

One other quote/nugget I gave journalist Adamy that she didn't use:  there has always been a rural underclass (think in terms of those widely thought of as "white trash"), and in this era of downward mobility, that underclass has drawn many more victims (a term I use advisedly) into its net.

And if you are not feeling empathetic and think it's those rural folks' own darn fault, consider this question:   How do you think you would fare if what you were facing were downward prospects for yourself and your children, less than you or your parents had?  It's not a situation most liberal/coastal elites face, and we have a hard time empathizing.  Indeed, we have a hard time responding with anything other than disdain.

(This story by Terrence McCoy in the Washington Post is something of a post-script to this WSJ story, coming one week after the latter and focusing on disability benefits).

Monday, May 22, 2017

New tack for getting rural kids to (better) colleges

Today's New York Times features this story, "Bringing the Dream of an Elite College to Rural Students."   It highlights College Advising Corps, a program that places recent college grads in public high schools to work full time for two years as college counselors, aiming to give "low-income rural students...a shot at the elite range of the American dream."

One of the counselors featured in Anemona Hartocollis's story is Emily Hadley, who is working in Hobbton High School in Newton Grove, North Carolina, population 569 (Sampson County, population 63,431).    Hadley, the story reports, seemed to one student "bizarrely interested in his future and pressed him to think beyond the confines of the sweet potato and hog farms."
Ms. Hadley, 23, a 2015 Duke graduate, said it was hard to make students see the value of a college degree when their parents relied on odd jobs, food stamps or disability benefits and they could improve the situation immediately by making $500 a week as field workers. “What happens in 10 years when your back gives out?” she tells them.
Hadley grew up in New Hampshire, and the story notes that she initially stood out because she did not speak "with the same Southern accent" nor "share[]an easygoing familiarity that [came] from having gone to the same schools and having spent their lives in the same county."  In short, she was an outsider, from "up North."

The story also features Nyreke Peters, a high school senior at Hobbton whom Hadley coaxed (and coached) into applying to Middlebury College in Vermont.  That's where Mr. Peters will be come this fall.  Previously, he had set his sights on the University of North Carolina, Chapel Hill.   Peters wrote his college essay about "what it would feel like to" return to his high school a decade on, as a Middlebury graduate.
He would tell the future Hobbton students that he used to worry that his friends would find out he had spent a summer “living in a hotel paid for by some government program that helped families who could not afford to pay rent.” 
Then he would add: “All I can say is look at where I stand. I am a college-educated man of color. I am a musician who composes music for high school bands because that’s where it all begins.”
For more on the rural-urban gap in the elite college sector, see here and here.

Wednesday, May 10, 2017

On "boosting" rural Colorado, apparently as a compromise

This from the Denver Post came across my Twitter feed about five minutes ago:

But when I clicked on the story, it took me several minutes to find the first mention of "rural" Colorado.  I found it when I got to this paragraph, the 14th paragraph of the story (OK, the paragraphs in newspapers tend to be brief ones):
The House passed the bill with wide bipartisan support on a 49-16 vote that sent the measure to Gov. John Hickenlooper, despite objections of a split Republican caucus torn between ideological objections and a desire to help members’ predominantly rural districts.
That paragraph was preceded by this one, which provides helpful context:
Earlier in the day, much of the debate in the House focused on Senate Bill 267, the far-reaching spending measure to boost payments to hospitals and schools; mortgage state buildings to generate $1.9 billion for transportation; increase pot taxes to the maximum 15 percent; give business owners a tax break; and increase Medicaid co-pays for the poor.
And it was followed by these:
The Republican opponents railed against the growth of Medicaid spending made possible through the hospital provider fee program and blasted the sheer reach of a bill, which they said violated a state requirement that legislation be tailored narrowly to a single subject. 
“I think we’re setting a pretty bad precedent, that we’re going to use words like ‘concerning Colorado’ in bills so that we can put everything and the kitchen sink in,” said Rep. Tim Leonard, R-Evergreen, a reference to the bill’s broad title, “Concerning the Sustainability of Rural Colorado.”
But the bill’s something-for-everyone scope was precisely what allowed it to pass the divided legislature, uniting rural Republicans with urban Democrats who said the benefits outweighed any misgivings they had about the measure.
Sounds like some purple state horse trading going on there at the close of the session.

In any event, labels and framing matter--or sometimes do.  So will "Concerning the Sustainability of Rural Colorado" appease rural voters.  And precisely what are the benefits to rural Colorado vis a vis urban Colorado?  Are rural folks merely getting a pro rata share or what?

Sunday, May 7, 2017

On abortion as "a free trip to the city" ... and having the last word

Last week, Alaska state representative David Eastman of Wasilla (a suburb of Anchorage, home of Sarah Palin), commented that some women "try to get pregnant to get a 'free trip to the city' for abortions."  He said this in the context of legislative debate about "abortions being covered by state funds and Medicaid."  Interesting because I'm not aware of any federal funds, which would include Medicaid, being available for abortion, as dictated by the Hyde Amendment.  In Alaska, however, state funds are apparently available, as this additional detail from the AP report explains.
The Alaska Supreme Court has held that the state must fund medically necessary abortions if it funds medically necessary services for others with financial needs.
How progressive of that high court.  This reminds me of one of the most knuckle-headed things a judge ever said about abortion access.
A woman in Alaska, for example, could be required to travel 800 miles to get to an abortion clinic merely because she lives in one place and the nearest abortion clinic is on the other side of the state. But that certainly doesn’t constitute anything even approaching an undue burden.
Interestingly, the judge who said this was Dee Benson (now a senior judge), and the case was Utah Women's Clinic v. Leavitt, 844 F. Supp. 1482 (D. Utah 1994) (discussed here).  Why the Utah judge thought it appropriate or necessary to use an example from Alaska is beyond me, but maybe he was looking for the most extreme example of distance he could find.  Given that Alaska is the largest state in terms of land area, Judge Benson necessarily turned to "The Last Frontier." In light of that point, it is perhaps significant that the second largest state, Texas, became the subject of the latest round of litigation over abortion restrictions, and that distance ultimately loomed so large in relation to the Supreme Court's assessment of the undue burden standard. Read more here and here.   

Speaking of distance and undue burdens also reminds me of a recent exchange between Prof. Carol Sanger of  Columbia Law and me regarding abortion and the significance of spatiality/geography/rurality regarding abortion access.  This is, of course, a topic I've been writing about for nearly a decade.  In the end, Sanger agrees that my plea for attention to rural women should be "the last word" in the exchange over Sanger's new book, About Abortion:  Terminating Pregnancy in the 21st Century, which says very little about the geography issue  (Sanger's "last word" phrasing is especially pleasing to me because my mother's nickname for me was "last word Lisa," an identity that may well have put me on the path to law school).

Sanger also includes some really interesting data on military women, who don't choose to be "rural," but who are assigned to bases in nonmetropolitan (or small metropolitan) places without ready access to abortion.  Sanger writes:
An amici brief,filed in Whole Woman’s Health on behalf of the Service Service Women’s Action Network And Retired Or Former Military Officers, explained that “the entire western half of the [Texas], covering over 130,000 square miles—in which five large military bases are located—would lack any abortion care providers at all.” If HB2 had remained in effect, the brief noted that service women at Goodfellow Air Force Base [San Angelo] would have a three hour drive to San Antonio, 199 miles away, and this is without the added difficulties of obtaining a pass, arranging a timely appointment, and finding the funds.
It's a sub-issue I had not not thought about amidst the many pages of my writing about spatiality in relation to abortion access.  But then I don't tend to think of military bases as "rural," located as they often are in small cities, in smaller metropolitan areas.  But when we look at what happened under Texas H.B. 2, women in places like Killeen (population about 150K)/Fort Hood certainly suffered serious detriments.  The sole abortion provider in Killeen closed after the Texas H.B. 2 admitting privileges requirement went into effect, a few months after the law's passage in 2013.  That closure left women on that massive Army base--the largest in the world in land area--forced to travel to either Austin or Dallas for abortion services.

But let me return to the issues raised by Eastman in Alaska, which are less about the burden of distance--which the state of Alaska has pragmatically taken care of--and more about the character of women.  The AP story, by Becky Bohrer, includes more helpful background for us on abortion availability in Alaska and--for late-term abortions--in Seattle, Washington.

First, here is more of what Eastman said:
We have folks who try to get pregnant in this state so that they can get a free trip to the city, and we have folks who want to carry their baby past the point of being able to have an abortion in this state so that they can have a free trip to Seattle.
Then Bohrer tells us more about the furor Eastman's comments have generated:
Eastman, who is a member of the House minority, made similar comments to another media outlet later.

In a speech on the House floor Friday, Democratic Rep. Neal Foster of Nome said Eastman’s comments were unacceptable and said he hoped Eastman would apologize.

“It shocks the conscience to think that a female in a village would want to endure the physical and the emotional pain of getting an abortion just so that they could get a free trip to Anchorage,” Foster said.

Most of the women who live in villages that Foster represents are Alaska Native and feel Eastman’s comments were directed toward them, Foster said. Many Alaska communities are not connected to a road system and smaller communities often have limited health services that necessitate travel to larger communities for care.

When asked if he felt he had anything he need to apologize for, Eastman said he would be glad to speak with Foster and “understand exactly what he’s getting at.”

Following the floor session, the House majority caucus distributed a letter to Eastman signed by Foster, House Speaker Bryce Edgmon and two other rural lawmakers, demanding a public apology. Rep. Geran Tarr, an Anchorage Democrat, said she may seek a motion to censure Eastman. She called Eastman’s comments “deeply offensive, racist in nature and misogynistic.”
Great to see other state legislators standing up for Alaska Natives and other rural populations.  That is encouraging.  And it also brings me to the really outrageous part of what Eastman said--that women might purposefully get pregnant so that they can have a day out on the town, a freebie trip to a place where they can get an abortion ... and then tie on some shopping or a fancy meal, maybe even a jaunt up the Space Needle.

This brings me back to Sanger's over-arching point in her new book:  women take abortion seriously--and we should presume they can make good decisions about it for themselves.  We should therefore not presume--as Eastman suggests--that they will get pregnant willy-nilly to "earn" a frolic in the city.  Insulting, misogynist and racist, indeed.

Friday, May 5, 2017

Literary Ruralism (Part XI): The Outsiders

This year marked the 50th anniversary of the publication of S.E. Hinton's The Outsiders, a coming-of-age novel set in Tulsa, Oklahoma, where two gangs, the Greasers (poor kids) and Socs (rich kids) have an ongoing rivalry.  The book was adapted for the big screen by Francis Ford Coppola in 1983, starring a number of heart throbs of the time, including Patrick Swayze, Rob Lowe, Leif Garrett, Tom Cruise, Matt Dillon, and C. Thomas Howell as Pony Boy.

The anniversary publicity prompted me to re-read the book--a staple of my own literary upbringing--with my own 'tween son.  In doing so, I was struck by a passage idealizing the rural.  Here, the book's central character, Ponyboy, is conversing with another "Greaser," Johnny about the nature of their lives when Pony boy lapses into a daydream about what his and his brothers' lives (Sodapop the middle son, Darry the eldest) would be like had their parents not perished prematurely:
"It seems like there’s gotta be someplace without greasers or Socs, with just people. Plain ordinary people.”

“Out of the big towns,” I said, lying back down. “In the country…”

In the country… I loved the country. I wanted to be out of towns and away from excitement. I only wanted to lie on my back under a tree and read a book or draw a picture, and not worry about being jumped or carrying a blade or ending up married to some scatterbrained broad with no sense. The country would be like that, I thought dreamily. I would have yeller cur dog, like I used to, and Sodapop could get Mickey Mouse back and ride in all the rodeos he wanted to, and Darry would lose that cold, hard look and be like he used to be, eight months ago, before Mom and Dad were killed. 
Since I was dreaming I brought Mom and Dad back to life… Mom could bake some more chocolate cakes and Dad would drive the pickup out early to feed the cattle. He would slap Darry on the back and tell him he was getting to be a man, a regular chip off the block, and they would be as close as they use to be. Maybe Johnny could come and live with us, and the gang could come out on weekends, and maybe Dallas would see that there was some good in the world after all, and Mom would talk to him and make him grin in spite of himself. “You’ve got quite a mom,” Dally use to say. “She knows the score.” She could talk to Dallas and kept him from getting into a lot of trouble. My mother was golden and beautiful …
It is interesting how this passage associates rurality and farm life with all things wholesome and good--and even a beautiful, golden mother.  But the book also includes a subsequent scene where Ponyboy basically acknowledges the downsides to country living, acknowledges that he was idealizing it.

Part of The Outsiders takes place outside Tulsa, in rural Windrixville, near Jay Mountain--both apparently fictitious place names.  Pony Boy and Johnny take refuge there in an abandoned church while evading law enforcement.  Some of the Windrixville residents they meet also arguably represent rural difference.   One Windrixville man focuses on the courage and goodness of  Pony Boy and Johnny after they risk their lives to rescue children from the burning church; he doesn't see the boys first as Greasers; he sees them first as heroes.  This surprises Pony Boy, who is accustomed to having adults pre-judge him based on class, generally seeing little worth in him as a consequence.

Very interesting to see this treatment of class from half a century ago, and to ponder how the ways in which we talk about class has changed--but also to know that class is still such an important organizing feature of our society, whether rural or urban.

Saturday, April 29, 2017

On Hillbilly Elegy ... and guest blogging class and rurality on a mainstream law blog

I'm a guest blogger over at Concurring Opinions this month, and I've so far written two posts on J.D. Vance's Hillbilly Elegy, a massive bestseller published in 2016.  You can read my posts here and here.  I'm expecting to write a few more about the book (with a continuing focus on the white working class, but with some attention to rural issues, too), as well as some posts about "rurality" so have a look from time to time.  I'll try to remember to post periodic links here, too.

Earlier this month, I participated in a Concurring Opinions book review symposium about Carol Sanger's new book, About Abortion (2017), and you can read my post, "Sanger's Tour de Force on Abortion (with a Blind Spot for Geography)" here.

Monday, April 24, 2017

Nurse practitioners join fight against opioid addictions by gaining ability to prescribe anti-addiction medication

Rural America is struggling with an opioid epidemic. Since 1999, opioid overdoses cause four times more deaths in America. In 2015, nearly 13,000 people died from heroin overdoses which were 20,6% more than in 2014. Although all states have experienced increases in opioid overdoses, states with large rural populations, like Kentucky, West Virginia, Alaska, and Oklahoma, have experienced disproportionately high increases. Various blog posts have recently discussed this issue (here, here, here, and here).

Unfortunately, there is a shortage of doctors in rural areas to treat this problem. In rural areas, the patient-to-primary care physician ratio is 39.8 physicians per 100,000 people. In urban areas, the ratio is 53.3 per 100,000 people. This shortage will only worsen after the United States Citizenship and Immigration Services made procedural changes to the temporary visas for skilled workers (H-1B visas) because rural areas depend heavily on foreign doctors. 

However, nurse practitioners may help to solve the shortage of doctors in rural areas. In 2012, 127,000 nurse practitioners provided patient care in the United States. Nurse practitioners are registered nurses who have also completed Master's degrees or other higher level nursing degrees. It takes much less time to become a nurse practitioner rather than a physician with an M.D. On average it takes six years of education and training to become a nurse practitioner and eleven to twelve years for a physician to complete their education and residency. Like physicians, nurse practitioners can hold hospital privileges, write prescriptions, specialize in certain practice ares. 

There are already significantly more nurse practitioners practicing in rural areas than physicians. There are 85.3 registered nurses per 10,000 rural residents compared to 13.1 physicians and surgeons per 10,000 rural residents. However, in many states, nurse practitioners cannot prescribe life-saving medication to opioid addicts.

This month two federal agencies gave over 700 nurse practitioners the ability to write prescriptions for buprenorphine to create broader access to the anti-addiction medication. In the United States, a federal licenses is required to prescribe buprenorphine. Buprenorphine is one of three anti-addiction medications approved by the FDA. It is a highly effective addiction treatment because it prevents withdrawal system and lessens cravings. The Comprehensive Addiction Treatment and Recovery Act passed in 2016 allows nurse practitioners and physician assistants to obtain federal licenses to prescribe buprenorphine. To obtain the license nurse practitioners must complete a 24-hour training and may only prescribe it to 30 patients a year. (Qualifying physicians may currently prescribe it to 275 patients a year).

Currently 28 states restrict nurse practioners' scope of practice by only letting them prescibe buprenorphine if they are working in collaboration with a doctor who has a federal license to prescribe it. However, 21.2 million people live in rural counties with no physician with a waiver for office-based physicians to prescribe buprenorphine. Of the total counties in the United States with no physician able to prescribe buprenorphine, 82.1% were in rural areas. In addition, Oklahoma, Tennessee, and Wyoming explicitly prohibit Nurse Practitioners from prescribing buprenorphine even if they are working with a licensed physician. 

Credit: Huffington Post

Some states recognize the potential positive impacts allowing nurse practitioenrs to prescribe buprenorphine. Oregon is currently updating its laws to allow nurse practitioners to prescribe buprenorphine for addiction. Currently nurse practitioners can prescribe Schedule III drugs like buprenorphine for pain management, but not for addiction treatment. In 2016, West Virgina changed its laws to allow nurse practitioners to prescribe all prescription drugs except Schedule II drugs (i.e., Percocet,  Vicadin, and OxyContin) without doctor supervision. West Virginia has a large rural population, a shortage of medical professionals, and the most overdose deaths in the country.

Hopefully, more states will follow Oregon and West Virginia's example and change their laws to allow nurse practitioners to prescribe buprenorphine. With the physician shortage and rise of opioid overdoses, rural areas can benefit from more medical professions having the ability to prescribe buprenorphine to treat addiction.

Saturday, April 22, 2017

Child Abuse Prevention (Part IV): Foster parent shortage in rural areas

As discussed in Part I, Part II, and Part III of this series, child abuse affects all communities, but the state's involvement can impact rural communities differently than urban ones. For more on one community's approach to this shortage, check out this earlier blog post.

A shortage of foster parents
Unfortunately, federal laws (such as the Fostering Connections to Success and Adoptions Act, Child and Family Services Improvement Act, etc.) do not address the fact that rural communities may have different needs than more urban communities. Rural areas are in desperate need of more foster and adoptive parents. All foster parents must be licensed and approved, must receive background checks and TB tests. Because all these processes need to be done and training usually spans over several days, maybe weeks, it is difficult for state workers to travel to a rural area to recruit and train just one or two prospective parents at a time. This leaves it to prospective foster parents in rural communities to step up and drive outside their communities, sometimes several times, to become approved as foster parents. For them to do that, they must first be aware of the opportunity to become foster parents, and state agencies are unable to recruit in rural communities effectively due to travel time and lack of resources. Some states have laws or funds established to address these challenges, but not all.

Rurality can create challenges for rural foster parents
This dynamic can create especially demanding circumstances for foster parents who are located in rural areas, or who are caring for a child who came from a rural or remote area. These volunteer caregivers are often asked to drive many hours and miles in order to help transport the child to family visits, court hearings, or doctor's appointments. Consider all the challenges that many rural families face: lack of connection with larger systems, lack of services, and a general lack of accessibility. Day-to-day caregiving activities may become more onerous. For example, one long-time foster parent living in rural Wisconsin said that the biggest issue that he faced was finding a dentist. Foster children are often covered under Medicaid, and it can be extremely challenging to find a dentist who will take Medicaid within a reasonable distance of the rural community where the child lives, so foster parents, or even social workers can end up driving hours to bring a child to see a dentist or other care provider. A social worker will always have to report to the dependency court about the child's health, which usually includes mandatory dental visits.

Children are impacted the most 
Foster parent scarcity heavily impacts children in foster care. One child welfare worker reported that in absence of enough high-quality foster placements in rural areas, and out of desparation a worker might place the child in a 'marginal' home that is available, possibly sacrificing things like consistent supervision or cleanliness. Additionally, while many other areas have "receiving homes" or emergency placements, many rural areas do not. (A 'receiving home' is a safe place where children who have just been removed from their families can stay until the social worker finds a more stable, sometimes long term foster placement. In many places places, such as San Francisco, this 'home' is staffed with people who are trained in crisis counseling for children.)

The shortage of foster homes in rural communities also means that children who are removed from their homes are much more likely to be moved from their communities and into different ones. Children who are already facing the trauma and fear that comes with being removed from their homes will be in a new place with a new school, likely far away from friends and relatives.

Kinship care
In recent years, federal and state lawmakers have facilitated a move toward kinship care: placing a child in the home of a relative caregiver in order to utilize the organic support systems that exist within families and minimize the trauma to a child by placing him or her in the care of a known caregiver. Federal law has kept up with this trend by enacting a law that requires "relative notification." Within 30 days after removal of a child, the social worker must conduct "due diligence" by identifying and notifying as many relatives as possible that the child has entered foster care. The hope is that a relative may want to offer a home to the child (or offer a permanent, safe, loving relationship in a different capacity).

This "due diligence" could be more difficult in rural communities if a  social worker is unable to access family members by phone, but I see it as a hopeful concept. Certainly, it comes with its own complications, mainly the lack of anonymity in rural areas. Depending on the type of abuse, a relative in the same community might not be able to protect a child from an abuser. Social workers might have less control and oversight in a community that tightly functions on its own if a child is placed in a nearby home and a social worker is stationed  somewhere else. Overall, increasing stability and familiarity where possible and minimizing the trauma of moving could make a big difference to a child. Though a commitment to kinship care may not relieve some of the challenges of the foster parent shortage and rural isolation, it might broaden the net of safe families where children can stay while caregivers work toward reunification.

Child Abuse Prevention (Part III) Reunification services in rural areas

Previous posts in this series (here and here) discussed some of the impacts that rurality has on the child abuse reporting and response systems. This installment will explore challenges that arise when families who live in rural areas attempt to reunify with their children who have been removed from their home and placed in foster care. I argue that rural parents involved in the foster care system face distinct barriers that make it especially challenging for them to comply with court orders and successfully reunify with their children.

When the CPS determines that a child is in danger if he or she remains in the home, a social worker will remove the child from the home and place him or her in another family's home temporarily.  Meanwhile, the child's parents or caregivers are charged with addressing the underlying problems that initially created the harm to the child. A child welfare worker creates a reunification plan that includes action steps that the parents must complete in order to have their child returned to their care. Reunification plans can include many different case-specific action steps, which may include: rehabilitation, anger management and parenting classes, or sometimes even a requirement that one parent move away from and stop contacting an abusive spouse. Generally, if the child is in foster care, the case plan will also outline a visitation schedule so that the child can maintain his or her relationship with the parents while in foster care. If the caregiver completes the reunification plan within the time allotted by the social worker, a dependency court must find that the danger to the child has subsided,  and then the child will be allowed to return home. If the case plan has not been completed, it may be up to the courts to decide whether to grant the caregivers more time to complete the case plan, taking into account arguments from parents, CPS, and child's counsel. State law controls the time periods that parents have to complete their case plans, and time limits usually vary with the child's age (see, eg, CA. Welf & Inst. Code 361.5)

While the foster care system impacts many many families in both rural and urban areas, rural families may face more difficulties completing their mandated case plans. In September 2015,  427,910 were children in foster care. fifty-five percent of these children stayed in foster care for over one year. In rural communities, it may take rural parents more time than their urban counterparts to comply with case plans because they have to travel to access the services that they are required to participate as part of their case plans. Sometimes, a specific program that has been mandated in a family's case plan is almost impossible to access for rural residents. Even judicial officers in rural places have reported that it is difficult to find educational and training programs to help them understand the realities that rural families face.

Sometimes, the very nature of rural life is held against parents in dependency court. Judges (sometimes outsiders to the communities come into their courtrooms) are tasked with discerning what placement or lifestyle decisions would be "in the best interest of the child."   Judges have scolded parents for living in an area that is isolated from services, expressing the concern that children may be isolated and not get the help or support they need. (See also: this article by Lisa Pruitt, beginning on page 175). In some courtrooms, a stereotype exists that urban children are more involved in school events and receive a higher quality education.

All this is to say: rural parents and caregivers who find themselves involved in the foster care system face significant barriers to reunification. Is the case plan system with mandatory participation in social services a one-size-fits-most approach that doesn't quite fit some rural communities? I shall return to the related issue of foster care placement in my next post.