Friday, June 14, 2019

Two big stories on rural schools, poverty and drugs

EdSource recently published this story out of Oroville, California (population 15,000, and county seat of Butte County, California, population 220,000) and the New York Times yesterday published this story out of Minford, Ohio, (population 693).  

The EdSource headline is "Lost days: Poverty, isolation drive students away from school in California’s rural districts:  The state's highest rates of chronic absenteeism are in rural areas."  The story is about chronic absenteeism, a term used to refer to students who miss at least 10% of school days.  About 11% of California students--some 700K in all--are chronically absent, and about 10% of the state's 1000 districts had rates of chronic absenteeism as high as Oroville's.  Here are some data points:

  • Of the 98 districts with rates higher than 20 percent, 84 were in rural areas.
  • Of the 27 districts with rates higher than 30 percent, 26 were in rural areas.
  • Of the 40 counties where rates were above the statewide average, 30 are rural as identified by Rural County Representatives of California, a statewide group.

The story does not, however, define "rural," and Oroville is not "rural" by the U.S. Census Bureau definition, and Butte County is not "nonmetropolitan" by the Office of Management and Budget standard.

The story's lede personalizes the data.  It features Kaylee Adkins, now 20: 
The daughter of two heavy drug users, [Kaylee] lived a transient childhood — rarely staying for long in the same apartment, let alone the same school. She hardly saw her father who was in jail or prison throughout much of her childhood.
* * * 
When Kaylee, now 20, was in grade school, her mother’s pattern was to stay in a place until the eviction notice came, then run. Sometimes it would be to another part of Oroville, a rural town of about 15,000 people in Northern California’s Butte County where her family was from. Other times it would be out of state to small towns in Texas or West Virginia.
As you can see, the story is not only about absenteeism.  It is about the constellation of social problems that contribute to it, including poverty, drugs, housing challenges, and sheer distance.  Indeed, perhaps because I'm researching rural housing--really the rural housing crisis--right now, eviction looms large for me in this story. 

But the story is also about "family commitments."  You see, Kaylee's parents both died when she was in high school, so she wound up living with a niece after that.  But when her niece had children, Kaylee was expected to miss school to care for them.  So Kaylee wound up missing about a third of the days of her senior year of high school--even though she was living just a few blocks from the school in Oroville. 

Interestingly, the other story from EdSource that I've blogged about also featured Oroville.   That story was about high rates of school suspensions in rural schools, framed as the school-to-prison pipeline.  And I as I wrote there, one reason for that high rate of suspensions is likely a lack of resources because smaller school districts can't achieve economies of scale.  So I was pleased to see that this story on chronic absenteeism quotes an expert who acknowledges that rural challenge problem. 
[I]n rural areas they have the fewest resources and the least access to the newest information about how to combat this.
The second story, the one by the New York Times out of southern Ohio, focuses on younger children.  The headline is "Inside the Elementary School Where Drug Addiction Sets the Curriculum."  About half of the students in the featured elementary school have experienced drug abuse at home.  As with the California story, the journalist (here Dan Levin), leads with a student who illustrates the phenomenon:   
Inside an elementary school classroom decorated with colorful floor mats, art supplies and building blocks, a little boy named Riley talked quietly with a teacher about how he had watched his mother take “knockout pills” and had seen his father shoot up “a thousand times.” 
Riley, who is 9 years old, described how he had often been left alone to care for his baby brother while his parents were somewhere else getting high. Beginning when he was about 5, he would heat up meals of fries, chicken nuggets and spaghetti rings in the microwave for himself and his brother, he said. “That was all I knew how to make,” Riley said. 
Riley — who is in foster care and who officials asked not be fully identified because of his age — is among hundreds of students enrolled in the local school district who have witnessed drug use at home. Like many of his classmates at Minford Elementary School, Riley struggles with behavioral and psychological problems that make it difficult to focus, school officials said, let alone absorb lessons.
Levin details the Minford program, funded with $550 million in "student wellness funds" from the State of Ohio. 

Minford is in Scioto County, population 79,499,  "long considered ground zero in Ohio's opioid epidemic."  Some 9.7 million pills were prescribed here in 2010, "enough to give 123 to each resident."   The poverty rate in Scioto County is 23.9%.   When I "Googled" Scioto County, Ohio, the top "hits" were news stories about abused children and drug arrests.  Oh, and there was a story about the state reviewing 2700 cases decided by a recently retired Scioto County judge accused of alcoholism

Thursday, June 13, 2019

The end of a story that's gotten a lot of attention on Legal Ruralism: $6.2 million settlement closes industrial hog farm in my home county

I have spilled a lot of (proverbial) ink on this concentrated animal feeding operation (CAFO) story since 2013, when I wrote posts like this one (and note its two prior embedded posts) about an industrial hog farm that slipped by regulators to get a permit for siting in the watershed of Arkansas's Buffalo National River, a major tourist attraction and ecotourism revenue driver for the state.  These events happened in my "own backyard" (or at least that of my mom, as I no longer liver in Arkansas), which helps my explain my engagement (and outrage).  Never mind the many blog posts about the "hog farm" here on Legal Ruralism, I even wrote an academic journal article about this matter, as well as an op-ed in the Arkansas Democrat-Gazette.

I hadn't been following the matter very closely in recent months, though I knew the industrial hog farm owners, under contract with JBS of Brazil, had lost some recent legal bouts with environmental interests over renewal of permits, including permits for where they could spread the hog manure.

So, imagine my delight when the (Republican) governor of Arkansas, Asa Hutchinson, made what has been billed as a "surprise" announcement that the State of Arkansas had reached a settlement to pay the owners of the hog farm $6.2 million to close the operation and grant the State of Arkansas a conservation easement.  The owners of the hog farm will retain a "fee simple" in the farmland, which sits right on the banks of Big Creek (a Buffalo River tributary), and across that creek from the Mt. Judea School.  Most of the funds going to the buyout will come from the state's coffers, but up to a million will be paid by The Nature Conservancy.

Perhaps most interesting is that Governor Hutchinson commented today, when announcing the settlement while speaking to the 85th Annual Arkansas Municipal League Convention, commented  the permit to the CAFO should never have been granted.  That's a dig at his Democratic predecessor, Mike Beebe, on whose watch the permit slipped (or was pushed?) through the Arkansas Department of Environmental Quality.  I've never quite been able to figure out (and as far as I know, no one else has either), whether the primary culprit was an ignorant bureaucrat or one on the take from corporate or business interests.  When the hog farm was built--essentially in secrecy--the farmers were to be under contract with Cargill, but Cargill's hog operations were eventually sold to JBS.   As I detailed in my academic journal article, the USDA approved loans for the hog farm, but it did so with a particularly shoddy environmental impact statement that did not acknowledge environmental justice concerns (Mt. Judea is the poorest part of a persistent poverty county, Newton County).

Here's a quote about what's next, from today's coverage in the Arkansas Democrat-Gazette, as well as some early backlash against the settlement.
In the recent legislative session, the Farm Bureau narrowly failed in a push to remove hog farm regulation from the Arkansas Department of Environmental Quality and move it to an agency where local farmers have strong influence and without less scientific expertise. The governor had urged a delay in that legislation after it passed the Senate. It was pulled down after it ran into House opposition
Opponents had developed a scathing attack on the hog triangle created by the farm: The farm sends dollars to Brazil (JBS); JBS sends pork chops to China, the farm sends hog manure to the Buffalo River. 
It’s a big win for the governor, though some social media criticism has already broken out about the $6.2 million payment. “Negotiating with terrorists,” was how one environmentalist put it.
And here's Governor Hutchison's Tweet about the matter.

The one commenter on that Tweet said, "More of that Republican Socialism.  It's only bad when they're helping the poor."   Hutchinson has drawn national attention to Arkansas for his advocacy and imposition of work requirements for safety net programs, such as the state's Medicaid expansion.  

Wednesday, June 12, 2019

In the competition between rural and urban for resources, this pretty much sums it up

The media (Sac Bee and New York Times) have given lots of attention in recent days to the just-revealed cause of the Ranch Fire, one of the fires in the Mendocino Complex that led to the largest wildfire in California's history last summer.  The fire burned through chunks of Lake, Mendocino, and Colusa counties in late summer 2018, destroying more than 150 homes.  Fighting it cost "tens of millions of dollars."  Here's an excerpt (from the NYT story) about the fire generally:
The fire burned 410,203 acres of California wild lands, an area half the size of Rhode Island, and killed a firefighter who was struck by a falling tree. Although it was one of the largest fires, it was far from the deadliest. The fire in Paradise, Calif., in fall 2018 killed more than 80 people.
There's a lot of "rural" in the story, especially if you associate buried wasps nests with rurality, but it was this quote from Jill Cowan, writing in today's New York Times California newsletter, that really caught my eye re rural-urban difference and--more precisely--urban primacy.  Cowan quotes a neighbor (Ms. Parker) of the man who inadvertently started the Ranch fire.  She lives along Highway 20 between Ukiah and Upper Lake: 
Ms. Parker shrugged as she described how Caltrans allows vegetation to proliferate along the side of the highway in front of her house.  
“We are in a rural area,” she said. “Cities are always going to come first.”
By the way, the dateline for the NYTimes story is Potter Valley, population 646.  (I passed near there and took some photos along this stretch of Highway 20 in early July, 2018, a few weeks before that fire).  And the photo caption for the NYT story mentions Ladoga, population 197 (in Colusa County).

As for urban primacy in pretty much all things, see a related post here.  

On access to transportation and health (and jobs, poverty and disability) in rural America

NPR reports today from upstate New York on the intersection of disability, rurality, poverty, and employment, with something of a focus on transportation as another feature of that cycle of poverty.  Here's the excerpt I wish to highlight: 
Having good access to transportation — or not — has a huge impact on the health of people living in rural parts of the country, says Dr. Kirsten Bibbins-Domingo, a professor of epidemiology and biostatistics at the University of California, San Francisco who studies the health of vulnerable populations. 
The story, by Selena Simmons-Duffin, quotes Bibbins-Domingo: 
If you go to less populated areas — rural areas — access to a car that functions well [and] the costs for gas becomes such an essential element.  Both to drive to seek medical care, as well as to drive to access the other resources that are necessary to pursue good health. 
Simmons-Duffin goes on to quote Bill Erickson of Cornell re: employability of people with disabilities.
Since the Great Recession, rural counties really haven't seen as much employment growth as urban counties. Also just the types of jobs that are available to those sorts of communities may be tending toward, you know, requiring people to be able to move things physically or whatever. 
And the limitations that the individual with disabilities may have may be preventing them from being able to do those particular types of jobs — or employers can't provide the accommodations that may be necessary.
On that latter point, see this excellent NPR story from 2013.   

Saturday, June 8, 2019

A story of rural extremes, out of Scotland

NPR's Celeste Noche reports today from the Outer Hebrides of Scotland, a remote region in the northwest of the United Kingdom.  This lovely feature story, with fabulous photos, provides a window into extremely remote rural living by focusing on the importance of what, in the United States, we call a bookmobile.  Here's the lede:
In Stornoway, the biggest town in Scotland's Outer Hebrides islands, a yellow van sits on a narrow, one-way street. The Gaelic word leabharlann is painted on the front, back and sides, with its English translation, "library," on the front and sides. 
Driver Iain Mackenzie has loaded his books in the van, organized his customers' orders and is preparing for his last run of the week on the island of Lewis and Harris. The 16-year-old van runs three days a week, covering more than 800 miles of rugged roads to deliver books to more than 800 residents.
Many of the residents featured in the story are elderly and/or disabled, but the story also touches on the importance of the mobile library for serving children and youth, including with efforts to keep the Gaelic language alive.

The broader context, of course, is population loss:
As rural high streets — the centers of local businesses — begin to disappear, and schools, jobs and other opportunities have seeped away to large cities, villages across the isles are facing depopulation and a decrease in resources. A 2007 Outer Hebrides Migration Study reported a 43% population decline between 1901 and 2001, as well as a long-term decline in the number of women of childbearing age, resulting in more deaths than births each year. "The key drivers of population change are the limited job opportunities available," the study said.
Noche explains that, under salient U.K. ecological definitions, "73% of the Hebridean population qualifies as very rural remote, defined as 'areas with a population of less than 3,000 people, and with a drive time of over 60 minutes to a settlement of 10,000 or more.'"  Stornaway, the largest population cluster on the Outer Hebrides, is home to some 8,000 residents. 

One of the mobile librarians, Steven Bryden, who is quoted throughout the story, touches on the lack of anonymity that marks rural communities, while also defying that stereotype.
There's a perception in [small villages] where everybody knows everybody, but it isn't always the case.  There are a lot of people on their own who are just missed. It's just keeping an eye out on people.
Bryden also comments on the extreme loneliness of living so remotely: 
A man in the [Harris] bays once told me, "The last person I saw was you."
This reminds me of another recent story out of a remote corner of the United Kingdom, the Lake District, a story that also featured many elderly.  I blogged about that story here.  Like this story from the Outer Hebrides, the Lake District story also implicated services for remote populations, but the English story was one of services lost to austerity policies, while the Scottish story was one of a service preserved (two new library vans to serve the islands and save the service).

Friday, June 7, 2019

North Carolina and Virginia take steps to address rural broadband

I have written fairly extensively in the past about the barriers imposed by lack of access to broadband infrastructure in rural spaces. Broadband is almost essential for economic growth and for helping to bridge the resource gap. Access to broadband opens doors, it allows students in isolated communities to enroll in courses that may not be offered at their local school, a farmer to have a new market to sell his crops, and in a world where broadband is a necessity, rural communities to successfully compete with their urban and suburban counterparts. Unfortunately for many people, mostly in rural areas, access to broadband is still an impossible dream. I have written in the past about New York's attempts to address this article. In this piece, I am going to talk about the work of North Carolina and Virginia, who have both recently taken steps to address this problem.

In Virginia, it is estimated that 600,000 people, roughly the population of Vermont, lack access to broadband. According to the Virginia Charter of Commerce, this represents roughly 47% of rural Virginia. This means that a sizable number of rural Virginians live in communities that do not have access to broadband infrastructure, a significant barrier to economic growth. In fact, according to Evan Feinman, Virginia's Chief Broadband Officer, many companies will disregard an entire community if they do not have access to broadband.

This issue also affects North Carolina. While North Carolina does not have an official number for how many in the state lack access to broadband, they do believe that the current figure of 93.7% of households having access is inaccurate and inflated. Both states have a shared problem however, the telecom providers are not playing ball on telling them exactly where the gaps are, which hinders their ability to address the issue.

Despite the existing barriers however, both states are persisting in their battle to expand access. North Carolina governor Roy Cooper recently signed legislation overturning the ban on electric coops using federal funding to expand broadband access. The legislation also clarified that it is legal for coops to use fiber that had been deployed to provide electricity for the secondary purpose of providing broadband service. In Virginia. Governor Ralph Northam signed legislation that created a pilot program that would allow electric utilities to utilize their infrastructure for middle mile deployment of broadband infrastructure. Northam and Cooper have also signed legislation that would appropriate funding to providers to expand their broadband infrastructure into rural spaces. By signing legislation that involves providers in the expansion of broadband, both governors may have created a mechanism for getting information on where the gaps exist and provided a means to address them. I would argue however that both states need to commission independent studies into broadband availability in order to reduce the reliance on providers to give information about gaps.

Addressing the broadband issue is going to important for rural Virginia and North Carolina. Northern Virginia and the Research Triangle are both tech hubs and a lack of broadband availability prevents that economic prosperity from spilling over into the rural corners of these states. I am encouraged by the progress that both states have made in recent months and hope to see it continue.

Thursday, June 6, 2019

A historical nugget: Great Depression era Yale Law graduates opted for rural practice

During a dive into some historical research, I came across an interesting nugget in The Boston Globe. In the October 24, 1932 edition of the newspaper (see right), it was reported that an increasing number of Yale Law graduates were opting for rural practice. The story attributes this partially to a decline in corporate recruiting, a fact that should not be surprising given that the country was struggling through the Great Depression at the time. The article is interesting because it provides a snapshot into a different era of rural lawyering and an era when lawyers began looking away from cities.

The article also notes that the role of the "country lawyer" in leadership, as opposed to the urban lawyer who seemingly just accumulated great wealth. While this is a slight simplification, it does speak to the historical role of the lawyer as a leader in their community. In a city, a lawyer is just another professional whereas in a smaller town, they may be one of just a few. As I have heard from rural lawyers in my research, a rural lawyer is rarely ever off the clock. The lack of anonymity in a rural community often does not allow for a rural lawyer to clock out and simply go home.

On April 23, 1891, over 41 years before the publication of this piece, the Globe reported on the retirement of Judge John Hopkins from the bench in Worcester County, Massachusetts. In his retirement speech, Judge Hopkins said, "I know of no position more honorable than a country lawyer and no position in which a lawyer can be of more use to his fellow man."

In 1932, Yale Law sent its graduates out to take that position. I aspire to see that happen again.

Wednesday, June 5, 2019

Rural California wins one (a rarity) in special election

Calfiornia's most rural politician has just defeated an urban (or, at best, suburban) politician for State Senate District 1.  The winner is not college educated.  The loser has a Bachelors degree from Harvard and a J.D. from Yale Law School.  Brian Dahle, the winner, has been mentioned in five prior blog posts here, one of them mentioning the occasion of his visit to my Law and Rural Livelihoods class several years ago.   Dahle garnered 53.4 % of the vote, and  his Ivy-educated opponent just 46.6%  One striking fact is that Dahle carried every nonmtro county by a considerable margin, while Kiley carried every metropolitian county--except Shasta County, the least metro of the metros, in the would-be State of Jefferson, which I'll discuss below.

As I have written elsewhere, it's hard to gain traction on rural issues in California because only about 2% of the state's population live in rural places, at least as "rural" is defined (admittedly, narrowly) by the U.S. Census Bureau (population clusters of less than 2,500 or open territory).  That trend was defied a few days ago when Brian Dahle of Lassen County (population 34,895, population density 7.39/square mile) defeated Kevin Kiley of Placer County (population 348,432, population density 230/square mile) to become California's newest State Senator.  Just as telling in terms of where these candidates come from spatially and culturally, Dahle is a seed farmer from Bieber, California, population 312.  (While Bieber is in Lassen County, it is on State Hwy 299, in the corner that connects Shasta County to very sparsely populated Modoc County, which may say something about the Shasta County vote; see below).  Kiley lives in the Placer County suburb of Rocklin.

District 1 includes all or part of 11 California counties and stretches from north Lake Tahoe to the Oregon state line.  Among the counties included in the district are all or parts of four metropolitan counties, including Sacramento County (1.4 million), Placer County (population 348.432), El Dorado County (population 181,058), and (much farther north), Shasta County, (population 177,223).

The California Secretary of State's page about this special election is here.  The Sacramento Bee's minimal coverage of the election is here.  The Redding Record Searchlight's coverage is here.  The Lassen County Times is here, though I was unable to click through to a story about the election, which might have been interesting since Dahle served on the Lassen County Board of Supervisors for 16 years before he was elected to the California General Assembly.

Here are the (approximate) votes (and population counts) for the Senate District's nonmetropolitan counties:

Lassen County, population 34,895: Dahle got 81.5% of the 4,000 votes.
Alpine County, population 1,175Dahle got 73.5% of the 223 votes.
Sierra County, population 3,240: Dahle got 67.2% of the 860 votes.
Plumas County, population 20,007: Dahle got 65.7% of the 4,400 votes.
Modoc County, population 9,686Dahle got 87.1% of the 1,857 votes.
Siskiyou County, population 44,900: Dahle got 69.7% of the 7,331 votes.
Nevada County, population 98,764Dahle got 67.1% of the 15,000 votes.

And here are the votes for the metropolitan counties--well, parts of some of those counties:

Sacramento County (partial 10.2%):  Kiley got 71.8% of about 21,000 votes.
Placer County (partial, 62.9%): Kiley got 60.8% of 38,000 votes
El Dorado County (all):  Kiley got 56% of about 31,000 votes.
Shasta County (all):  Dahle got 82.2% of about 28,000 votes.

The prior State Senator for this district was Ted Gaines, who lives in El Dorado Hills, a posh suburb/exurb of Sacramento, just over the Sacramento/El Dorado County line.  Thus, the election of Dahle, the seed farmer with a high school education, is quite a shift culturally and experientially.

In the run up to this run off, some controversies about the Senate District 1 election were reported in the Bee here and here.  Regarding the former, I can't help wonder if the lack of anonymity associated with rural people and places played a role in its possible efficacy (leaving aside, for now, the very dodgy ethics) of the mailer threatening to disclose folks' voting records.  The latter story describes how these two Republicans (Dahle and Kiley) were the top two vote getters in the primary, while the Democrat, a woman from the Truckee/Lake Tahoe area, came in third. Needless to say, it's a conservative district.

Cross-posted to Working Class Whites and the Law

Monday, June 3, 2019

New Mexico forms working group to address rural lawyer shortage

Law 360 reports today on an initiative out of New Mexico that seeks to respond to the rural lawyer shortage there, as well as to the lack of affordability of legal counsel to those who might be considered "middle class."  Here's the lede:
Twenty-one percent of New Mexico’s counties have five or fewer lawyers, and two counties have no attorneys at all. These legal deserts, a huge access to justice barrier, have forced the state court system to take a hard look at possible solutions.
* * * 
District Judge Donna Mowrer, who oversees courts in two counties that have just 58 total attorneys for a combined population of nearly 70,000 people, told Law360 that the inspiration for the idea came from Washington, which has allowed limited license legal technicians, or LLLTs, to help low-income litigants in family law disputes since 2015.
Mowrer sits in in the Ninth Judicial District, in Portales, New Mexico, population 12,280, not far from the larger and better known Clovis, population 38,962.  Together, the counties for which these cities are the seats, Roosevelt and Curry, respectively, are home to 70,000 people and 58 attorneys, which is not a bad ratio.  Some other data points in the story are more sobering: 

  • one county has no lawyer (but a journalist from that county will serve on the working group)
  • 51 percent of newly filed civil cases in 2018 had at least one party without an attorney, up significantly from 2011, when pro se litigants appeared in just 36% of civil cases.

Interestingly, the New Mexico judiciary seems to be viewing favorably a program to license paralegals.  The program they are looking to as a model, however, has not been terribly successful in Washington State, where it has been running for the past few years.  At best, only tepid success was reported to the California Commission on Access to Justice when we considered a few years ago the Washington program, which licenses "limited license legal technicians."  One big problem with the Washington program:  the state's law schools are unwilling or unable to divert (from the education of JD students) the resources necessary to support the training of the LLLTs.  In Washington, LLLTs are licensed to handle family law matters.  Utah recently adopted a similar program, and there the para-professionals handle only landlord-tenant and debt collection matters. 

Mowrer also commented on the access-to-justice challenge for middle-income and modest means clients, saying that "a key selling point is the notion that firms can actually have LLLTs in their offices to accommodate those who can’t afford a traditional counsel." 
She also pointed out that firms need not be limited by geographic area. Being based in a city like Albuquerque won’t necessarily prevent a firm from hiring a technician in a rural area.
* * * 
We don’t have extra attorneys in the rural areas, and we’ve seemingly priced even the middle class out of an attorney.
Given the relative lack of success of the Washington program (at least as presented to the Cal Commission on Access to Justice a few years ago), it'll be interesting to see how Utah's program fares and where the New Mexico working group goes.   

Thursday, May 30, 2019

When rural and urban compete for resources

That's the scenario at stake in the proposal of the Centers for Medicare and Medicaid Services  to shift some reimbursement funds to rural hospitals.  Because the pot of money is (apparently) fixed, this is a zero sum game, meaning that urban hospitals will lose what/if rural ones gain.  Bloomberg Law reports this morning under the headline, "Rural Hospitals See $200 Million Medicare Win at Cities' Expense."  Here's the lede from Tony Pugh's story:
Low-wage rural hospitals would see more than $200 million a year in additional Medicare payments under a Trump administration plan to shift money from urban hospitals in areas with higher wages, a leading health-care law firm found. 
The proposal by the Centers for Medicare & Medicaid Services is designed to cut payment disparities between urban hospitals and rural facilities. Rural clinics and hospitals are struggling in many states that haven’t expanded eligibility for Medicaid under the Affordable Care Act. 
Since the proposed rule was published earlier this month, "hospital associations in states with higher concentrations of urban facilities" have been protesting.  Pugh cites the analysis of the Hall Render law firm, which shows, for example, that California's Medicare payments would be reduced by $108 million annually.  Other big losers would be New York ($41 million); Massachusetts ($19 million) and New Jersey ($18 million).  Southern states stand to gain most, presumably because the South is the most rural region in the nation.  The reductions would be phased in, taking full effect in 2021.

Sarah Jane Tribble, covering the same issue for NPR, provides an illustration of the "wage index," which has been around since the 1980s. 
[It] means under the current index a rural community hospital could receive a Medicare payment of about $4,000 to treat someone with pneumonia while an urban hospital received nearly $6,000 for the same case, according to CMS.
They "why" for the shift is hinted at in the article's opening line:  the wages paid by rural hospitals are lower than those at their urban counterparts, and Medicare reimbursements have typically been pegged to an "area wage index."  This has meant rural hospitals with low local labor costs have typically received lower Medicare payments than urban ones, albeit for rendering the same services.  A related story on NPR, by Sarah Jane Tribble, is here.

I'm very sympathetic to the needs of rural hospitals, and I'll be fascinated to see if this proposal goes into effect because I've never seen a proposal that takes from the urban (rich?) and gives to the rural (poor?) implemented--at least I cannot recall such a circumstance.  For example, since it was published in 2010, I have been pondering the careful word choice of the California Commission on Access to Justice Report, "Improving Access to Civil Justice in Rural California," framed to avoid a rural-urban contest for funding streams.  Here's a quote of one of the key recommendations from that report:
2.  Expand Funding for Rural Legal Services The significant lack of funding for California’s rural legal aid programs must be addressed. All legal aid programs face the challenge of inadequate resources, including programs in urban as well as in rural areas; therefore any initiative to address the severe lack of resources in rural areas should not be developed in a way that unnecessarily undermines urban programs. The goal is to increase the total resources available for all legal services programs across the state, not merely to reallocate existing resources. 
In fact, what has happened in the years since that report was published is that per "poor person" funding for legal aid organizations serving rural populations has fallen relative to that for organizations serving urban populations.  This just emphasizes again how hard it is for rural institutions to get their "fair share" of funding in all sorts of contexts.

Maybe this Robin Hood-like move at CMR will go forward, however, at least if the Trump administration sees it as currying favor with the president's rural "base." 

Tuesday, May 28, 2019

Suddenly, (small-scale) farming is hip everywhere (including the developing world)

An alternate headline might have been:  African millennials follow in the footsteps of their US counterparts (or might it be the other way around?).  In any event, the catalyst for this post is Sarah Maslin Nir's New York Times story, dateline Agotime Beh, Ghana, "Millennials 'Make Farming Sexy' in Africa, Where Tilling the Soil Once Meant Shame."  Here's the lede:
After he graduated from university, Vozbeth Kofi Azumah was reluctant to tell anyone — even his mother — what he planned to do for a living. 
“I’m a farmer,” he said, buzzing his motorcycle between freshly plowed fields on a recent afternoon. “Here, that’s an embarrassment.” 
In some parts of the world, farmers are viewed with respect and cultivating the land is seen as an honorable trade. But in a region where most agriculture is still for subsistence — relying on cutlass, hoe and a hope for rain — farming is a synonym for poverty.

But Mr. Azumah is among a growing number of young, college-educated Africans fighting the stigma by seeking to professionalize farming.
The entire story is well worth a read.  An interesting factoid:  60% of Africa's population is under the age of 24, but the average age of a farmer is 60.  This trend is similar to that in the US, where farmers are a rapidly aging group.  Seems like that might be changing, albeit slowly, on both continents; at least one can hope.