Rural healthcare in the news (Part II)

It's the day after Mitch McConnell pulled BCRA (the Budget Care Reconciliation Act) from consideration, a decision prompted by the announcement of Senators Mike Lee of Utah (R) and Jerry Moran  (R) of Kansas that they would not support the bill.  Some pundits have noted that both Lee and Moran were elected in 2016 with comfortable margins, suggesting that they are lending cover to other more vulnerable Republicans who would be more reluctant to stand up to McConnell and Trump.  Others have noted that Moran was rare among Republican Senators in that he held town hall meetings with constituents during the recent summer recess.  I have not, however, seen folks talk about the rurality or urbanicity of Utah and Kansas.  I suspect that most are like me in that they think of Utah and Kansas as largely rural states.  In fact, both are highly urbanized, especially Utah, which is the 8th most urbanized state in the nation, with 90.58% of the population living in "urban" places, as that term is defined by the U.S. Census Bureau (population clusters of 2,500 or more).  As for Kansas, 74.2% of the population live in urban areas.  (Compare these figures with Maine, which is the least urbanized state, with 38.7% of the population living in cities, and with Mississippi, where just under half of the state's population are urban; ditto Montana).  I wonder, nevertheless, if a certain rural ethos or understanding or concern still dominates (or at least survives, persists) in states like Kansas and Utah--if the urban residents of these states still know lots of rural folks and care about the likely closure of rural hospitals that would have been wrought by the BCRA.  Might this have influenced Moran and Lee and even their urban constituents?

While I was in the midst of drafting the paragraph above, I got the push notification from the New York Times that three Senators have already declared that they will vote against McConnell's Plan C:  Repeal Obamacare now, but make the repeal effective only two years from now, which would give the Senate time to develop a replacement.  Those three Senators are all from states popularly thought of as rural:  Alaska, Maine and West Virginia.  Here's an excerpt from the story:

Senators Susan Collins of Maine, Shelley Moore Capito of West Virginia and Lisa Murkowski of Alaska, all Republicans, immediately declared they could not vote to repeal the Affordable Care Act without a replacement — enough to doom the effort before it could get any momentum.

For the record, 66% of Alaskans live in urban areas, but just 48.72% of West Virginia residents do.  Maine is the state with the highest percentage of rural residents, at nearly 39%, as noted above.

Claire McCaskill (D-Missouri), Shelley Moore Capito (R-West Virginia), Heidi Heitkamp (D-North Dakoa), Martin Heinrich (D-New Mexico), Ron Wyden (D-Oregon), Jeff Merkley (D-Oregon) (see image below from July 16) and Michael Bennet (D-Colorado) are among those I've seen expressing concerns about rural folks and rural hospitals as the vote on the BCRA has loomed.

As the headline for this post suggests, it is Part II of a short series on the attention rural people and places--and especially rural hospitals--have been getting since the U.S. House passed the AHCA and the U.S. Senate responded with the BCRA.  Part I is here.   Another such story is focused more on the rural doctor shortage, which it notes has not been part of the health care reform discussion.   Like the stories featured in my prior posts, this one is also from NPR, this time out of Bisbee, Arizona, a remote community (population 5,575) that lies some 70 miles south of Tucson and just about five miles north of the Mexican border.  The headline is especially interesting to me because it invokes a theme we've seen a lot post election--the fact (or at least assertion) that rural American has been forgotten.  It is "Doctor Shortage in Rural Arizona Provokes Another Crisis in 'Forgotten America.'"  The story provides some data that isn't very surprising for those of us who study rural:  By 2020, rural areas could be short 45,000 doctors by 2020, and those are conservative estimates according to some trade groups.  More than 70 rural hospitals have closed since 2010.

I find the story heavy on nostalgia as a reason we should care about places like Bisbee.  Kirk Siegler of NPR quotes the town's mayor, David Smith, who says many Bisbee residents are uninsured or rely on Medicaid.  He also says it's hard to recruit doctors because of the lack of amenities:

Among other things, this summer, the public pool is finally reopening. 

Still, there is no movie theater. There is only one grocery store left in town and no soccer fields. Little things like these can be a deal-breaker when it comes to recruiting new doctors and other professionals.

Siegler notes that this rural physician shortage isn't "even part of the health care debate in Washington right now." Smith sees the shortage as "part of a broader story of rural neglect" commenting that "Rural America is forgotten America."  And that leads into the nostalgic bit, again quoting Smith:  

Copper from Bisbee, Ariz., is what helped win World War I.  And yet, when we are in need, we are forgotten because it's not convenient — and because it's not a whole bunch of people here that are voters.

The CEO of the 14-bed Copper Queen Community Hospital notes the negative feedback loop in communities like his who are looking for physicians--physicians don't want to come because the pay is low, but the pay isn't going to get better and the amenities are not going to increase unless the local economy rebounds.  That's unlikely to happen because it wasn't diversified to begin with, hence the hard hit when copper ceased to be mined.  It's also hard to revitalize the economy in such a remote place.  The principal economic driver now is tourism, but that is largely seasonal.  Siegler also touches on the role of caps on visas for foreign-trained doctors, a source of physicians that communities like Bisbee have relied on in the past.  For now, the hospital is relying increasingly on telemedicine, including through the Mayo Clinic's Phoenix outpost.

All of this reminds me of another truth in relation to rural health care--well, rural services generally:  consolidation seems to be the name of the game.  Here's a June story from the Washington Post about how Planned Parenthood is closing clinics as services are increasingly consolidated.  With the most recent round of closures, Wyoming joins North Dakota as the only two states without a Planned Parenthood clinic.  

It'll be interesting to see, in the coming weeks, whether the GOP tries once more to repeal the Affordable Care Act and, if they do, what role rural people and their health care will play in this important policy discussion and decision making.