A spate of reporting on rural health care issues

Four feature stories on rural health care, three with compelling profiles of individuals, have come across my news feed in the past few days, so I decided to collect them here.  All of these stories are well worth reading in their entirety, and I'll acknowledge up front that this post won't do them justice in terms of complexity and nuance of the situations addressed.  This post also won't do justice to the incredible journeys of some of the health care providers and other care givers featured.  It also won't do justice to the atmospherics of each of these stories and the rural places on which they are centered.

It's hard to say which story is most tragic but I'll start with one that is a clear contender for that designation, Eli Saslow's report out of Poplar Bluff, Missouri on the high incidence of medical debt in that high poverty community.  Poplar Bluff, population 17,023, is the county seat of Butler County (population 43,000) in the southeast region of the state (near the bootheel).  Here's the lede, plus some in a story that depicts better than I've ever seen in the mainstream media the link between health care costs and poverty/bankruptcy.  

The people being sued arrived at the courthouse carrying their hospital bills, and they followed signs upstairs to a small courtroom labeled “Debt and Collections.” A 68-year-old wheeled her portable oxygen tank toward the first row. A nurse’s aide came in wearing scrubs after working a night shift. A teenager with an injured leg stood near the back wall and leaned against crutches.

By 9 a.m., more than two-dozen people were crowded into the room for what has become the busiest legal docket in rural Butler County. 

“Lots of medical cases again today,” the judge said, and then he called court into session for another weekly fight between a hospital and its patients, which neither side appears to be winning. 

So far this year, Poplar Bluff Regional Medical Center has filed more than 1,100 lawsuits for unpaid bills in a rural corner of Southeast Missouri, where emergency medical care has become a standoff between hospitals and patients who are both going broke.

Twenty-seven year-old Matthew McCormick is an attorney representing the hospital, which means he appears in a different county courthouse each day of the week for lawsuits against that county's residents who have received health care from Poplar Bluff Regional Medical Center.  On the day featured in Saslow's story, McCormick was representing the hospital in 19 cases worth $55,000 total against Butler County residents.  The facility treats 50,000 patients a year, and the cost of the uncompensated care it renders has risen from $84 million to $60 million in recent years.  The hospital is one of about 100 rural and suburban facilities owned by Community Health Systems, who stock price is now below $3/share, having dropped from $50/share in 2015.  Other interesting characters in this story include a self described "old hillbilly lawyer," Daniel Moore, who began a few years ago to take cases pro bono on behalf of those being sued by the medical center.  He has sometimes succeeded in cases that have gone to trial, in part by demonstrating the self-evident unfairness of the prices charged, e.g., $838 for a pregnancy test.

In buckling under bad debt, Poplar Bluff's hospital is not alone among rural facilities.  More than 100 have closed in the last 10 years and many others are on the brink of insolvency.  (A recent related story by Saslow, this one out of Oklahoma, is featured in this blog post).  Saslow notes what many of us already know:  "Unpaid medical bills are the leading cause of personal debt and bankruptcy in the United States according to credit reports."

Indeed, the story reminds me of what Elizabeth Warren found when she began to investigate the causes of bankruptcy several decades ago, as reported in the NYTimes Magazine a few months ago.  Another really interesting feature of this story is its depiction of the debt collector--the under-30 lawyer employed by the hospital to show up at these rural courtrooms and bargain literally every day with people who have not a dime to spare.  (Other relatively recent posts out of his corner of rural America are here and here, some of them based on reporting by the Washington Post.  Here is a post on the region as a high poverty one).

Next is this Bloomberg News piece out of Montana, "The State with the Highest Suicide Rate Desperately Needs Shrinks."  Monte Reel's story is set mostly in Glendive, Montana, population 4935, and the county seat of Dawson County, and it also refers to Glasgow, Montana, population 3319, and the county seat of Valley County.  Both are in the state's eastern section.  The face of this story is Dr. Joan Dickson, the founding director (2002) of the mental health unit of Glendive's Medical Center, an inspiring character who, as this story was being written, had taken a leave of absence to help care for an ill sibling in another state, leaving the unit abandoned.  Dickson,who is both a family practitioner and a psychiatrist, has a dual-specialty private practice in Glendive.  She also works part time for the Veterans Administration as a regional psychiatrist and she serves (for the nominal fee of $1/year) as medical director for Eastern Montana Community Mental Health Center, a network of clinics.

Here's an excerpt about the struggle for the unit in Glendive to hire and keep a psychiatrist, the only one between Bismark, North Dakota and Billings, Montana:  

Last fall, after years of fruitless recruiting drives and ad placements, the center finally snagged a recently graduated psychiatrist to oversee the unit. This spring, not long after the local newspaper celebrated her arrival, she quit. “I think maybe it was just a little too much for someone without experience to take on, and I don’t blame her,” says Shanks, who as marketing director is part of the recruitment team. “There’s such a huge need out here, and I can see the burnout in mental health providers that comes out of that.”

This echoes what young lawyers sometimes say about why they don't want to work in rural areas--they just don't feel competent enough not to have mentors around.

I also want to highlight this language from the an ad the local hospital ran seeking to attract a new psychiatrist:

Welcome to Glendive, Montana! Outdoor enthusiasts will thrill to almost limitless possibilities around Glendive. Imagine watching the Milky Way nightly and counting shooting stars as you fall asleep; quiet so deep you can hear your soul relax; hunting or just having a staring contest with wildlife. The Yellowstone River, the nation’s longest untamed river, starts in Yellowstone Park and flows through the heart of Glendive. It’s a great source of recreation, agate hunting, and paddlefishing … .”

This reflects the strategy I've often advocated for attracting young lawyers to rural areas rich in natural amenities:  lead with those outdoor amenities on the assumption that the persons you are likely to be successful in recruiting will one seeking such a lifestyle.

As for the need for mental health services in places like this, here are some data points:

• The national suicide rate has jumped 33% since 1999, and the spike has been sharpest in rural counties, 52%, compared to about 15% in urban areas.  
• Rural residents are twice as likely to commit suicide as urban residents. 
• The stressors include farm debt and diminishing farm incomes.  
• About two-thirds of all rural counties lack a psychiatrist, and about half lack a psychotherapist.  

The third recent story on rural health care is this Cal Matters report, "Paging More Doctors:  California's Worsening Physician Shortage" about the situation primarily in rural far northern California, between Sacramento and the Oregon state line.  It's set mostly in Bieber, California, population 312, which I've written about previously here and here, and features Bieber's local son--now aged 71--Daniel Dahle.  Here's the story's lede:

In a northern California valley stretching under miles of bright blue sky between two snowy volcanic peaks, Mt. Lassen and Mt. Shasta, Daniel Dahle is known as a godsend, a friend, a lifesaver, a companion until the end.

For more than three decades, “Doc” Dahle has been the physician in Bieber, serving a region about the size of five smaller U.S. states. When he started, he was one of five doctors in the region. Today he is joined by only one other full-time physician.

At 71, Dahle has delayed retirement for years — waiting for someone to take his place.

“I was going to retire November 8th of last year; it was going to be a third of a century,” he said. “It’s tough to recruit young new vibrant family practitioners or internists or pediatricians to come up here.”

Unfortunately, Dahle’s situation is not unique.

California is facing a growing shortage of primary care physicians, one that is already afflicting rural areas and low-income inner city areas, and is forecasted to impact millions of people within ten years. Not enough newly minted doctors are going into primary care, and a third of the doctors in the state are over 55 and looking to retire soon, according to a study by the Healthforce Center at UC-San Francisco.

The Washington Post ran this story, dateline Dover-Foxcroft, Maine (population 4213), last week.  It's not exactly about health care, but really about elder care.  An excerpt from Jeff Stein's story follows:

Across Maine, families ... are being hammered by two slow-moving demographic forces — the growth of the retirement population and a simultaneous decline in young workers — that have been exacerbated by a national worker shortage pushing up the cost of labor. The unemployment rate in Maine is 3.2 percent, below the national average of 3.7 percent. 

The disconnect between Maine’s aging population and its need for young workers to care for that population is expected to be mirrored in states throughout the country over the coming decade, demographic experts say. And that’s especially true in states with populations with fewer immigrants, who are disproportionately represented in many occupations serving the elderly, statistics show.

* * *

By 2026, Maine will be joined by more than 15 other states, according to Fitch Ratings, including Vermont and New Hampshire, Maine’s neighbors in the Northeast; Montana; Delaware; West Virginia; Wisconsin; and Pennsylvania. More than a dozen more will meet that criterion by 2030. 

Across the country, the number of seniors will grow by more than 40 million, approximately doubling between 2015 and 2050, while the population older than 85 will come close to tripling.

* * *

About one-third of Maine’s physicians are older than 60. In several rural counties in the state, close to half of the registered nurses are 55 or older and expected to retire or cut back their hours within a decade.

And here's a story, not explicitly oriented to rural but with clear spatial implications, about the use of telemedicine for the elderly.  Here's a rural healthcare story from the New York Times in July, 2018, which previously evaded me on the blog.  It includes brief anecdotes from rural health care providers from around the United States and Canada. 

Don't miss the new documentary out from Bullfrog Films, "The Providers," (as in healthcare providers) out of rural northern New Mexico.