Significance of rural votes in Colorado's 2014 gubernatorial general election.

Prior to the 2014 mid-term elections, earlier this month, reporter Jack Healy wrote an article in the New York Times projecting a tight governor’s race in the state of Colorado. The gubernatorial race pitted incumbent Gov. John W. Hickenlooper, a Democrat and former Mayor of Denver, against Bob Beauprez, a Republican and former congressman. This was the second time these two have faced each other in the race for Governor’s Mansion—Beauprez losing in the last match by 17 points.

The article explains that Republicans focused their efforts on distinguishing Beauprez’s stance from Hickenlooper’s on gun control, the death penalty, and hydraulic fracturing. Republicans believed that rural votes would pay an important role in this election, so they focused on these issues hoping to play off the differences between urban and rural Coloradoans. Reiterating Republicans’ focus on the importance of rural voters in this election Beauprez expressed, “Rural Colorado, I think, probably determines the outcome of this election.”

Well, Tuesday, November 4, 2014 came and Tuesday, November 4, 2014 went. Election results were tallied. CNN and Fox News reported on those tallied results. And when it was all said and done, Beauprez lost the gubernatorial race.

Beauprez was unable to oust incumbent Hickenlooper. The race was tight, but Beauprez lost. He won 46.2% of the votes, but Gov. Hickenlooper won 49.1%. Post-election, I was interested to see whether Republicans and Beauprez were correct in claiming that rural Colorado would “…I think, probably” determine the outcome of this gubernatorial race. Did Beauprez lose because he lost the rural vote? Or was the importance of the rural vote overhyped by Republicans?

To decipher the impact of rural votes, I will compare the Beauprez-Hickenlooper gubernatorial results to the Gardner-Udall senatorial results. These two races had similar facts, a Democratic incumbent challenged by a Republican, who had served in Congress, for a statewide seat. Despite the similar settings between the two races, the results differed drastically. While the Hickenlooper was reelected, Udall’s incumbency was terminated in a 2.5 point loss to Gardner.

In Colorado, there are 47 nonmetropolitan counties, according to US Census data. Of those 47 rural counties, in both races, Democratic candidates won the same 14 counties and Republican candidates won the same 33 counties. The margins of victory and number of votes won in those 14 democratic-leaning, rural counties were larger for Hickenlooper than Udall. For example, in Ouray County, both Hickenlooper and Udall won, but Hickenlooper acquired 53.6% (1,430 votes), while Udall won only 42.9% of the vote (1,145 votes). In the same county, Gardner lost by a smaller margin and won more votes than Beauprez did. Gardner won 45.9% of the vote (1,228), while Beauprez won only 42.9% (1,145 votes). The outcomes in all rural counties won by Democrats look the same: Hickenlooper obtain more votes than Udall; Gardner obtained more votes than Beauprez in their loss. When analyzing the 33 counties that Republican candidates won, the same occurs: Gardner obtains more votes than Beauprez, but in the county victory; Hickenlooper obtains more votes than Udall, but in a losing effort. Looking solely at rural counties, it might seem that rural votes did largely determine the gubernatorial race. However, that doesn’t appear to be the case because of what happened in the metropolitan counties.

In the metropolitan Mesa County, Republican candidates won. But like in the rural counties won by Republicans, Gardner won more votes than Beauprez did in the county victory (Gardner: 37,607 votes; Beauprez: 33,655 votes) and Hickenlooper won more votes than Udall did in the county loss(Hickenlooper: 18,969 votes; Udall: 14,639 votes). Additionally, Beauprez failed to win a metropolitan county that Gardner won, Jefferson County. Beauprez, also, gained fewer votes than Gardner gained in metropolitan counties that both Republican candidates lost (e.g., Denver County).

Thus, it seems as though rural or nonmetropolitan votes did not play as significant as role in the gubernatorial race as Republicans speculated. It seems as though had Beauprez gained more votes in metropolitan counties that he both won and lost, he might have been able to edge out Hickenlooper in the same way that Gardner beat Udall. So, it appears that Beauprez merely lost the race, hands down. Had he performed as well as Gardner did in the rural counties, he likely still would have lost because of his under-performance in metropolitan counties.

The presidential pardon power--Thanksgiving edition

According to article II, section 2 of the United States Constitution, the president has the “[p]ower to grant [r]eprieves and [p]ardons for [o]ffenses against the United States.”  Accordingly, those who have been convicted of federal crimes may petition the president through the Office of the Pardon Attorney at the U.S. Department of Justice. 

Seemingly, this authority to pardon federal criminals has been extended to turkeys.  Most turkeys have been privately executed each Thanksgiving season, but for at least the past half century, the president has pardoned one or two birds each year. 

On this year’s Thanksgiving eve, President Obama pardoned two turkeys.  Each bird was 20 weeks old and weighed 48 pounds.  One of the turkeys was named Mac, and the other was named Cheese. 

To most people, including myself, the turkey pardoning has merely been just another White House tradition that the president undertakes for the public.  Perhaps it is a tongue-and-cheek way of showing support for our nation’s agriculture, and more specifically, turkeys.   

The origin of this annual tradition is unclear.  Legend has it that the tradition began in 1863 during Lincoln’s presidency.  According to an official White House blogger, the story begins with Tad Lincoln who pled to his father to grant clemency for a turkey destined for the White House dining table.  In another legend captured by a New York Times article, Tad Lincoln named this lucky turkey “Jack”, which then became a “First Turkey”—that is, a pet that followed Tad around.   

From 1873, during President Grant’s term, a Rhode Island farmer named Horace Vose began sending turkeys to the White House every Thanksgiving, even though not all birds ended up on the dinner table.  However, since Vose continued this practice for the next quarter century, he earned himself publicity and established a new White House tradition.  Vose died by the start of World War I, which then prompted a wide range of individuals and organizations to send turkeys to the White House.   

The present day tradition has been somewhat consistent since 1947.  In 1947, President Truman hosted a photo-op for the turkey donated by the National Turkey Federation.  Since that Thanksgiving, the National Turkey Federation has provided turkeys to the president; this year’s event marked the 67th annual National Thanksgiving Turkey presentation.  

Although President Truman might have started an annual turkey presentation, the turkeys in this era were not pardoned, but were rather cooked for the president.  It wasn’t until 1963 when President Kennedy chose not to eat the turkey presented to him and returned it to its farm.  President Nixon did something similar by sending his turkeys to a local petting zoo. 

President George H.W. Bush was the first president to grant an official pardon to the White House turkey.  Ironically, upon release, one of the turkeys was sent to a park named “Frying Pan Park” in the outskirts of the Washington, D.C. metro area.   

Gone are the days where a private citizen like Vose can offer a turkey to the White House each Thanksgiving, as the White House does not currently accept perishable donations, such as food, for security reasons.   

If you want to eat a presidential turkey, though, you can do so by purchasing the Grand Champion brand turkey from Jaindl Farms, which is the Orefield, Penn. farm that has supplied the White House with turkeys for actual consumption for the past forty years.  

Happy holidays!

Souq day, the most important day of the week

The trucks arrive early in the morning, around 4:30 a.m. By 6 a.m. the dusty field in the middle of town is transformed into a small tent city. By 3 p.m. they will all be gone and the field will be littered with trash. It’s Sunday or what I call ‘souq’ day in Had Ait Mimoun. Had Ait Mimoun is a small village in Morocco. It was my home for two years while serving in the Peace Corps. I estimate the population to be around 1,000. However, on souq day the number easily swells to 2 or 3 times that.

Souq means marketplace in Arabic. It generally refers to an open-air market place. Imagine a swap meet/farmers market hybrid. You can buy anything and everything there, from groceries to clothes to household goods. The souq can be daily or weekly. There are even specialty souqs, where the entire marketplace is devoted to one kind of product like the spice souq in Marrakech. The weekly souq is the most common form. Vendors travel around a souq circuit in their respective regions and each village in the area has souq one day per week.

The souq is of tremendous importance to a village like Had Ait Mimoun. The souq is the only opportunity for villagers to buy fresh food. In Had Ait Mimoun, there are only three small stores called hanouts. A hanout is nothing more than a walk up window where you can buy staple items like milk, eggs, flour, oil, sugar, and tea. And the milk and eggs are not always guaranteed to be in stock. A weekly souq eliminates the hardship of travelling 30 kilometers to the nearest city to buy food and goods.

A key difference between shopping at a hanout and the souq is price. At the hanout, all the prices are fixed. There is no negotiating. At the souq, the prices are flexible and fluctuate with your bargaining skills. Prices are always negotiable. If you buy in bulk or all your produce from one vendor you can usually get a lower price. I witnessed people argue over price down to the half Dirham (1 Dirham = $.11). Five cents may not seem like a lot, but in Had Ait Mimoun every Dirham counts. Vendors even sell on credit. They keep a ledger of what is purchased, the price, and by whom.

A good majority of the villagers work in agriculture. By no coincidence payday is on souq day. On souq day the farm managers come to town with large wads of cash. The field workers seek them out one by one and get their money to live off for the next week. By days end most of that money is gone.

Souq day is about more than just shopping for food. It is an important day for community. It’s guaranteed that the whole village will be flooded visitors. Relatives visit with each other. Business deals are negotiated. The Sheriff comes to town. The normally vacant cafes in town are full of people chatting over a cup of tea or coffee.

I had a souq tradition. Every Sunday I would wake up early because my bedroom window was on the perimeter of the souq field. I would get up and buy sfinge. Sfinge is fried dough like a doughnut but without a sugary topping. Then I would go shopping with my host mother. I was always looking for the most outrageous thing I could find. The best souq find I made was a knockoff Dolce and Gabbana belt. It was thick white leather and had a gaudy belt buckle. The buckle was shiny chrome and in the shape of my initials DG in cursive font. After navigating the souq my host mother would make a large lunch and we would share it with friends and relatives.

I miss the souq. It is one of my fondest memories of Had Ait Mimoun. I forged good relationships from the vendors I shopped from. I spent a lot of time talking and visiting with people on souq day. Most of my cultural and language competence came from my experiences on souq day.

Souq:

Hanout:

Museums in rural America

From the Louvre in Paris, to the British Museum in London, to The Metropolitan Museum of Art, Guggenheim, and American Museum of Natural History in New York, I visit as many museums as I can whenever I vacation. Reflecting on my visits to my favorite museums, I realized they all have one thing in common: location. Many of the world-renowned museums are located in metropolitan cities. This realization compelled me to wonder: what about people who live in rural areas? Are they deprived of the culture and education that museums provide?

According to data from the Institute of Museum and Library Services, an independent government agency that counts the number and type of museums in this country, there are over 35,000 museums in the United States. Museums are defined broadly to include aquariums, arboretums, botanical gardens, art museums, children’s museums, general museums, historic houses and sites, history museums, nature centers, natural history and anthropology museums, planetariums, science and technology centers, specialized museums, and zoological parks. This comprehensive definition may help explain why the number of museums is so high. Although the places with the most museums are big cities, including Los Angeles, New York, Chicago, San Diego, and Washington D.C., rural areas are not devoid of museums. For example, Storey County, Nevada, population 3,942, has 11 museums. In fact, 43% of all museums are located in rural towns! For an interactive map of the museums all over the United States, click here.

Even though museums do exist in many rural areas, there are still many counties that do not contain any museums. Up to 175 counties, mostly in the South, do not contain any museums. One of the major reasons is a lack of funding. Unfortunately, funding is often a concern for current museums, too. Due to their location, museums in small, rural towns often have the fewest opportunities for funding or technical assistance, and they cannot afford to bring in the types of desirable exhibits that museums in bigger cities can afford. Because museums are important for a variety of reasons, including providing education and employing people in the community, keeping museum doors open is vital. Luckily, the Federation of State Humanities Councils and the Smithsonian InstitutionTraveling Exhibition Services understand the importance of keeping museums in rural America alive and have partnered together to create the Museum on Main Street (MOMS) program.

MOMS provides museums in rural areas with access to resources they wouldn’t otherwise have and helps them improve their current institutions. For example, MOMS circulates various Smithsonian exhibitions. Since 1994, they have served more than 900 communities with a median population of 8,000 in 46 states and Guam. Not only do rural museums benefit from the resources offered by MOMS, but the community is enriched with greater access to historical and cultural artifacts. To see if MOMS is coming to your area, click here.

Personally, I was happy to learn that museums are not limited to the bigger cities because every individual, no matter where they live, should have access to these educational opportunities. Next time you find yourself in a rural town, you should take the time to check out the local museum – you never know what you might learn!

Detention centers in the deportation equation

Immigrants awaiting deportation – whether refugees seeking asylum or green card holders with years of legal residence in the United States – are often incarcerated in detention centers located in remote areas throughout the country. The government’s use of rural, geographically isolated prisons is presumably an effort to prevent overcrowding in the large cities where most illegal “aliens” are arrested by ICE officers. However, the rural location of the detention centers has such blatant and devastating effects on deportation defense, that it is questionable whether the government doesn’t purposefully isolate immigrants facing deportation in order to make the removal process easier. 

Although I will briefly explain the terms “legal immigrant” and “illegal immigrant” as understood in the Immigration and Nationality Act (INA), I will not use the statute’s term “alien.” No human is an alien. I use the term “non-citizen.”

A legal immigrant is a non-citizen that has been admitted into the United States under the country’s immigration laws. Examples include legal permanent residents (“green card” holders) and temporary seasonal agricultural workers. An illegal immigrant is a non-citizen not admitted into the country through legal channels and without a documented legal status.   

Both groups are potentially vulnerable to removal through the deportation process. Unlike a defendant in the criminal system, a non-citizen does not have a right to counsel at a deportation trial. Often lacking basic English, a non-citizen may be pitted against the forces of the Department of Homeland Security’s team of attorneys. 

Locating immigration detention facilities in rural counties prejudices both legal and illegal immigrants because it impairs the ability to gather evidence for defense and limits access to legal counsel. 

A legal immigrant might qualify, for example, for Cancellation of Removal. That form of relief requires a redwood tree of paperwork and evidence. A successful Cancellation of Removal case often includes: written declarations from friends and family attesting to the non-citizen’s good moral character, proof of a clean criminal history from law enforcement, medical records, financial documents spanning back half a decade. A non-citizen held in a rural detention facility simply does not have access to those documents. The remote location makes it physically impossible to gather the necessary documents. Likewise, friends and family on the outside might have a difficult time traveling to the detention center to offer help with collecting the myriad of documents. 

To further illustrate the problem of an isolated detention center, consider the effect on legally complex cases. For example, an illegal immigrant might defend against deportation by asking for asylum. The United States has joined the humanitarian effort to allow non-citizens to stay when they show a well-founded fear of being persecuted if returned to their home country. The process is incredibility complicated and most people have small prospects of succeeding when they represent themselves. For example, in 2007, Human Rights Watch noted that represented asylum seekers were granted asylum at a rate of 45.6%, almost three times as high as the rate for those without legal counsel. A non-citizen held in a remote detention center simply does not have access to competent immigration attorneys that are found in larger cities like Los Angeles and New York. The Wickersham Commission observed that in “many cases” a lawyer acting for an alien would prevent a deportation “which would have been an injustice but which the alien herself would have been powerless to stop.” Although representation is clearly crucial, many non-citizens are represented by pro bono attorneys that simply cannot afford to travel to rural detention centers to help prepare a case. As Human Rights Watch laments, “[a]lmost invariably, there are fewer prospects for finding an attorney in the remote locations” where immigrants are detained.

Cesar Garcia Hernandez proposed a particularly innovative method to advocate for the rights of detained immigrants. Mr. Garcia Hernandez correctly noted that a non-citizen is not afford the protections of the Sixth Amendment, which includes right to legal counsel and right to a speedy trial, because they are not US citizens. However, Mr. Garcia Hernandez suggest that the governments process of detaining immigrants violations the Due Process Clause, which protects all regardless of legal status. A claim of Due Process violation, then, might effectively provide non-citizens with a legal remedy for the detrimental practice of detainment in rural locations.  

Whether the rural location of many detention centers is a pernicious strategy on the part of the government may be difficult to prove. Slowly the issue is gaining attention in the media and in the courts. In 2003, the Supreme Court recognized unconstitutional violations to Due Process that may occur from the government’s power to “detain, transfer, and isolate aliens away from their lawyers, witnesses, and evidence.” Let’s hope that recognition can serve as a spring board for immigration reform.

It’s okay to be a LGBT student in rural America – or is it?

The lesbian, gay, bisexual, and transgender (LGBT) community has made great strides in the last decade. Although some aspects may be improving, such as marriage equality, young people who identify as LGBT are still suffering in a big way: bullying and harassment in school. According to a study from the Gay, Lesbian and Straight Education Network (GLSEN), rural and small town schools pose the greatest threat for LGBT students.

GLSEN’s study documented the experiences of more than 2,300 LGBT students, ages 13-20, who attend schools in rural areas. This in-depth examination uncovered many significant challenges for these students. For example, 81% of students in rural schools reported feeling unsafe in school because of their sexual orientation or gender expression; students in the South and Midwest felt the most unsafe. Eighty-seven percent of students reported being verbally harassed, 45% reported being physically harassed, and 22% reported being physically assaulted at school in the past year because of their sexual orientation. Most rural youth reported that such incidents were not effectively addressed by school staff; only 13% of rural LGBT students said that school personnel intervened when they heard homophobic remarks, while 11% said school personnel intervened when they heard negative remarks related to gender expression.

Many LGBT students cope with bullying and harassment by taking steps that ultimately affect their academic performance. For example, 53% of LGBT students who experienced a high level of verbal harassment reported skipping classes or missing school to avoid hostile school environments. Those students who experienced high levels of harassment and assault had significantly lower grade point averages (2.9 versus 3.2) and lower college aspirations.

Faculty and students can do several things to counter bullying and harassment in rural schools. For example, school administration can implement comprehensive anti-bullying policies. Although forty-nine states already have anti-bullying laws, attaining funding for bullying prevention programs is often troublesome for schools, so schools fail to implement required policies and programs. Additionally, many state laws have lax standards and/or do not have a clear definition of which types of behavior and what situations constitute bullying. To truly help LGBT students in rural areas, faculty and administration need to hold themselves accountable to state laws, and possibly even create more extensive policies within their own schools. Schools can also create curriculum that includes lessons about LGBT people and issues (such as California, which requires public schools to teach students about the contributions of lesbian,gay, bisexual and transgender Americans), and support student clubs, such as Gay-Straight Alliances. Students in rural schools have reported that these kinds of resources provide higher levels of feeling belonging and lower levels of victimization.

Reducing bullying and harassment may be a challenging task, especially in rural schools that may have fewer resources. Luckily, organizations exist that are dedicated to helping LGBT students. For example, Outright Vermont is an organization that has worked with LGBT youth since 1989. Although they generally work in both urban and rural areas of Vermont, they have recently teamed up with the Department of Justice on a special three-year project that is designed to reduce bullying in Vermont’s rural communities, such as Bennington, Caledonia, Essex, Lamoille, Orange, Orleans, Windham, and Windsor counties. Outright Vermont helps LGBT students in rural areas by training faculty and staff on LGBT issues, expanding the network of Gay-Straight Alliances and support groups, and providing anti-bullying training and resources. In addition to organizations like Outright Vermont, there are also online resources such as GLSEN. In short, even schools in rural communities who may have more limited resources than their urban counterparts can reach out to various organizations to help LGBT students.

Although the LGBT experience seems to slowly be getting better in rural areas due to national campaigns and new regulations (see posts here and here), bullying and harassment is still a problem. LGBT students in rural communities tend to suffer more than students in suburban and urban areas, and these problems must be addressed. By tackling these issues, faulty and school administrators can help remove barriers to academic success and emotional well-being for LGBT students.

Domestic violence and seeking help in rural communities

We often hear about the isolation of rural America as one of the defining features of rurality. In particular, the social isolation of rural America cuts off its residents from important resources and opportunities, from meaningful access to the political process to access to health care. This geographic and social isolation, and the resulting concerns about confidentiality in small communities can be especially problematic for women who are victims of domestic abuse. Rural women may hesitate to seek services anonymity. This isolation and limited resources can further entrap these women in their violent relationships. More than one-third of women in rural areas will be victimized by an intimate partner. However, domestic violence and sexual assault services are primarily concentrated in urban and suburban areas. As a result, in many parts of the country it is not unusual for victims to be forced to drive several hours, or even fly out, to obtain victim services.

The geographic isolation experienced by many rural families limits the opportunities for the identification of and timely intervention to domestic violence. There are often large expanses of land that separate one family home from another, and sometimes these distances are also spanned by mountains or impassable waterways. Coercion through deprivation and isolation are common tools used by abusers to maintain their power over the victim, and these problems are only exacerbated in rural areas. In Alaska for example, there have been a number of instances where abusive partners have relocated their families to remote communities to isolate them from the support of their friends and families. With the wintry climate of Alaska, victims are often held hostage in their own homes with no winter clothing or means of escaping their extreme isolation.

In addition, public transportation can be very limited or non-existent in rural areas. Families may not have access to an automobile or may only have one vehicle that is not available to all members of the family. And aside from the problem of transportation, reliable telephone service can also be expensive in certain regions due to the topography and geography of some areas, and as a result many rural families do not have telephones in their homes. This sort of rural isolation decreases the opportunities for the identification of an abusive situation as violent incidences are less like to be witnessed by objective parties and as it boosts the abuser’s ability to prevent a victim’s escape. It is not uncommon for rural victims to report that their abuser controlled the access to any vehicles, refused to allow the victim to learn to drive, or disabled any existing telephone system.

Women in rural areas are much less likely than urban women to have credit in their own name, personal savings, individual checking accounts, or control over their own earnings. Rural women overwhelmingly report economic reasons, such as limited job opportunities, lack of available housing, insufficient child care resources, as barriers to leaving their abusers. Although economic conditions vary across rural communities, persistent poverty is common, particularly in the southeast, southwest and Appalachian region and rural economics are generally unfavorable to women

Unique aspects of rural life, such as distance from victim services, the close-knit nature of rural communities, and the scarcity of employment and educational opportunities make it difficult for victims of domestic violence and sexual assault to report the abuse, leave abusive relationships, and seek services. This paints a bleak picture of rural areas that are typically seen as warm, safe and inviting in contrast to the violent and unwelcoming urban spaces.

Rural public education faces many obstacles far beyond insufficient funding

Recently the South Carolina Supreme Court ruled in favor of rural schools in a 21-year long court battle over education funding. While the South Carolina Supreme Court requires actions from the state legislature, they do not provide explicity parameters on what action is required. They must simply submit their plan to the justices within “reasonable time.”

This ruling provides South Carolina with a prime opportunity to address the shortfalls of the rural public education system – an issue that goes far beyond simply increasing funding. Not only do rural public schools experience problems similar to those of low-income, inner-city public schools, but they have a whole set of different issues specific to the fact that they are located in rural places. Moreover, this issue reaches far beyond South Carolina, and is an issue faced by many rural communities across America.

Rural communities often face teacher shortages. According to an article published in Education Week, 10 to 15 percent of teachers in rural communities are not licensed to teach the subjects they are teaching. This includes math, sciences, languages, and special education. Additionally, in some states, tenure laws and job protections make it difficult to fire teachers after just two years of being in the classroom, regardless of their performance. And even if states don’t have such protections, the shortage of teachers in rural areas makes it difficult to find a replacement, period.

Additionally, the lack of public transportation in rural communities makes it difficult for students to get to school, especially because of the expansiveness of rural space. Many schools are not located near student's homes, their families may not own a car, and effective school bus systems can be scarce. Moreover, it is not uncommon for states to charge public school students to ride the bus -- an additional burden for economically disadvantaged rural families. The Education Week article illustrate this issue through the story of a 17-year old boy named Raymond who lived in the Arkansas Delta and went to school fairly far from his home:

On stifling-hot days, he had a 10-minute walk down a rutted dirt path to the main road, where he caught the school bus. On days when the rain poured down, the ruts in the dirt path converged into an insurmountable river. Even if Raymond could have forded the river, odds were good the bus wouldn't make it down the main road anyway. Raymond couldn't ask his grandparents for a ride; they didn't have a car.

Finally, the school-to-prison-pipeline, traditionally seen as problematic for low-income, urban schools, is an issue facing rural communities, too. This refers to the phenomenon of pushing disadvantaged kids out of school and into the American justice system. The geography of rural communities makes it difficult for juvenile offenders to have access to rehabilitation and diversion programs because they are scarce and often widely dispersed. Thus, as pointed out by the Marshall Project, judges will sentences kids to detention facilities because they have treatment on-site.  Additionally, many rural states take an aggressive approach to minor infractions, such as school fights, truancy, violations of probation, and alcohol consumption. Moreover, mental health and substance abuse programs are often so far away, that rural youth cannot access them; as a result, rural youth experience high rates of incarceration.  

“Code Blue”: Medicare reimbursement reform needed to save the life of rural hospitals.

The healthcare industry has undergone drastic reforms over the last few years. It has been strained by inflating costs and pressed with questions about the Affordable Care Act’s implementation and future. Few hospitals and patients are immune from these stressors. Rural hospitals have been impacted especially hard. The hardships that rural hospitals face are largely a byproduct of the special Medicare rules for rural hospitals. These rules substantially differ from that of urban and suburban hospitals. 


Rural areas typically have hospitals that are categorized as “critical access” hospitals. Critical access hospitals are much smaller than their urban counterparts. These hospitals can have no more than 25 inpatient beds, they must maintain an annual average length of stay of no more than 96 hours, and they have to be a minimum 35 miles from the next nearest hospital.


Certification as a critical access hospital allows that hospital to receive cost-based reimbursement from Medicare, as opposed to the flat rate reimbursement that non-critical access hospitals typically receive. Medicare requires that a patient pay 20 percent of the amount that the critical access hospital charges. Patients also pay 20 percent coinsurance at non-critical access hospitals, however that 20 percent is based on the amount Medicare reimburses, which is typically significantly lower than what the hospital charges.


This reimbursement structure stresses both the critical access hospital and the rural Medicare patient. For example, in 2012, when a Medicare patient received an electrocardiogram at a rural critical access hospital, they owed an average of $33 for that procedure. Patients at other, more urban hospitals would only have had to pay about $5. According to a recent report by the inspector general at the Department of Health and Human Services, many Medicare beneficiaries who received treatment at these rural critical access hospitals have ended up paying between two to six times more for services than patients non-critical access hospitals.


When interviewed on this topic, Eric Draime, chief financial officer for Avita Health Systems, stated that this difference is not the rural hospitals' fault. "Critical access hospitals don't charge more. They charge less, but the way Medicare developed the system, the enrollee ends up footing more of the bill," CFO Draime said.


To make matters worse, the rural population is not only paying more, but their hospitals are closing due to this payment structure. USA Today recently reported on these closures, stating: “[l]ow Medicare and Medicaid reimbursements hurt these hospitals more than others because it's how most of their patients are insured, if they are at all.”

Thus, the costs that the rural population is currently facing is not only financial, but the cost in the length of time that it takes to get to the next nearest hospital post critical access hospital closure. In another USA Today report, this issue was shockingly addressed in the case of a man who had a stroke and, because of the closure of his local critical access hospital, had to be ambulanced for nearly 40 minutes to the county’s urban hospital. 

The inspector general’s office has advised that Congress change the law so that a Medicare beneficiary’s financial responsibility better reflects the cost of the service. Brock Slabach, a senior vice president at the National Rural Health Association, said that “[t]he reason this hasn’t been solved is it would require the Medicare program to subsidize more. . . .” 

In addition to reconfiguring the reimbursement aspect of Medicare, Congress should mandate that the 23 states that refuse to participate in the Medicaid expansion do so. Without reform, more hospitals will close, cost will continue to rise, and rural Americans will bear the burden of the very program intended to help them.