Tuesday, January 31, 2017

Voting for change: Why rural America found hope in Trump

The morning after Donald Trump was named President-elect, many Americans, myself included, found themselves asking the same question: Who voted for Donald Trump? Following the election, BBC published statistics aptly named "Reality Check: Who voted for Donald Trump?"Donald Trump won the rural vote by significant numbers (62% to Secretary Clinton's 34%). Regardless of what the statistics tell us about who (else) voted for Donald Trump, rural America has been getting a lot of attention (and blame) for the surprising election results.

Recent headlines describe Trump's victory as revenge of the rural voter and call Americans to shame "dumb" Trump supporters. Such an overgeneralization of the election results paints rural America in a petty, spiteful, and uneducated light. At the same time, people across the nation have responded to Trump's success with genuine interest in understanding the rural vote. Productive dialogue is seen through the many, many, many on-line forums exploring the reasons why rural America voted for Trump.

An op-ed recently published in the New York Times gained traction by addressing the question, "Who are these rural, red-county people who brought Mr. Trump into power?" This is an important question. The op-ed's author, Robert Leonard, concluded that Republicans and Democrats fail to agree on issues such as gun control, regulations, and social justice because they live in "different philosophical worlds, with different foundational principles." Ending his piece, Leonard concluded that:
Rural conservatives feel that their world is under siege, and that Democrats are an enemy to be feared and loathed. Given the philosophical premises . . .  presented as the difference between Democrats and Republicans, reconciliation seems a long way off.
Nothing is accomplished by villainizing the other side, regardless of which side one stands on. Rather than focusing on philosophical issues that Republicans and Democrats are unlikely to agree upon whether they live in rural or urban areas, it is more productive to approach the question of why rural Americans voted for Trump by addressing the legitimacy of their concerns and the problems they face in their communities. 

Commenting on the widening urban-rural divide in the 2016 election, Katherine Cramer, Professor of political science at the University of Wisconsin described "rural resentment" in an interview with NPR
[Rural Americans] feel like their communities are dying, and they perceive that all that stuff — the young people, the money, the livelihood — is going somewhere, and it's going to the cities.
Now, there is a sentiment most can empathize with. Rural Americans watch lawmakers spend billions of dollars on improving urban infrastructure while rural towns die. As my friend, Willie Stein, pointed out in his previous blog post, Trump's campaign capitalized on painting a "portrait of a hobbled and deeply troubled America." There is no surprise as to why such a campaign strategy resonated with rural Americans given the decaying nature of many rural communities.

With his nod to President Reagan's campaign, Donald Trump used his presidential campaign to call Americans to action. Commentators maintain that "Make America Great Again" proved to be a successful slogan as it evoked an emotional response to better times for hard-working Americans in the United States. 

But does nostalgia for the Reagan Administration make sense in the context of rural America? Many remember President Reagan's era as "Mourning In America." During Reagan's presidency, homelessness became a fact of life in many cities and towns across the country, even reaching rural areas. Moreover, while the rich continued to get richer, the wages of average workers fell nationally, increasing the wage divide.

A recent piece on The Washington Post, featuring the small town Wilmington, Ohio, addressed why Trump's campaign sparked hope in rural America. Eight years ago, Wilmington suffered a devastating blow when DHL shipping left, taking more than seven thousand jobs with it. 

Michael O'Machearly, a former DHL bus driver, described the impact the loss of jobs had on his community: 
There are people in this town that went through divorces because of it. That lost their homes because of it. . . . Our downtown used to be this precious place--it died . . . . My bank account usually has five bucks in it . . . I'm making my house payments--maybe just barely, but I'm making my house payments. . . I'm doing okay, but I do understand not everyone had that opportunity. 
While politicians have praised America's economic comeback, Wilmington didn't feel it--they continued to struggle. When Donald Trump visited the town, twice during his campaign, promising to bring jobs back to the people of Wilmington, that mattered. 

Josh Sams, a Veteran and resident of Wilmington, returned home from combat to a different town. He said, "You come back and it's kinda run down. There isn't the cash flow to maintain the everyday things you take for granted." Noting the success of Trump's campaign in his community, Sams stated: "That make American slogan kinda sticks out here, you know, to try to get the town back back to where it was." 

Whether or not President Trump will follow through on his promises to the people of Wilmington (or the nation), it's easy to see why people in rural communities latched onto his campaign promises with optimism. While Secretary Clinton campaigned to build on the Obama Administration, Donald Trump proposed change and action. When you live day to day with five dollars in your bank account watching the home you knew and loved disappear, it's understandable why you might take a chance on change. 

Sunday, January 29, 2017

Obamacare (ACA) in Trump Country

Obamacare has dominated headlines since its enactment in 2010, and the controversies surrounding it seem to only keep growing. Health care, more specifically Obamacare, was a very important voting issue in the divisive 2016 election According to a PEW report, 74% of registered voters cited health care as a very important issue to them. But only 37% of registered voters thought Trump would do a better job of dealing with health care. Ironically, the states with the most people signing up for health insurance under Obamacare voted for Trump in the 2016 presidential election. These states included: Florida, with 1.3 million sign ups; Texas, with 776,000, North Carolina, with 369,077; Georgia, with 352,000; and Pennsylvania, with 290,950.

Rural America experienced the highest rates of coverage gains through Obamacare. The Urban Institute's Health Reform Monitoring Survey found that coverage for rural individuals between June 2013 and March 2015 increased by 7.2%. If Obamacare was so good for rural America, why did rural America support Trump in such overwhelming numbers when he promised to repeal it? Because as a previous post put it, rural America loves and hates Obamacare, and nobody actually believed he would do it.

Vox recently interviewed residents of a rural county in Southeastern Kentucky about their feelings towards Obamacare and Trump. Whitely County Kentucky, like many rural regions, overwhelming supported Trump; 82% voted for him. Whitley County has a median per capita income of $16,748, is 97% white, and 88% of the residents don't have a college degree. In the three years since the passing of Obamacare, the percentage of the population with insurance rose from 75% to 90%. Like other lower-income, less-educated white Americans, Whitley County benefitted disproportionately from Obamacare. However, these residents like many other Americans are unhappy with Obamacare because of the unaffordable premiums and deductibles. But Whitely County residents had a nearly uniform belief that Trump, as a business man, would not entirely repeal Obamacare and leave millions without health insurance. They believed Trump would instead come up with a more affordable alternative. They were frustrated with the current law and willing to take a gamble on a new law under a new administration.

Rural voters, like those in Whitley County, are right to be frustrated with Obamacare because it wasn’t tailored to help rural people and address their specific needs. Under Obamacare, health care is more integrated, moving away from fee-for-service and towards coordinated care and value-based models which link payment to patient outcomes. This new model created accountable care organizations (ACOs) that allow groups of hospitals and doctors to work together to provide coordinated care to patients while being paid through bundled payments. But this value-driven model doesn't translate well to rural areas. It requires a clinically integrated network, financial alignment and integration of providers, and team-based care delivery, which all require large investments of money, time, and human capital. The shift to value-based health care is more difficult in rural areas, because they often have scarce resources, limited providers, small populations, and greater potential exposure to financial losses from poor risk management. Rural areas require payment reform models tailored to the special circumstances of rural providers and health systems, which Obamacare isn't providing.

Rural health insurance marketplaces are also facing higher-than-expected costs because rural populations are much sicker than anyone expected. For example, patients enrolled in the West Virginia insurance exchanges were 88% more likely to have heart disease, 69% more likely to have high blood pressure, and 110% more likely to have kidney disease, compared to non-exchange patients. As discussed in a previous blog post rural Americans, especially women, are experiencing large increases in death rates. From 1990 to 2014, women's mortality rose in most parts of the U.S. but rural areas were some of the hardest hit. In 21 rural counties across the South and Midwest the mortality rate doubled, or worse, for middle-aged women.

Multiple factors are converging to produce this rise in mortality rates. First, the epidemic of heroin and opioid overdoses has been particularly devastating on rural areas. Heavy drinking is also a major issue in rural areas and the number of rural middle-aged white women dying from cirrhosis of the liver doubled since the end of the 20th century. The suicide rate also recently doubled for rural white women between the ages of 50 and 54. Finally, obesity is contributing to a myriad of health problems for rural women like liver disease, diabetes, heart attacks, and strokes. The Washington Post found that these high white mortality rates correlated to voting for Trump and that "in every state except Massachusetts, the counties with the highest rates of white mortality were the same counties that turned out to vote for Trump."

Rural counties are also experiencing disproportioantely higher rates of insurer drop outs compared to urban areas, which is contributing to rising health care costs. In 2016, the number of rural counties with only one insurer nearly quadrupled. In 2017, almost one third of rural counties will have only one insurer compared with 19.6 percent of urban counties. But rural areas have long struggled to attract insurers because of their small populations and low concentrations of hospitals and doctors, which make it hard to compete with urban areas. The marketplaces established under Obamacare were intended to solve this problem by creating a new online platform to more easily reach individuals. However, insurers are still dropping out of marketplaces around the country. Obamacare cannot be solely blamed for the lack of competition in these rural coverage regions, or rating areas.

Poorly drawn rating areas are contributing to rising health care costs in rural areas. Under Obamacare, states define their own rating areas which are used by insurers to set rates and premiums. The prices vary by rating area depending on how sick the population of the area is estimated to be and insurer competition. This rating can be problematic if only rural areas make up a rating area, because as discussed above rural areas are sicker than the general population. In 2014, a team of Stanford researchers found that if states combined rural areas with nearby urban areas in a single rating area that rural areas saw an average of 0.6 to 0.8 more insurers and significantly lower premiums. The bundling of rural and urban areas also led to an average decrease in annual benchmark premiums of between $200 and $300 in rural areas.

These issues with Obamacare and the resultant rising health care costs are problematic in rural areas, so it's understandable why these areas were so desperate for a chance to shake up the system. Nevertheless, I anticipate they will be sorely disappointed, especially if Obamacare is repealed without a replacement, and millions lose insurance coverage.

Fewer children, more brain drain

"Brain drain" in the context of the United States is a phenomenon best described as the loss of educated individuals from rural areas, either for career purposes or to obtain higher education unavailable in a small town. Several years ago, an important study on the causes and effects of brain drain was discussed on this blog. In the time since that 2009 study, the problem has certainly not dissipated. Why? I posit that one important factor is the milllenial generation reaching child-rearing age, but instead exercising their choice to forego children in increasingly higher numbers.

A report released recently by the Urban Institute tells us that American women are now reproducing at the slowest rate in U.S. history:
 The decline in twenty-something fertility affects young women across races and ethnicities (figure 1). From 2007 to 2012, Hispanics experienced the largest decline in birth rates, 26 percent (from 1,570 to 1,158), followed by a decline of 14 percent for non-Hispanic blacks (from 1,216 to 1,046) and 11 percent for non-Hispanic whites (from 976 to 866).
 Fewer children means fewer opportunities for rural communities to grow and flourish. Oftentimes, rural communities can count on those former residents--who left the community to "spread their wings" in pursuit of education or career in more urban or suburban areas--to return when it comes time to raise children. There is certainly a recognized idealistic view of rural communities as being "a good place to raise a family." If raising a family is no longer part of the equation, perhaps returning to your roots becomes significantly less appealing as well.

One study by the University of Wisconsin found that young professionals under the age of 40 prioritize safe streets, place for family, and public schools in spots as their first, second, and fourth most important considerations, respectively. These factors take precedence over scenic beauty, a sense of community, and even proximity to friends and family. Those factors are also inherently dependent on a choice to have children; without children, it appears millennials are finding very few persuasive reasons to return.

As a millennial myself, I find it freeing and exhilarating to live in a time of increased reproductive choice and options that challenge the traditional family structure. With that being said, I do often face tough questions from my own relatives and primary school classmates who stayed behind in the rural town I grew up in. My decision not to return to my small hometown was tough, and I know many have found themselves in the same boat. The decision not to have children is, of course, highly personal and requires a lot of thoughtful introspection, but as we see more and more milllenials choosing to forego children, I believe we will see a nearly proportionate corresponding reduction in hometown-returners.

Saturday, January 28, 2017

Sacramento-San Joaquin Delta people amid water wars

The Sacramento-San Joaquin Delta is a region where two of California’s largest rivers naturally meet and feed into the San Francisco Bay. The network of creeks, tributaries, and irrigation channels from the Sacramento and San Joaquin Rivers provide water to about 25 million people, well over half the state’s population.

Amid anthropogenic climate change and natural weather fluctuations, demands on the water running through the Delta have increased. The past few decades’ competing uses for water supply and habitat have jeopardized the area. Fights over water in the Delta have been framed as northerners versus southernersenvironmentalists versus business, and small farmers versus large conglomerates. The latest shift prioritizes habitat preservation and restoration above all other concerns. Indeed, Delta Smelt and Chinook Salmon are subjects all people familiar with the region are well-informed of and opinionated about.

Where parties representing farm, municipal, and environmental interests are heard in fluctuating volumes, the local Delta community is largely under-consulted relative to their geographic centrality in the issues. As it is used here, the Delta community is those people who live in the statutorily-defined Delta. The statutory Delta is a smaller area than the true watershed stretches. Indeed, the Sacramento, San Joaquin, and Tulare watersheds that feed the Delta stretch over half the state's geographic area.  Despite being low in population, the Delta communities are surrounded by vast and expanding rings of urbanization which leaves them unnamed and largely unconsidered in large debates over how to manage the Delta.

The Delta is composed of 57 islands formed by a network of levees about 1,100 miles long that divert the 700 miles of waterways that feed it. These islands are largely uninhabited farmland and wetland reserves. Touching parts of Alameda, Contra Costa, Sacramento, San Joaquin, Solano, Yolo and portions of Rio Vista counties, the total population of the Delta is 515,000. Only about one-tenth of the Delta is considered urbanized, meaning the vast majority of the population is dispersed widely over the 738,000 acres.

According to the main Delta community website, DeltaCalifornia.com, there are a handful of small towns but “[f]rankly, some of these places are just too small to find much about them online!” These communities have names like Snug Harbor, French Camp, and Bird’s Landing. Stockton and Antioch, cities on the edge of the Delta border, are bedroom communities for Bay Area and Sacramento commuters. Of cities in the central Delta, the largest is Walnut Grove. It is a Census-Designated Place that the government recognizes as a concentration of population but has no legal status. Its population is just over 1,500. The next largest town, under a mile away, is the historic city of Locke, built by Asian immigrants seeking refuge from Walnut Grove’s racist sentiments in the early 20th century. It has fewer than 80 residents. About 30 minutes from Sacramento and just over an hour from San Francisco, these communities are a short distance from some of the state’s largest metropolitan areas.   

Scholars have struggled to provide a clear definition of “rural.” Geographic markers, public sentiment, and daily subsistence are useful indicators of what is “rural.” Each index remains problematic for the Delta communities. If we were to apply a geographic analysis to these populations, their proximity to large cities like San Francisco and Sacramento overshadow any claim to being remote and unconnected. Locke is a designated National Historic Place with a series of shops and bars that attract tourists year-round. Further, the desolate islands only accessible by boat juxtaposed against population pockets of recreational boat marinas, shops, diners, and docks, shorten any claim that the population is rural. One San Francisco blog described the area as “undeveloped and quirky” where the little towns blend into each other. Essentially, these Delta communities are not traditional rural landscapes qualifying them for distinct consideration. Nor are they connected enough to the metropolitan strong arms to have a meaningful voice in Delta management.

The presence of many voices in the debate over management of the Delta is understandable. The water supply running through it supports California’s stronghold as the fifth largest economy in the world, including a $27 million agricultural industry. Indeed, because of the conflicts over the Delta, California’s water system has been one of the most observed in the world. With this, the Delta Vision Blue Ribbon Task Force observed in 2008, “[t]he Delta is a regional, state, and national treasure. Its unique combination of estuary, water supply, recreation and tourism, aesthetics, lifestyle and rural character make it a special place that we must recognize and protect.” Indeed, this goal demands inclusion of all voices.

Social media as a support-network in rurality?

As I walked into the street in Oakland for the Women's March the day after the Inauguration of President Donald Trump, I did a thing that I rarely do. I looked around at the thrilling, lively, and heartening action around me, and then, I got out my phone and immediately opened all my social media feeds. This was an embarrassing moment for me, because I fight against 'falling into the device' so-to-speak, particularly when real-life is quite active. However, I had a few excuses. First, I had joined the March with one friend, and we'd been planning to meet up with several other women-marchers, but in the crowd of between 60,000 and 100,000 people, meeting up with our friends was impossible. Secondly, I knew I had dear friends marching in New YorkBoston, Philly, DC, and all across the globe. I felt distant from my friends in the Oakland crowd, and from those in solidarity in other cities, and I desperately wanted to connect. Social media allowed me to feel that I was marching with all of them; through their photos and sentiments, I felt that they were right beside me.

When I read Lydia O'Connor's Huffington Post article about marches in rural areas and small towns (also mentioned by fellow Legal Ruralism bloggers), I immediately understood why I had reached out via social media and why so many others did too. What's more, through O'Connor's article I reflected on the fact that we are informed about rural attendance of this particular political movement largely because of social media. The entire article was built on inspiring tweets such as Olympic skier Gus Kenworthy's comment: "My tiny hometown of Telluride did a Women's March & over 1,000 people showed up and marched in the snow. 50% of the population. Incredible!"

The internet in general and social media in particular have begun to allow people to feel a part of the national and global conversation (in the US and abroad), regardless of where they are physically located. If one lives in a remote location, she might, not too long ago, have felt entirely isolated, not only in her geography, but in her ideology. She might feel hesitant to speak of her views, or even to seek out views different from those in her immediate community. Now views from all directions come across over the internet-waves. Now she might be more informed that she would have, say, in 1997, or even 2007. Even better, social media can allow people to feel part of a larger community in a demonstrable and undeniable way, regardless of their physical distance (as evidenced by Women's Marchers marching even as remotely as Antarctica). It appears that social media in its function as community-building technology might serve to help people who prefer to live in rurality –social media may allow our rural comrades to remain rural and connected at once.

Rural people have found innovative uses for typically "urban" technology since the days of Bell Telephone or earlier. SMS networking has allowed farmers in Morocco to share best practices, and the Chinese social media platform WeChat helped gather estranged residents of a soon-to-be-demolished coal mining town for one last goodbye (among about a zillion other things WeChat does). The government of a small town in Spain had been using Twitter as its main means of communicating with its citizens for years before it became popular in the US (to my chagrin). My old town of Northampton, MA still updates me about snow emergencies via email and twitter. This is an example of how social media can be a powerful tool used to connect and standardize communication in rurality, where it might, not too long ago, have been impossible to communicate with everyone at once.

However, what if you don't want a standardized message? Many people love their small towns and really enjoy living in a rural location, but lack connection with like-minded individuals. It seems, by the news coverage lately, that social media be used as a way to disagree, just as much as it can be used to homogenize. This might be the perfect way that ideologically isolated people can feel a part of political and social movements. Of course, social media has been a large part of conflict and government-control all over the world, including in Syria, Iran, and more. However, it's also been a great source for activism in wartime truth-telling, in times of protest, and in civil rights.

Speaking out online, perhaps even under a pseudonym, allows people who are connected to their small communities and fear ruffling feathers (such as Hannah Adams reported about for Youth Radio) to feel heard. These platforms can be an outlet despite a political or belief-based disconnect from one's neighbors, and they may allow us to feel outspoken without having to openly oppose those people in our geographic proximity. Indeed, it seems that social media has been a life-raft for many people in the past few months.

To play Devil's Advocate, some feel this double-life can distance us from ourselves, and others find that only truculence and arguments await them when they post their views (we've all been there). As fellow bloggers on this blog have noted, social media can also have very negative effects in small towns (e.g. here and here). Despite their negatives, internet connections and social media are increasingly seen as important to promote human rights, and even seen as a legal right in themselves. Indeed, it felt as thought social media was trending that way last weekend, as it improved the efficacy of grassroots organizing greatly, by getting the word out across the nation.

Susan Cherones (@CousinSugar) loves the 360-person mountain town of Mentone, Alabama where she has made her home for over two decades. However, when 50 people came out to march on January 22, she knew that they weren't necessarily representative of the ideology of the rest of her neighbors and Alabamians. She indicated that connections like social media help her feel ideologically supported, though her rural area (and entire state) might be diametrically opposed to her thinking.

In an article for The Outline, Cherones encouraged "progressives in less-than-progressive regions" with these thoughts, which are perhaps the best way to end this post:
“Hang on to each other, no matter what’s around you,” she said. “We know what’s right. It doesn’t matter if the entire state of Alabama bled red on Election Day. We can see, we have eyes, and we will say that to each other.”

Friday, January 27, 2017

Exorcising the "fallen world": Further thoughts

Like Willie (see his thoughtful and intelligent blog post below), I was also struck a comment made by Robert Leonard in his recent New York Times op-ed, "Why Rural America Voted for Donald Trump." In the article, Leonard quotes a statement made by a former Republican congressman now practicing Baptist minister, J. C. Watts. Mr. Watts’ statement—that the differences between Republicans and Democrats can be reduced to beliefs about whether humans are “fundamentally bad” (i.e., the Republican belief) or “fundamentally good” (i.e., the Democratic belief)—conceptualizes the political divide as built upon fundamental belief-systems. Leonard writes:
Hearing Mr. Watts was an epiphany for me. . . . no wonder Republicans and Democrats can't agree on things . . . We live in different philosophical worlds, with different foundational principles.
While compelling, I find Mr. Watts' appeal to human nature curious, not the least because it seems to discount many of the traditional sources of individual voting behavior—namely: evaluations of government performance, personal characteristics of the candidates, economics, race, region, education, and social class. Interestingly, social science suggests that factors ranging from peer pressure and the desire to "fit in," to a candidate's physical attractiveness, are as likely to affect voters' decision-making as more traditional factors, like economic performance. But if we set such considerations aside and take Mr. Watts' conceptualization seriously, casting political ideology in terms of fundamental beliefs has consequences . . . 

In thinking about the "fallen world" and ideas of inherent goodness and evilness (to borrow Kyle Kate's phrasing), I am reminded of an article by Robert Wright published in the February 2015 edition of the New Yorker. Like Leonard's piece, Wright's article discussed a clash-of-values theory, albeit one of an international (rather than national) character.

In the early 1990s, political scientists spilled a lot of ink discussing the "Clash of Civilizations (COC)." Bernard Lewis first used the term in a 1990 article in The Atlantic, which sought to explain the perceived animosity toward America from the Muslim world. Lewis wrote:
. . . this hatred goes beyond hostility to specific interests or actions or policies or even countries and becomes a rejection of Western civilization as such, not only what it does but what it is, and the principles and values that it practices and professes. These are indeed seen as innately evil, and those who promote or accept them as the "enemies of God." (emphasis added)
Since the 1990s, of course, COC theory has gained quite a bit of traction; the idea that Muslims hate America on the basis of a fundamental "good-versus-evil" ideology is frequently bandied about as a hypothesis to explain the motivation for terrorism by Islamic extremists. (I will note that there is ample evidence suggesting the idea of generalized "Muslim rage" is, at best, simplistic and, at worst, untrue.) However, as Wright notes in his article, and as Trump surely understood in crafting his inauguration speech, describing any conflict as an ideological war of values packs a rhetorical punch. After all,
It's natural, when you're freaking out, to accept simple and dramatic, even melodramatic, explanations. It's a clash of civilizations!
For the sake of argument, let us make some assumptions. First, let us assume that Republicans and Democrats—rural ones especially, what with their "traditional American values" and "Puritan work ethics"—vote on the basis of beliefs about human nature. Let us also assume that such beliefs are fundamental. Ostensibly, such beliefs would by definition transcend economic, education, and class considerations—which might explain the discrepancies between the empirical metrics (referenced in Willie's post) and the resonance of Trump's inauguration rhetoric with the rural electorate. It would seem the logical extension of this line of reasoning is that voting patterns are set—pre-determined, even. If white rural evangelicals, for example, believe the Republican party reflects the worldview that humans are fundamentally bad, they would have voted for Trump (and will continue to vote along party lines) regardless of their economic fortunes and social circumstances. Can this possibly be true?

Here is what we know: Yes, 80% of white evangelicals voted for Trump. Yes, rural Americans voted overwhelmingly for Trump. And yes, rural populations are composed of evangelicals at a higher percentage than urban populations. Perhaps the alignment of this segment of the population is attributable to Trump's co-opting of the "fallen world." Perhaps rural Americans were swayed by apocalyptic discourse and the notion of a society trapped in sin. On the other hand, perhaps we—"we" referring to the collective consciousness that inevitably awakens to pick apart our political fate ex post facto—simply like to believe that Americans care about things like "good" and "evil." Perhaps we prefer to believe that Americans choose the candidate that they see as the good guy (even if we disagree with the choice).

In terms of what we know, it is also worth noting that:
To be clear, I am by no means suggesting rhetoric is an irrelevant piece of the political puzzle. Rather, I am suggesting the puzzle is a 1000+ piece jigsaw. In minimizing the relevance of economic and social factors, I worry that statements like Mr. Watts' miss a critical point: socioeconomics still matter.

Obamacare: can't live with it, can't live without it

One of the many, many political issues in recent headlines is the proposed repeal of the Affordable Care Act. Republicans on The Hill continually push to dismantle President Obama's pride and joy, but just six days ago I saw a woman marching through the streets of Oakland, CA sporting a sign with "The ACA saved my life" in large block letters. It's been a national debate for years: Is the ACA a blunder, destroying the federal budget, or is it a huge step toward universal healthcare? For rural communities, the ACA did not go far enough to save crumbling hospitals in small towns across the country.

Rural USA has a love-hate relationship with the ACA. Why? Well, just like for the rest of the U.S., the ACA allowed more people to get health insurance, allowed young people to stay on their parents' insurance for longer, and allowed people with pre-existing conditions to have the same access to insurance. That's the love part. The hate part is where millions were still left uninsured because states didn't expand Medicaid the way the federal government planned. Poorer states couldn't do it (as noted here). NPR's Weekend Edition reported that half of the 37 million people who were supposed to get coverage under the ACA would fall under the Medicaid expansion. But, if your state didn't expand, then you were left out. Millions of people in rural states: left out. That's the hate part. Not to mention that provisions in the ACA could have helped recruit and retain hospital employees, but Congress failed to fund those initiatives. That's the love-hate part - they tried, but execution didn't exactly pan out for everyone. (More gaps in ACA coverage in "the country" discussed here.)

ABC recently published an article entitled, "Rural hospitals bracing for effects of Obamacare repeal." Highlighting Marengo Memorial in Iowa County, National Rural Health Association's CEO, Alan Morgan, gives statistics showing both sides of this roller coaster of attitudes toward the ACA. Since the Act took effect, more patients are insured and hospital debt has decreased. On the other hand, as an employer, expenses have gone up due to coverage mandates. On the other other hand, Morgan cites the biggest concern as uncertainty among patients about where their coverage will come from moving forward. Repeal? No repeal? Replace? No replace? No one knows. Rural communities can't afford more uncertainty when it comes to healthcare.

In March of 2016, the PBS NewsHour did a special on hospital closings in rural communities. They cited that 19 states failed to expand their Medicaid programs under Obamacare. This in combination with Congress' decision to cut Medicare payments has "left many rural hospitals with unpaid bills." According to the National Rural Health Association, at the time of the PBS Program, more than 280 hospitals were on the verge of closing down.

The following week, The NewsHour followed up their story by highlighting a hospital in Fredericksburg, Texas (population: 10,000). Hill Country Memorial Hospital caused a horrible tragedy in 1999. A teenage boy, Quinn Kott, arrived at the hospital after suffering a stroke, but wasn't examined by a doctor until the following morning. He passed away that day. At the time, the hospital was "in the red," both employee and patient satisfaction was dwindling, and members of the community were known to find alternative sources of healthcare based on the hospital's reputation.

Like many small towns with hospitals, Hill Country Memorial was the largest employer in Fredericksburg; its success was vital to the community. After Quinn passed away, the hospital began turning itself around. They hired folks from Toyota, Southwest Airlines, and the Ritz Carlton to improve their efficiency, values, culture, and customer service. Now, it is one of the top 100 hospitals in the country. Unfortunately, Hill Country Memorial's ability to recover and excel as a healthcare provider is the exception, not the norm, in rural America. The original NewsHour episode did a better job of portraying the reality of rural healthcare: hours long travel times for people to get to appointments, inability to tend to emergency situations before the patient passes, debt, out of date equipment, lack of doctors and nurses, and myriad other problems.

But the ACA fixed America's healthcare problems right? Maybe? No? (See this previous post to learn that it depends.)

During NPR's report, Maggie Elehwany, also from the National Rural Health Association, said that she has concerns about a repeal of the ACA, but "We want to make sure that they understand that the well intentions of the ACA have really fallen short and may actually be exacerbating the hospital-closure crisis." A repeal could be extremely damaging, but that doesn't mean that our healthcare laws wouldn't bear improvement.

Where the ACA fell short, some states are trying to find their own solutions. In an effort to improve the scarcity problem of healthcare professionals, an Alabama law offers tax incentives for physicians who live and work in rural areas. Now, The Anniston Star reports, there is a bill in the works to expand the incentive. The bill would offer a $5,000 annual income tax credit to doctors and physicians in rural areas for 10 years, slightly expanding the current incentive (which only lasts 5 years and is only offered to physicians). Rising costs of medical school, increasing retirement of older doctors, and the promise of a higher pay in the city are all contributing to dwindling access to healthcare in rural Alabama. Only 2 of 54 rural counties in the state do not have a health professional shortage, that means that 52 counties are facing shortages. Wayne Rowe, CEO of Quality of Life Health Services, says that scarcity of professionals is the "main challenge" of his clinics and "'any kind of incentive would be beneficial.'"

So, what is rural America saying about healthcare? The ACA isn't bad, it's just not nearly enough. Elehwany got it just right, "We are not mad at Republicans or Democrats. We're mad at Republicans and Democrats." Maybe she was just speaking for rural hospitals, maybe she was speaking for the whole country.

Rural children and guns (Part I): The basics of children gun deaths in rural v. urban communities

As an individual who grew up almost exclusively in suburban areas, I have had very little personal experience with rural communities. When I was really young I associated rural areas with "the country," which at the time I believed was composed of ranches filled with beautiful horses. I would dream of the day I could own my own land and have as many live horses as I did plastic ones (which was a truly excessive amount). As I grew older and was exposed to more media portrayals of rural communities, my association with rural communities changed from horses to guns. It seemed like anytime I watched a movie or read a book that involved individuals living in rural areas, they were always either hunting or shooting at each other.

As I did not see a gun in real life until I was twenty-two, reading about and seeing the casualness with which both adults and children handled guns was completely alien to me. While I have begun to understand rural communities more as I have grown older and met individuals from such areas, I still am baffled by the protectiveness (both rural and urban) individuals tend to feel about their gun rights, as well as their comfort with a weapon that can so easily kill or injure. I remain particularly perplexed by how often children are allowed, and sometimes even encouraged, to handle these potentially deadly weapons.

Given how many different aspects there are of the culture surrounding children and guns in rural communities, this will be the first of several posts regarding this topic. This first post will deal with the basics of children gun deaths in rural v. urban communities in America. In later posts I will take a deeper look at the issues surrounding rural children and guns in terms of hunting, suicides, and accidents.

The basics of children gun deaths in rural v. urban communities.

In the US, an average of seven children are killed by guns everyday and American children are killed by guns eleven times as often as children in other similarly high-income countries. Indeed, firearms are one of the leading causes of death among children, killing more minors than cancer and heart disease. Additionally, in 2007, eighty-five pre-school-aged children died a gun related death in the United Stated, which was more than the amount of police officers who were killed in the line of duty that year. According the Everytown for Gun Safety, a movement of Americans attempting to end gun violence, there have already been at least thirteen child shootings in 2017.

While children gun deaths happen in all regions and states in the US, where there are more guns, there are more gun deaths for all types of intents (including homicides, suicides, and accidental shootings). In a 2013 Gallup poll, rural Americans were more than twice as likely to have a gun in their home than those living in urban cities.

Children in rural communities often grow up around guns and are taught gun safety. While sometimes these gun safety lessons are taught by family members, gun safety classes are also offered to rural children, which some believe is a way to pass on the communities' tradition of gun ownership. Indeed, many American families view guns as a way to bring the family together.

There is a commonly held belief that children in rural areas do not die due to guns at the same rate as their urban peers because people often seem to associate gun deaths with murders or other violent crimes that occur in urban areas. However, a 2010 study completed by the American Journal of Pediatrics found that children in rural counties experienced a firearm mortality rate that was essentially indistinguishable to the rate at which children in urban counties die from guns. Indeed, in 2011, the "crude youth firearm death rates in the most urban counties... when compared with the most rural counties... [was] 4.64 and 4.04, respectively."

The main difference between child gun deaths in these communities is that children in urban counties tend to die more often from gun homicides while children in rural communities tend to die because of either gun suicides or accidents. My next blog posts will address the reasons for these differences.

Thursday, January 26, 2017

Civil rights and the USDA in the modern era (Part 1)

The U.S. Department of Agriculture (commonly referred to by its acronym, USDA) is a central and vital government agency to many rural people. However, their track record with civil rights has been particularly egregious.

The USDA was first established by the Lincoln Administration in the 1860s. It goes without saying that there was open and obvious discrimination against minorities in the USDA at this time. These discriminatory practices reformed much more slowly than some other government institutions, causing many to call it 'the last plantation'. After several successful and expensive lawsuits against the agency in the 1980s and 90s there were efforts to reform the institution, but these were largely ineffectual.

The Bush Administration 

When the Bush Administration took office in 2001 they made a number of changes to the way civil rights claims were handled at the USDA.

In an effort to decrease budgetary expenses, the travel budget of the Office of the Assistant Secretary for Civil Rights (ASCR) was eliminated. Instead, all reports of discrimination were investigated over the phone, if at all. The negative results of this change are clearly evidenced by the statistics. Between 2001 and 2008 over 14,000 civil rights program complaints were filed at the USDA, but only one complaint was found to have merit. For over half of these complaints the review was “no more than cursory: although they were assigned a case number, no one had even taken the time to determine which USDA agency the complaint concerned.”

Furthermore, one of the requirements of the USDA is to conduct a Civil Rights Impact Analysis before implementing any new policy action, rule, or decision in order to ensure that the change would not have any unintended consequences.  However, between 2001-2008 none of the analyses caused a program to be rejected, or even approved, contingent on minor changes being made.

The Obama Administration 

After the Obama Administration took office, Tom Visak was appointed the head of the USDA and was given the authority to make major overhauls to the civil rights department.

In May 2009 11,000 of the 14,000 cases were reviewed by a task force managed by a former Director of the USDA’s Civil Rights program. Of the cases reviewed, 3,800 had enough evidence to merit further investigation. The ASCR’s travel budget was also restored, and claims determined to have merit were now investigated in person.

Next, in order to get at the root of the problem, the service delivery programs were evaluated.  An outside firm was hired to do an independent external analysis in order to identify problem areas and potential solutions.  During the previous administration the Office of the Inspector General had made a number of management challenges relating to civil rights, and now all but one was resolved.

In addition to these changes new departments were established. The Office of Advocacy and Outreach (OAO) was created to “improve access to USDA programs and enhance the viability and profitability of small farms and ranches, beginning farmers and ranchers, and socially disadvantaged farmers and ranchers.”  The OAO developed a Minority Farmers Advisory Committee to provide guidance on policies and strategies that would affect minority farmers and to be staffed by socially disadvantaged farmers.  And in response to the strained relationship between the USDA and Native Americans the Office of Tribal Relations was created, and a Senior Advisor on Tribal Relations was appointed.

To improve the culture competency of the workers at the USDA a new training program was developed and implemented.  Every Washington, DC-based political appointee in the USDA was required to attend a civil rights training, even those who had been with the department for a significant amount of time.  Cultural sensitivity trainings were provided in states who had the majority of discrimination complaints, such as Alabama, Arizona, Florida, and Tennessee.

Next week I will discuss the effects these changes had on the USDA, and what changes are likely to occur under the new administration.

Wednesday, January 25, 2017

Women’s march not just for urban folk

On Saturday, as I browsed media coverage of the Women’s March, my husband was the first to alert me to the number of rural communities participating in the march that day. As he referred to the spreadsheet organized by Professors Erica Chenoweth and Jeremy Pressman, who were collectively documenting crowd sizes across the country, he began to name the small communities in Michigan where women were gathering. Small towns in Michigan were of particular interest to us because we both grew up in the state. “Clare, Michigan, somewhere between 24 and 75 people,” he read aloud. “Copper Harbor, Michigan…19 people?!” (19 people and 2 dogs to be exact). 

By all accounts these communities are considered rural. Clare consists of approximately 3,118 residents, while Copper Harbor consists of only 108 residents. Needless to say, we were surprised to see organized groups in these areas.

Meanwhile, across the country, millions of people were marching for women’s rights and against Trump. Although the largest crowds were reported in Washington, D.C. and other metro areas like Los Angeles, New York, Chicago, and Boston, news outlets also reported on the number of “sister marches” led by groups in small towns and cities in rural America. 

Given the contentious nature and geographic divide of this year’s election, one might assume that women would only march in states where Clinton won the vote, or at least in large urban areas that are more likely to represent democratic views. After all, rural America is disproportionately white, and Trump won 62% of the vote among rural white women

In fact, a Vox headline covering the Women’s March seemed to suggest surprise at the idea that women would organize in traditionally Republican states and communities. The headline read: “Women are marching in cities across the Midwest, the Rust Belt, and the South. They are even marching in states where Donald Trump won the presidency.”

My husband and I also shared that initial sentiment of surprise. We grew up in Michigan and we had some familiarity with the cultural make-up of the Michigan communities listed on the database. But as I reviewed the crowd estimates across the country, I began to feel ashamed that I doubted the ability of these communities to organize or thought that they wouldn’t be interested in showing their support for women’s rights.

Contrary to my initial assumptions, many rural communities across the country banded together in support of women’s rights, regardless of size. Here are just a few stories of those who participated: 
  • A small group of about 38 people organized in Unalakleet, Alaska   a city with a population of 700 – despite a weather forecast that predicted Saturday afternoon temperatures with a high of -19 degrees Fahrenheit.
  • Singer-songwriter Carole King showed her support by protesting in her hometown of Stanley, Idaho, along with half the town, which has a population of approximately 60 people. 
  • Michelle Barton, a retired librarian, prepared to march in her rural town of Longville, Minnesota (population of less than 200) because she was unable to travel to a larger march in Bemidji or Fargo. Barton had posted a local Facebook event about the march, but she didn’t think anyone would join her and prepared to march solo. To her surprise, 66 people showed up to march with her on Saturday.
Finally, I stumbled across an opinion piece written by Zachary Michael Jack - an author who writes about life in the modern Midwest. His article should serve as a reminder that this isn’t the first time rural women have banded together to advocate for women’s rights.

Jack’s piece, published in the Des Moines Register a few days before the march, reflected on his first experience with a women’s protest  – when he attended the Fourth of July parade at age 12 in his hometown of Cedar Bluff, in rural eastern Iowa. That year, in July of 1986, five women dressed as Lady Liberty and rode topless across a women’s rights float, sending a message against pornography and objectification. And on that day, a crowd of approximately 15,000 people gathered, even though Cedar Bluff had less than 50 residents.

Although some participants used the march to protest against the Trump administration and Trump’s remarks on the campaign trail  – donning pink knit “pussy hats” and “nasty woman” tees  – to many participants, the march meant more than that. The national mission of the march was to send a message to the new administration that “women’s rights are human rights.” But organizers in Anchorage, Alaska insist that the march was also about issues that have affected their local communities for some time. 

To them, it was an opportunity for these communities to “stand up and do something.” The march was a way for their voice to be heard and they did not hesitate to show their support for women's rights. Regardless of their size or cultural backgrounds, some women in rural communities chose to stand together in solidarity.