Monday, July 31, 2017

Optimism, out of (and about) rural Minnesota

The President of the University of Minnesota, Eric Kaler, published this in The Hill today, asserting that the rural brain drain is being stemmed, to at least some extent, in Minnesota. The lede and a further excerpt follow:
The challenge of the “brain drain” from rural America to the big city, in some parts of the country, is very real. But the Pew Charitable Trust’s recent report provides proof that it doesn’t have to be. 
The reality is that rural America can continue to prosper and grow, but only by using all of the tools and techniques available to rural communities. Higher education, particularly land-grant institutions, must be part of the equation. 
* * *  
Years ago the county extension agent, typically focused on agricultural issues, was a mainstay in states across the Midwest. In Minnesota, our University of Minnesota Extension, a college-like entity within the University of Minnesota, served all 87 counties (and still does) but again, with a focused effort to improve the productivity, efficiency and safety of agricultural producers. Today the focus remains, but with a multi-layered effort, using resources across the university to support entire communities toward their shared success.
* * *
University of Minnesota research quantifiably demonstrates, using the 2010 Census data as a benchmark, that some rural communities are actually growing their population of 30- to 49-year-olds. This cohort is not moving back to a dismal future at the peak of their earning potential. They are moving back to vibrant, exciting opportunities that enrich their lives, their families, and their communities.
Then there is this column/post from a few weeks ago on the blog Minnesota Brown, by Aaron Brown who writes from the state's Iron Range--we're talking Hibbing, Virginia and Chisholm.  (If you don't know anything about the Iron Range, an entertaining--and gripping--two-hour introduction is Charlize Theron's 2005 movie "North Country.")  Brown's bottom line is that his community needs to think more about the future and spend less time lamenting the passage of the good ol' days.   Here's an excerpt, starting with the lede:
On the Mesabi Iron Range, our society rests upon the achievements of this region’s fading youth. We speak of our ancestors’ hungry demand for better working conditions and pay. We memorialize their desire to build schools and small towns to elevate humans from the morass. Yes, we call this history and print it on our signs. 
But what are we doing to improve the working conditions and pay of a majority of the people who live here now? How will we raise people from the maw of an economy that chews them up?
And speaking of people, his focus is young people:
Listen to our young people. Not just your kid, but other kids. Poor kids. Kids without connections. Kids like I was, growing up on the junkyard out in Zim. If you listen, they talk about a future beyond what they see around them. They want more than the same job mom or dad had. They want a world that provides options and opportunity.
As illustrations of a different, robust, appealing future, Brown touts a new Iron Range Makerspace, Hibbing's Dylan Project, and the Borealis Art Guild (also in Hibbing).

Brown also takes up the pervasive rural-urban tension, associating federal regulation with the urban enemy (not in his mind, but he suggests it is part of the ethos of his region)
If some find pleasure in pitting our future against that of our state’s metropolitan region, so be it. I too have chosen to live here, not there, for reasons familiar to most reading this column. And if your ideology leads you to despise regulation, the Clean Air Act, or anything so much as whispered by a self-described “environmentalist,” well, our country allows you to hold and even shout those beliefs. 
But do not be fooled. Regulation kills far fewer jobs than apathy, shrinking demographics and opposition to market and cultural change. 
One of his overarching messages is that rural northern Minnesota will be just fine, thank you very much, and that it will be able to compete in the future.  In fact he seems to anticipate a rural gentrification of sorts, an influx of city folk who will come, whether the region actually welcomes and encourages them or not.
The cold fact is that our region needs people: workers, customers, students and entrepreneurs. We need more people than we can produce. Hardly our enemies, people who live elsewhere will one day enrich this region by becoming part of it. We can invite them. Or we can wait for our fresh water, cheap real estate, and drought-free environment to attract them independently. They will come. We might be in rough shape. We might be dead. But they will come. The only thing we can resist is our ability to accept and influence the inevitable change.
That passage reminds me of the story of Christopher Ingraham of the Washington Post, a story now well known to Minnesotans.  Read more here.  (To be clear, Red Lake County is not in the Iron Range, but it is in northern Minnesota and, by many accounts, quite scenic).

But back to Brown's post.  One of his closing lines is the best, most uplifting, and inspiring of all (pithy, too!).
We must expand the meaning of the honorable title, Iron Ranger.

Friday, July 28, 2017

Retrospective out of southwest Oregon

Jeff Brady, a journalist with National Public Radio, filed this story out of his home town, Gold Beach, Oregon (population 2,253), a week or so ago.  Brady grew in Curry County (population 22,364), and he's returned as part of an NPR series where journalists visit their hometowns to see and talk about what has changed since they left.  Gold Beach's story is not uncommon in that part of the world.  It is one of a transition from commercial fishing, logging and timber-based economy to one based largely on tourism.  You see, the Rogue River meets the Pacific Ocean at Gold Beach. 

Here's an excerpt, but the story is well worth a listen in its entirety. 
Most of my classmate's parents worked in jobs connected to logging. My dad, for example, worked for the U.S. Forest Service where he helped manage the two-thirds of Curry County that is federal land.

Back then, timber was king and it seemed like the industry always would be at the center of Gold Beach's economic life.
"It was our number one employer at the time. People came from everywhere to work at the mill," says Gold Beach City Councilor Tamie Kaufman. She's a friend and former classmate of mine. 
Recently Kaufman and I walked around an old plywood mill site, a few miles up the Rogue River from Gold Beach. The mill closed after logging slowed down in nearby federal forests. One factor was environmental concerns and efforts to preserve the spotted owl. 
The mill burned in 1991 and never re-opened. Now the site has, ironically, been taken over by trees. 
Without the wages and regular overtime the mill paid, Tamie says the region has struggled economically. Poverty is a persistent problem.

Wednesday, July 26, 2017

NYT Coverage of Remote Area Medical site in Appalachian Virginia

The New York Times' Trip Gabriel reported in Monday's paper on the Remote Area Medical Clinic that had run in Wise, Virginia over the weekend.  A photo of the clinic appeared on the front page, with the full story on page 9.  The headline is, "When Health Law Isn't Enough, the Desperate Line up at Tents." Here's the lede:
Anthony Marino, 54, reached into his car trunk to show a pair of needle-nosed pliers like the ones he used to yank out a rotting tooth. 
Shirley Akers, 58, clutched a list of 20 medications she takes, before settling down to a sleepless night in the cab of a pickup truck. 
Robin Neal, 40, tried to inject herself with a used-up insulin pen, but it broke, and her blood sugar began to skyrocket. 
As the sun set in the mountains of southwest Virginia, hundreds of hurting souls were camped out or huddled in vehicles, eager for an early place in line when the gates swung open at 5 a.m. for the nation’s largest pop-up free clinic.
I first learned of this RAM clinic in Wise on Saturday when Ralph Northam, Democratic Party nominee for Governor of Virginia and a physician, Tweeted that he was volunteering at the clinic.

Wise is quite near Grundy, Virginia,  the dateline for this Washington Post piece, which appeared in print on Sunday.

Monday, July 24, 2017

Chuck Shumer's big idea for the Democratic Party (and its explicit attention to rural America)

Chuck Schumer, Senate Minority Leader, has an op-ed in today's New York Times, and it makes several references to rural America.  The title is "A Better Deal for American Workers."  Here's an excerpt about the over-arching plan Schumer says Democrats have for the country:
First, we’re going to increase people’s pay. Second, we’re going to reduce their everyday expenses. And third, we’re going to provide workers with the tools they need for the 21st-century economy. 
Over the next several months, Democrats will lay out a series of policies that, if enacted, will make these three things a reality. We’ve already proposed creating jobs with a $1 trillion infrastructure plan; increasing workers’ incomes by lifting the minimum wage to $15; and lowering household costs by providing paid family and sick leave.
Here's an excerpt that acknowledges the economic needs of rural people and places:
Right now millions of unemployed or underemployed people, particularly those without a college degree, could be brought back into the labor force or retrained to secure full-time, higher-paying work. We propose giving employers, particularly small businesses, a large tax credit to train workers for unfilled jobs. This will have particular resonance in smaller cities and rural areas, which have experienced an exodus of young people who aren’t trained for the jobs in those areas
In the coming months, we’ll offer additional ideas, from rebuilding rural America to fundamentally changing our trade laws to benefit workers, not multinational corporations.
A couple of thoughts:  (1) I wonder what "rebuilding rural America" means.  (2)  I have become a skeptic of public-private partnerships, which seem to enrich the private at the expense of the commonwealth.   I also wonder about what sorts of small businesses in truly rural or very rural places might be available to engage in these partnerships.  (3) I doubt Schumer is going to reach many rural voters by publishing this piece in the New York Times.  But at least he can say he mentioned them--twice!

Sunday, July 23, 2017

Maine Governor (and mini-Trump) Paul LePage's expensive taste exposed

Don't miss this piece in the Portland (Maine) Press Herald on the recent spending habits of Governor Paul LePage and his entourage, particularly in DC.

With his imprudent and loose-lipped communication style, I have often thought of LePage as a little Trump, a Trump wannabe, or a Trump minion in any event.  Indeed, LePage was in Washington, DC, for meetings with the Trump administration.  Turns out, LePage is also fond of Trump's International Hotel in DC.  Those are pricey digs for public servants in a state in perennial financial straits.  I'm glad to see the state newspaper digging into this story.  

Meanwhile, Susan Collins (R) in the U.S. Senate looks as sensible and pragmatic as ever--and at least pays lip service to rural Maine.

Saturday, July 22, 2017

New Netflix series set in my part of the country: Ozark

The Atlantic magazine reports this week on Netflix's "Ozark" under the headline:  "Ozark: Netflix's Grim Foray Into Flyover Country" and the subhead, "The new 10-hour drama follows a Chicago financial adviser forced to move to Missouri to launder money for a cartel."  Here's an interesting excerpt:
Ozark has the potential to be many interesting things, and the fact that it commits to none of them feels like overextension. With America’s rural and coastal divide sharper than ever, a premise that drops a tony Chicago family into flyover country is full of promise, particularly because Bill Dubuque, the show’s creator, worked in the area during college, and still lives in Missouri. Even if you’re as hell-bent on dourness as Ozark is, the environment is rich with narrative potential, as the stories of Daniel Woodrell and the 2010 film Winter’s Bone would attest. And yet Ozark can’t get into it. It wants to unpack this intriguing rural community, but it also wants to be a drama about an unlikely criminal, like Breaking Bad, and a show about a boring marriage revived by a shared mission, like The Americans, and a fable about how everyone’s trying to make a living the best way they know how, just like The Wire.
 The link embedded there is to a New York Times review of the series.
Elsewhere on the lake, assumptions about families and class are similarly subverted. An extended clan of petty crooks is overseen by one of its youngest members, a teenage girl. Perhaps the warmest relationship on the show is a marriage between two other local criminals, a pair of murderous heroin dealers.
That story also makes this statement, which reminds me of the series "Justified," specifically where matriarch of the local crime family Mags Bennet gets the best of the Harvard-educated lawyer trying to do a land deal with her on behalf of "Big Energy."  Here's the NYT excerpt about the "Ozark" equivalent.  
Marty, the arrogant Chicago financial expert, is consistently thwarted by locals who are smarter than he assumes, with schemes of their own. “He makes a really bad miscalculation in what he perceives that environment’s going to be, and his ability to manipulate it,” Mr. Bateman said.
By the way, the lake referred to is the manmade Lake of the Ozarks, a section (Party Cove) of which the NYTimes referred to in a 2005 story as “'the oldest established permanent floating bacchanal in the country'”— where expansive waterfront mansions sit within a few miles of trailer parks."

For some of my posts on Daniel Woodrell's Winter's Bone --or, more precisely, Debra Granik's film based on it--see here, here, here, and here.  A post on another Woodrell book set in the region, The Maid's Tale, is here.

As a 6th generation Ozarkian myself--albeit from the Arkansas side of the state line--I'll be keeping an eye out for "Ozark."

Friday, July 21, 2017

On arson (and love?) in rural, coastal Virginia

A student emailed me this NPR story a few days ago; it's actually a review of a new book, American Fire:  Love, Arson and Life in a Vanishing Land, by Monica Hesse, a Washington Post journalist.  The book tells the fuller version of a story Hesse reported for the Post in 2014, that of 86 fires that besieged Accomack County, Virginia, on the DelMarVa peninsula, over the course of just a few months in 2012-13.  Here's how Hesse describes her attraction to the story:
This story had everything. It had 86 fires ... over the course of five months; it had a community that was in a panic; it had the setting of a place that used to be the richest rural county in all of the United States and has now fallen into disrepair, which is the reason they had all of these abandoned buildings to begin with. And then it had a love story. And so you couldn't ask for a more epic human experience than everything that was wrapped up in this story for me.
Here's another absolutely priceless part of Michele Martin's interview with Hesse--priceless, I think, for what it captures about rural America--or at least some slices of it--right now (and, I suppose, for what it captures about human nature):
There was one person who I didn't quote in the book, who said to me, "Don't put this in your book, but I kind of miss the arsons because I really felt like my life meant something at that time; because I really felt like I knew what my community needed from me and I could do that in a really tangible way." And so one of the things that I hadn't expected to find was how, while the community was being burned down, the community was also knitting itself together in really close and unexpected and kind of lovely ways, too.
One of the most interesting aspects of my dig into this story and the book it spawned was the comments readers left on the initial Washington Post story, once they were drawn back to it by the book's publicity.  That is, these comments were left in July, 2017, not in 2014 when the story initially ran.  The point I want to make about the story (and presumably the book) is the defensive posture they put Eastern shore residents in.  Here is one comment:
Hesse is spinning a fantasy to promote her forthcoming book. The Eastern Shore is gorgeous - not the Dogpatch she depicts. She makes it sound like all the residents are uncouth white trash. In reality, the Eastern Shore is like most places, only more beautiful - the affluent residents have a wonderful lifestyle while the poor people, unemployed people, and living-on-the-dole people have it not so great. She has taken two miscreants who would generally be considered white trash and tried to romanticize them into something more compelling and glamorous. Hesse has attempted to make sense in a sensationalist way of an irrational act while idealizing a petty crook and his attention-seeking moll - but, hey, she is now marketing a basically uninteresting crime in the vehicle of a non-fiction best seller. Please leave that to Joseph Wambaugh who had a really compelling arsonist as well as writing talent. Sorry, but reading about this is about as interesting as shopping at Walmart and getting coffee at McDonalds.
Here's another:
I am stunned and frankly angered by the reckless hyperbole of this writer in describing the Eastern Shore of Virginia as a "vanishing land," "decimated" and "half gutted before the fires even began." That's complete nonsense. It's true we have many economic challenges, like most of rural America, but we chose to live here, run a business and never regretted it. I've never had such good friends and neighbors who look out for each other, and any day of the week and I can experience pristine nature, see myriad bird life, and get out kayaking on the water within minutes (no traffic!). We have the longest undeveloped seaside left on the East Coast, 70+ miles of it. We haven't wrecked our barrier islands like other places. We have the Chesapeake Bay on the other side, a booming aquaculture industry and some of the best sea kayaking on the East Coast. Come and stay longer, going kayaking or get out on a fishing boat and see what life is really about here. We work hard, play hard enjoying unspoiled Nature and are very proud of our Shore. I'm disappointed that the antics of two disturbed individuals of 5 years ago somehow makes this a sad and forlorn place in anyone's eyes. Believe me, we have moved on.
I'm not saying whose depiction of the Eastern Shore is accurate--just that it's interesting to see how the folks who've chosen to live in a place can be so sensitive about its depiction--and vigorous in their defense of it. I first noticed that when I started to write about my own hometown.  In some ways, bad-mouthing someone's home town is tantamount to bad-mouthing their mother.  The stuff can be pretty close to the heart.

As for the descriptions of Accomack County, they remind me of time I've spent in the northern neck of Virginia.  Read more here.

And back to the book for a moment:  I see it is on the NYTimes list of 10 books they recommend this  week.  

Part III of Washington Post series on rural disability: Disabled and Disdained

The third part of Terrence McCoy's series on rurality and disability was posted this morning to the Washington Post website, and this one focuses on the disdain that rural community members often feel and express towards their neighbors who are receiving disability benefits.  I blogged about the earlier installments of the series here.

The dateline for this story is Grundy, Virginia, population 1,021, in the southwestern part of the state, coal country, Appalachia.  McCoy features the McGlothlin family, the matriarch of which receives disability--a $500 check each month for her anxiety and depression.  Her 19-year-old son Tyler is the family member who panhandles at a busy intersection 30 miles away from their home.  He does that when the cupboards are bare, as on one of the days when McCoy follows him:
Tyler would hold a sign on the side of the road and beg for money. He would go to a town 30 miles down the road and stand at one of the region’s busiest intersections, where he prayed no one would recognize him, to plead for help from people whose lives seemed so far removed from his own. 
To Tyler, the collapse of the coal industry had left two kinds of people in these mountains. There are those who work. And there are those who don’t: the unemployed, the disabled, the addicted, and the people who, like his family, belonged to all three groups. Those who work rarely mix with those who don’t, except in brief encounters at the grocery store, at the schools or, for Tyler, along the side of the road, where he knew he was likely to encounter acts of generosity as well as outbursts of resentment.
The other person featured prominently in the story is Dennis Hess, who had previously confronted Tyler's dad, Dale, for panhandling.  (Dale is now in jail for selling drugs).  After the elder McGlothlin, who also received disability benefits after working for 30 years as a coal miner, declined Hess's offer of employment, Hess stood by McGlothlin with a sign that said, "I offered him a job.  And he refused."  Hess also posted about McGlothlin on Facebook and soon many were criticizing him, with comments such as:
  • He is a lazy bum.  Im sorry if he can stand there outside and hold a sign he could work in some capacity..I have cancer and I’m ill but I work yet. 
  • Why don’t his wife get off her butt and get a job?  
McCoy provides some context: 
Nearly two-thirds of rural Americans say it’s more common for irresponsible people to receive government help they don’t deserve than for needy people to go without assistance, compared with 48 percent of city residents, according to a recent Washington Post-Kaiser Family Foundation poll. Rural Americans are also more apt to say poverty is the result of laziness (emphasis added).
McCoy also quotes me, along with Jennifer Sherman, author of Those Who Work, Those Who Don't:  Poverty, Morality and Family in Rural America, about which I wrote extensively here.  Indeed, the sub-head for the Washington Post piece is "In rural America, some towns are divided between those who work and those who don’t."

Media treatment of work, industry, and laziness is so important in this era when liberal elites frequently focus on "privilege" and downplay the importance of work, which might be seen as synonymous with "merit."  As for me, well, I see more "merit" in work and industry  than I do in being born into the right family, the family that can afford for its children to do an unpaid externship rather than get a paid job, the family that can afford an SAT prep course but then see their child's academic success as the product of discipline and merit.  When elites poo poo the importance of work and tell whites that they don't get ahead because they work hard but rather because of the color of their skin, they are running seriously afoul of an ethos that sees work as king.

McCoy's story is a powerful one of the potent, even vitriolic clash between those who work and those who don't in rural America, and it's one in which the lack of anonymity that marks rural communities looms large.  Here are some telling quotes of Sheila McGlothlin, Tyler's mother, about her place in the community and the role of reputation:
“Once you get a name, you always got a name,” she had said the day before to a relative who also draws disability. “You can never disappear.” 
“The only way something dies on you around here is if the people dies out,” the relative had said. “I worked in the coal mines, and my nephews won’t even give me the damn time of day. Act like I’m going to steal something off them all the time because I ain’t got much.”
The piece is well worth a read in its entirety.   As usual, McCoy lets his subjects do most of the talking for themselves, using many direct quotes.  The photos, by Linda Davidson, are searing.

Tuesday, July 18, 2017

Rural healthcare in the news (Part II)

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

While I was in the midst of drafting the paragraph above, I got the push notification from the New York Times that three Senators have already declared that they will vote against McConnell's Plan C:  Repeal Obamacare now, but make the repeal effective only two years from now, which would give the Senate time to develop a replacement.  Those three Senators are all from states popularly thought of as rural:  Alaska, Maine and West Virginia.  Here's an excerpt from the story:
Senators Susan Collins of Maine, Shelley Moore Capito of West Virginia and Lisa Murkowski of Alaska, all Republicans, immediately declared they could not vote to repeal the Affordable Care Act without a replacement — enough to doom the effort before it could get any momentum.
For the record, 66% of Alaskans live in urban areas, but just 48.72% of West Virginia residents do.  Maine is the state with the highest percentage of rural residents, at nearly 39%, as noted above.

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

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

I find the story heavy on nostalgia as a reason we should care about places like Bisbee.  Kirk Siegler of NPR quotes the town's mayor, David Smith, who says many Bisbee residents are uninsured or rely on Medicaid.  He also says it's hard to recruit doctors because of the lack of amenities:
Among other things, this summer, the public pool is finally reopening. 
Still, there is no movie theater. There is only one grocery store left in town and no soccer fields. Little things like these can be a deal-breaker when it comes to recruiting new doctors and other professionals.
Siegler notes that this rural physician shortage isn't "even part of the health care debate in Washington right now." Smith sees the shortage as "part of a broader story of rural neglect" commenting that "Rural America is forgotten America."  And that leads into the nostalgic bit, again quoting Smith:  
Copper from Bisbee, Ariz., is what helped win World War I.  And yet, when we are in need, we are forgotten because it's not convenient — and because it's not a whole bunch of people here that are voters.
The CEO of the 14-bed Copper Queen Community Hospital notes the negative feedback loop in communities like his who are looking for physicians--physicians don't want to come because the pay is low, but the pay isn't going to get better and the amenities are not going to increase unless the local economy rebounds.  That's unlikely to happen because it wasn't diversified to begin with, hence the hard hit when copper ceased to be mined.  It's also hard to revitalize the economy in such a remote place.  The principal economic driver now is tourism, but that is largely seasonal.  Siegler also touches on the role of caps on visas for foreign-trained doctors, a source of physicians that communities like Bisbee have relied on in the past.  For now, the hospital is relying increasingly on telemedicine, including through the Mayo Clinic's Phoenix outpost.

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

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

Sunday, July 16, 2017

On crime, policing and addiction in small-town New Hampshire

This feature appeared in today's New York Times Magazine, "A Small Town Police Officer's War on Drugs," dateline Laconia, New Hampshire, population 15,951:
In September 2014, Eric Adams became the first person in New England — to his knowledge, the only person in the country — whose job title is prevention, enforcement and treatment coordinator. ‘‘I never thought I’d be doing something like this,’’ he told me. ‘‘I learned fast.’’ The department printed him new business cards: ‘‘The Laconia Police Department recognizes that substance misuse is a disease,’’ they read. ‘‘We understand you can’t fight this alone.’’ On the reverse, Adams’s cellphone number and email address were listed. He distributed these to every officer on patrol and answered his phone any time it rang, seven days a week. Strangers called him at 3 a.m., and Adams spoke with them for hours.
And here's a June story from the New Yorker on what communities in West Virginia are doing to protect their neighbors from opioid addiction. The headline is "The Addicts Next Door," and the subhead is "West Virginia has the highest overdose death rate in the country. Locals are fighting to save their neighbors—and their towns—from destruction."

Friday, July 14, 2017

Location, location, location: rural law schools and their role in the rural lawyer shortage

Location, Location, Location - a familiar mantra to most of us. It refers to the idea that location is a very important determining factor in the success of a given project or initiative. In this post, I will explore the role that rural law schools play in addressing the rural lawyer shortage. I will admit that my analysis of this issue will be focused on the eastern United States and I apologize in advance to any readers who may feel that I am ignoring great initiatives in the West.

Rural law schools are a relatively rare thing and understandably so. Law schools want to be in locations where internships, externships, and clerkships are easily accessible. Students, after all, expect a return on their law school investment and think that attending a law school where there are plethora of job opportunities will give them the best opportunity to make this happen. Even law schools associated with rural colleges are often placed in urban areas. We see this is in North Carolina with Elon and Campbell Universities, whose law schools are located in Greensboro and Raleigh respectively. In fact, when Campbell University moved their law school from their campus in Buies Creek in Harnett County, NC to downtown Raleigh in 2007, the move was justified by school administrators as a move designed to give students greater access to judges and law firms. The board chairman even said that the "world is changing" and that the move to Raleigh was in the best interests of the school.

There is the understandable idea that we have too many law schools. Much like lawyers, law schools are increasingly concentrated in just a handful of urban centers. For example:

  • The City of New York and Long Island, NY have 10 ABA accredited law schools (11, if you count Pace just to the north in White Plains). There are only 4 (Syracuse, Buffalo, Albany, and Cornell) in the rest of the state and only Cornell is located in what may be considered a rural community (but even that is stretching the definition of rural). 
  • 7 out of the 9 law schools in Massachusetts are located in the Boston metropolitan area and only 1 out of the 9 is located west of I-495.  
  • In the rest of New England, only Vermont Law School in South Royalton would qualify as particularly rural.
  • North Carolina has 8 law schools, not a single one is located in a rural part of the state and all are clustered along the I-40 and I-85 corridor in Central North Carolina. 
  • Virginia also has 8 law schools, and two are located in rural communities, Washington and Lee in Lexington and Appalachian Law in Grundy. 
With only ~50% of law graduates getting long-term legal jobs, it may seem obvious that reducing the number of law schools would result in a favorable outcome. However, is it possible that law schools, like lawyers, are distributed in a manner that encourages economically inefficient clustering in urban centers?

Lawyering - an urban profession

Data from the Occupational Employment Statistics within the Bureau of Labor Statistics bears out the idea that lawyers are disproportionately urban and that rural areas are facing a dramatic shortage. As mentioned in an earlier post, only one non-metropolitan area has a location quotient of >1.0, Southwestern Montana. In fact, looking at the maps embedded in the link I just provided, you can pinpoint metropolitan areas by looking for the darkly shaded regions on the location quotient map. Even in historically predominantly rural states like West Virginia, lawyers tend to congregate in urban centers like Charleston, which has a concentration of lawyers that is almost twice the national average.

What about rural students? Wouldn't they be good candidates for rural practice?

The best analysis of this that I have seen came from this piece, co-authored by our own Lisa Pruitt, that examined Arkansas and students at the University of Arkansas. I do not want to duplicate their work but I do want to mention one takeaway, there are relatively few students from rural communities attending law school.

The University of Nebraska is attending to address this and recently announced the creation of the Rural Law Opportunities Program, which will give high school graduates from rural Nebraska scholarships to attend one of three state universities and provided they meet certain criteria, admission into the University of Nebraska School of Law. As their website notes, 11 out of Nebraska's 93 counties have no lawyers at all. This is one approach to addressing this shortage.

Rural students are underrepresented in higher education more broadly. According to the New York Times, only 29 percent of rural 18-24 year olds are enrolled in higher education, a figure which pales in comparison to 47 percent of their urban and suburban peers. Further, undergraduate institutions are only now starting to actively recruit rural students. Even if law schools try to recruit rural students, absent a pipeline program like what the University of Nebraska has pioneered, they are going to find the pool a bit shallower than they may want.

The role of the rural law school

There is perhaps no more better exposure to an issue than being immersed in it. A student, attending a law school in an urban center, can go through their entire law school career without being exposed to any rural issues and never be provided with a reason to consider practicing there.

A student attending a law school in a rural community, such as South Royalton, Vermont or Grundy, Virginia, has the opportunity to be immersed in the local environment and have contact with local attorneys, local courts, and the problems of rural people. Rural schools can facilitate this exposure by offering legal clinics, as Vermont Law School does. Prolonged first hand exposure is perhaps the best way to help someone decide whether or not they want to practice in a given area.

The onus is on the rural law school however to make sure that these opportunities are available. It is possible to attend school in a rural community and learn little about rural practice, especially if a person leaves to extern in a larger city during the summer. The law school existing in a rural space is not enough, it has to try to integrate the students into their surroundings and it has to create partnerships with local attorneys and government agencies to make this possible.

Even if a person decides not to stay in a rural area after attending law school however, being in the area and working with the local legal system will make them more aware of the issue and the fact that the shortage needs to be addressed. Many of my friends, including those who attended law school, are unaware that there is even a shortage. Many of them, believing the news reports about the lawyer surplus, assume that the market is universally oversaturated with lawyers. Someone with first hand experience learning the law and working in a rural community would be able to see this for themselves and it would increase awareness of this issue. The hope is that these people will advocate for policies, such as increasing legal aid funding, that will lead to an increase in the supply of lawyers in a rural community.

I will admit a limitation to this idea. In my own research of the quantitative data behind the rural lawyer shortage, I have not seen any correlation between non-metropolitan areas where law schools are located and an increase in local lawyers but I concede that getting access to county level data may help me understand this better. Right now, my answer to this is inconclusive.

Would more rural law schools be a net positive?

There is little empirical data that could definitely answer this question. We certainly do not need more law schools more generally. However, relocation of some law schools out of urban centers and into rural communities could have favorable outcomes. For example, if Campbell University were to move back to Buies Creek, North Carolina, it may increase the number of people interested in working in rural North Carolina and alleviate the glut of law schools in the Research Triangle area. On a bigger stage, if a law school in Boston or New York were to move to a surrounding rural community, it would lessen the amount of law schools in these cities and also be a benefit to the rural communities that they would relocate to. It would also provide people interested in rural practice with a place to study and work and a place for people who may never have considered rural practice to live and learn.

There is little question however that the current distribution of law schools is overwhelmingly urban and that prospective lawyers are gaining little exposure to rural practice and rural problems. We also know that rural students are not attending law school (or college for that matter) at a comparable rate to their urban and suburban peers. These factors limit the ability to train and recruit people to work in rural communities.

Monday, July 10, 2017

Quantifying the rural lawyer shortage

This is my first post in a while so I thought I would break the silence by providing a sneak peek into a project that I have been working on and am incredibly excited about.

I have spent the past couple of months working on a project for my MPA program where I have used Department of Labor data to analyze the quantitative aspects of the rural lawyer shortage.

What is clear from the data is that the lawyer shortage is widespread and only one rural area exceeds the national average in employment (as measured by examining the location quotient), Southwest Montana. My research has so far only focused on the Carolinas and Virginia and has found that the lawyer shortage is unique in its ubiquity. Another profession of similar prestige and educational requirements (and student loan debt), family and general practitioners do not experience the same levels of rural shortages that lawyers do. This is particularly troubling but not terribly surprising, given that there are already programs that actively encourage doctors to move to rural areas. There is also no correlation between the number of general medical practitioners and lawyers in a given rural community, thus possibly questioning the idea that lawyers may gravitate to areas where there are similarly situated professionals.

I encourage readers to look at the embedded links for themselves. It is difficult to argue with objective data, especially when we have a similarly situated profession as a comparison point.

I will be talking more about this in the future but just wanted to provide a quick sneak peek.

Friday, July 7, 2017

BCRA has rural hospitals, rural health in the headlines (Part I)

The now-months long effort to repeal and replace Obamacare (aka the Affordable Care Act) has brought rural people, their health and the hospitals who serve them onto politicians lips and into national headlines in recent weeks.  I've seen a number of U.S. Senators--mostly Democratic, but  also Susan Collins, Republican of Maine--mention their rural constituents as a reason they are opposed to the Senate version of Obamacare's repeal, the so called Better Care Reconciliation Act (BCRA).  Indeed, on June 27, Collins posted three consecutive Tweets (emphasis added), two of which used the word "rural":
○ “I want to work w/my GOP & Dem colleagues to fix the flaws in ACA. CBO analysis show Senate bill won’t do it. I will vote no on mtp.” 1/3 
○ “CBO says 22 million people lose insurance; Medicaid cuts hurt most vulnerable Americans; access to healthcare in rural areas threatened.”2/3 
Senate bill doesn’t fix ACA problems for rural Maine. Our hospitals are already struggling. 1 in 5 Mainers are on Medicaid.”
In this post, I want to highlight a few recent mentions of rural health care in the national media, starting with this piece on NPR on June 22:
Since 2010, at least 79 rural hospitals have closed across the country, and nearly 700 more are at risk of closing. These hospitals serve a largely older, poorer and sicker population than most hospitals, making them particularly vulnerable to changes made to Medicaid funding. 
"A lot of hospitals like [ours] could get hurt," says Kerry Noble, CEO of Pemiscot Memorial Health Systems, which runs the public hospital in Pemiscot County, one of the poorest in Missouri.

The GOP's American Health Care Act would cut Medicaid — the public insurance program for many low-income families, children and elderly Americans, as well as people with disabilities — by as much as $834 billion. The Congressional Budget Office has said that would result in 23 million more people being uninsured in the next 10 years. Even more could lose coverage under the budget proposed by President Trump, which suggests an additional $610 billion in cuts to the program.
That is a problem for small rural hospitals like Pemiscot Memorial, which depend on Medicaid. The hospital serves an agricultural county that ranks worst in Missouri for most health indicators, including premature deaths, quality of life and even adult smoking rates. Closing the county's hospital could make those much worse.
And a rural hospital closure goes beyond people losing health care. Jobs, property values and even schools can suffer. Pemiscot County already has the state's highest unemployment rate. Losing the hospital would mean losing the county's largest employer.
And on top of all that, annual payroll is about $20 million for the hospital as employer.

That provides some helpful background from a persistent poverty county in the Ozarks, where the need for healthcare for the poor is especially acute, not least because so many are so poor and in need of government assistance--for healthcare and otherwise.  The story, reported by Bram Stable-Smith, also covers the Missouri decision NOT to expand Medicaid, which was on offer as a bargain to states under the Affordable Care Act.

Since this story out of Missouri several weeks ago, the situation with the BCRA has gotten more acute in the sense that we now know what is in the BCRA.  The other two stories I'm featuring here are also by NPR and were published on July 1 and July 5, the first out of Hugo, Colorado (population 730), and the second out of Modoc County, California (population 9,686).  Both of these stories illustrate well the critical role that rural hospitals and healthcare facilities play in rural communities.

From the NPR story reported by John Daley out of Hugo, home to a regional hospital that lies between Denver and the Kansas state line, comes this quote:
From the outside, Lincoln Community Hospital looks more like a small 1960s-era apartment building. But it has all the essential high-tech health care equipment: modern imaging machines, tele-medicine links — even an AirLife helicopter. Rachel Smith, the assistant director of nursing, says the thing that really sets the hospital apart is the quality of its care. 
"It's definitely not treat 'em and street 'em," Smith says. "It's definitely somebody you're going to see — maybe even later that day, later that week."
From the NPR story out of Modoc County:
Modoc County, in the northeast corner of California, is roughly the size of Connecticut. It's so sparsely populated that the entire county has just one stoplight. The nearest Walmart is more than an hour's drive, across the Oregon border. Same with hospitals that deliver babies.
Greta Elliott runs a tiny health clinic in Canby, on the edge of the national forest. "Rural" doesn't begin to describe the area, she says. This is "the frontier."
"There are more cows in Modoc than there are people," Elliott says. 
There's a frontier mentality, too. People take care of each other, and they take care of themselves.
April Dembosky of NPR goes on to report that Ms. Elliott has herself chosen not purchase health insurance, thus reflecting the frontier mentality.  But the "frontier" reference is not just cultural.  It's a term used to designate the least populous MSSAs (Medical Service Study Area) in and by the State of California, which also uses "rural" and "urban" designations, though not in a way synonymous with the U.S. Census Bureau definitions.

Dembosky then explains the regional politics of far northern California (discussed in this recent post) and explains how the region's reliance on California's expansion of the ACA/Obamacare--called Covered California in the Golden State--has made strange political bedfellows.  She quotes Dean Germano, CEO of  Shasta Community Health Center.
The data shows it's the rural communities that have greatly benefited from the Medicaid expansion. That's the irony.  These are places that voted much more heavily for Donald Trump.
In fact, 70% of the voters in Modoc and neighboring Lassen County voted for Trump in 2016, and 64% of voters in neighboring Shasta County (home of the regional population center, Redding) voted for him.
But now a coalition of clinics from across the northeast corner of the state is lobbying local officials to take an unpopular position in this conservative land: defend the Affordable Care Act. 
And the right-leaning Shasta County Board of Supervisors took them up on it.
Germano commented on that decision:  
We thought "Whoa! That is really bold." I was surprised.
Though the Shasta County Board of Supervisors has lobbied their U.S. Congressman, Doug LaMalfa, to vote against the AHCA--the house version of Obamacare's repeal--LaMalfa has supported the repeal, defying at least this faction of his constituents.  

I'll return soon with another post on the issue of rural health care and the attention it's drawing from the national media and politicians.  

Thursday, July 6, 2017

NYTimes piece on rural, far northern California struck a nerve among liberal elites

Let me begin this post by acknowledging that I am a member of a group I often reference, frequently pejoratively:  "liberal elite."  This is different, mind you, from being a liberal elitist.  But I am in the privileged position of being an academic, and I am liberal/ I must own up to being a liberal elite. I am also a coastal elite by virtue of the fact I've lived in California for the past 18 years, doing the job that conferred "elite"-ness on me.  But I found myself really annoyed at another group of liberal elites yesterday when, following the New York Times story I blogged about here, some of the ones on Twitter started bashing the great grey lady (the New York Times, that is) for running that story!  Joy Reid of AM Joy (an MSNBC weekend program) let loose with this Twitter storm, partly captured in these images, but then transcribed below because the screen shots can be difficult to read.

Joy Reid: So let me get this straight: they got the president they wanted and receive the bulk of federal/state aid but they feel disempowered?

NYT Politics: Conservative voters in the northernmost reaches of California feel alienated by the state’s liberal urban majority

Joy Reid: And now they would very much like to secede from “liberal cosmopolitan elite” California but they’re broke so they wouldn’t survive alone?

Joy Reid: So in sum, they want their dole, they want all the guns they can stockpile, AND they want to run California and dominate their benefactors?

Joy Reid: Otherwise they’ll feel sad and disrespected and the @NYTimes will write doleful odes to their misery so the rest of us will pity them?

Joy Reid: People please. Your ethos is now running the United States. We are run by your rural, right wing Christian “values” and Ted Nugentian ethos.

Joy Reid: The vulgar, erratic, embarrassing president you wanted plods through the White House daily.

Joy Reid: Despite getting millions less votes, your congress IS expanding water and air pollution and gun proliferation and legislating women’s bodies

Joy Reid: just as you want. Sure, you may loss your Medicaid, but THAT’S WHAT YOU VOTED FOR: to “repeal Obamacare!” and free you from liberal tyranny!

Joy Reid: You hate clean air and water rules? Meet Secretary Zinke! I’m sure he’ll be turning over federal lands to your billionaire friends soon

Joy Reid: and I’m SO CONFIDENT they will trickle down the benefits to you (though I would advise against holding your breath w/o healthcare.)

Joy Reid: You are getting everything you wanted PLUS blue states/cities money to pay your dole. What is it you want now? Hugs? A parade?

Joy Reid: Hollywood to make movies about you so you feel important? @robreiner could you please get on that right away???

Joy Reid: These durges are getting old. These demands that we pity the poor victors who have achieved rural domination of urban America.

Joy Reid: You know who I feel sorry for? Urban America, whose values are denied while our hearts bleed to GIVE red states our money…

Joy Reid: Urban communities who have now been told their country will no longer fight climate change, and will let polluters run free to poison them.

Joy Reid: Immigrants who now live in fear of federal raids, Muslim students afraid to go home for holiday breaks or to wear their hijabs outside…

Joy Reid: Black motorists terrified of MAGA-amped police and children taunted with “Trump” as they are bullied for being brown or girls or LGBT.

Joy Reid: Let’s have some durges about how they feel. I’m weary of these demands that we cradle the people who clairm they “took their country back.”

Joy Reid: You go the White House and congress. You don’t need a cuddle. And we in the majority have bigger fish to fry than your hurt feelings.
* * *

In a similar vein, Anita Creamer, formerly of the Sacramento Bee, Tweeted:
Anita Creamer: THIS. What next, NYT? Want to interview the 5 sad Trump voters in Hawaii who are scared and lonely and need a hug? Enough.
Various folks chimed in to cheer Reid on, with one calling her Tweet storm "poetry." 

I guess the best way to sum up my response to Reid (and the many others who chimed in by re-Tweeting her or by writing their own similar Tweets) is to publish my own Tweet storm response here, in full:  

Lisa Pruitt: I find the tone of this #thread disdainful & #unproductive. Would we coastal #elites have spoken this way to #rural #white folks be #Trump?

Lisa Pruitt: No, before #Election2016, we were largely ignoring them, forgetting them, letting them know they & #food they produce don’t matter #rural

Lisa Pruitt: Here is my analysis of #rural bashing by #media #MSM during #Election2008.… Must we #liberalelites be so contemptuous

Lisa Pruitt: Oh & where’s evidence that folks in #rural northern #California are on the dole? Not saying it doesn’t exist, but let’s map data, show it.

Lisa Pruitt: #federal & #California funding streams not same: cannot tax #publiclands; #spatialinequality #unevendevelopment problems to be reckoned with

Lisa Pruitt: If we want to tell these folks to “move to town” & be #urban, then let’s be straight & say it. But many are suffering economically as is.

Lisa Pruitt: I understand how easy it is to be angry at #Trump voters; I’m furious at them, nearly unconsolable. But his thread is contemptuous of #rural

Lisa Pruitt: The #thread & its tone are so #destructive. Garnering #Twitter followers, yes, but not showing empathy or building bridges to others…

Lisa Pruitt: As for pollution, #rural areas bear brunt accdg to many analyses. Environmental injustice not only #urban phenomenon #environmentaljustice.

Lisa Pruitt: We #liberalelites #coastal #elites need to keep our eye on the prize: removing #Trump from office & then #coalition building to bring #USA back.

Lisa Pruitt: or is our plan to extract proverbial “pound of flesh” #poundofflesh from #swingvotoers #Trump voters if we get out of this mess alive?

Lisa Pruitt: Remember marital advice: do U want to be right or do U want to be happy? Do #liberalelites want to be right or build coalitions for future?

Lisa Pruitt: And why bash @nytimes for running this story on #rural northern #California? a polestar of #media integrity that we should support #MSM.

Lisa Pruitt: On @nytimes bashing, did U notice story ran on page 9? do we want further polarization where #NYTimes doesn’t cover #rural America at all?

All of this reminds me of something someone asked several months ago following a talk I gave about some of my work on rural white poverty. Essentially, he asked me why he should care, and he later circled back to explain his hostility:
some of these people were quite powerful in some domains, even exercising electoral power over California (and me) in the last election.
Frank Rich in a March 2017 article in New Yorker Magazine expressed similar anger at Trump voters.  He argued that Democrats should not "waste time and energy chasing unreachable voters in the base of Trump’s electorate." Rich calls it 
a fool’s errand for Democrats to fudge or abandon their own values to cater to the white-identity politics of the hard-core, often self-sabotaging Trump voters who helped drive the country into a ditch on Election Day. They will stick with him even though the numbers say that they will take a bigger financial hit than Clinton voters under the Republican health-care plan. As Trump himself has said, in a rare instance of accuracy, they won’t waver even if he stands in the middle of Fifth Avenue and shoots somebody. While you can’t blame our new president for loving “the poorly educated” who gave him that blank check, the rest of us are entitled to abstain. If we are free to loathe Trump, we are free to loathe his most loyal voters, who have put the rest of us at risk.
I'm reminded of a discouraging story from a few months ago that suggested that Democrats will cease to vie for seats with populations that are low-education, rural, and lacking in diversity.

Meanwhile, one commentator on Rich's article challenges the proposition that the media are looking to appease Trump voters, writing:
There is nothing but open contempt for Trump voters on every channel, in every magazine. Misplaced contempt perhaps (people didn't vote FOR Trump, they voted AGAINST coastal social justice pandering and identity politics). Out side of Fox Farce, who have you ever seen publish or speak kindly about Trump voters? 
Sadly, the commenter is describing the world in which I'm living, one with surplus disdain for low-income, low-education whites, rural or not, who are all presumed to have voted for Trump and therefore to be racists and sexists beyond redemption. But I won't go there right now, for that's too big a topic for this little blog post; indeed, it would be better suited for a book...