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Problems in Rural Health Care

The subject line of this post may sound specific. Wonky, even. But think of it in coldly political terms. The Senate wildly over-represents rural states. A number of the key votes -- Conrad, Snowe, Baucus and Nelson, among others -- come from substantially rural states. In some ways, the rural/urban divide may be as important to passage as the partisan divide.

The forum I just moderated, which was presented by the Center for Community Change, featured a number of rural Americans telling heart-wrenching personal stories. The concerns, though, fell into two main categories: Health care is too expensive, and it is too far away. The problem is that these concerns conflict.

The cost of care has been well trod in this debate. But its distance hasn't. One woman, for instance, complained that there was no MRI machine in her town, or even anywhere near her town. Treatment required hours of commuting. Emergencies were unthinkable. People nodded their heads. Fixing this is important. But it's also expensive. If we're going to have a cardiac unit in every rural hospital, and an MRI, and everything else, costs will shoot through the roof. You can't have the best of everything, everywhere, and also ensure affordability.

This is not really a case where the market has failed. It's a case where the market has succeeded, and we don't like its judgment. It's not profitable to provide some of this technology to rural areas. But rural areas, quite understandably, want these technologies anyway.

Like much else that keeps rural communities vibrant and livable, this militates towards pretty hefty government subsidies. Maybe a public plan overpays for these services in these areas. Or the government offers grants of some kind. But the legislators representing these areas are big on cost control, at least as a rhetorical maneuver. They're also skeptical of a public plan, even though these areas are the least likely to feature a number of private insurers competing against each other to offer affordable options. But what are the alternatives, really? These areas aren't economically viable. But our political system does not want them to become unlivable. The government is really the only player able to bridge that gap.

By Ezra Klein  |  October 1, 2009; 1:39 PM ET
Categories:  Health Reform  
Save & Share:  Send E-mail   Facebook   Twitter   Digg   Yahoo Buzz   StumbleUpon   Technorati   Google Buzz   Previous: Rural America and Health Care
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Naturally, these same rural voters are the same ones who will speak movingly about the upstanding self-reliance of America's rural communities - the "real America".

Posted by: Sophomore | October 1, 2009 1:52 PM | Report abuse

+1 on "self-reliance"

It's the same principle as living in a flood plain and wanting the government to rebuild your house when you get flooded.

People buy cheap in some areas because of problems with what they're buying (floods, no healthcare, earthquakes, etc.), then want the government to fix the problems.

Posted by: fuse | October 1, 2009 1:55 PM | Report abuse

Medicare already subsidizes many rural hospitals using the Critical Access Hospital and Rural Health Clinic reimbursement schedules. This seems more like a conversation to have with CMS than a problem that can be fixed in the scope of the current bill...

Posted by: rusty_spatula | October 1, 2009 1:59 PM | Report abuse

The high cost of being over-represented in the Senate.

You can have a Baucus or a Conrad too, if your willing to live far from medical care, high speed internet, and public transit.

Posted by: bcbulger | October 1, 2009 1:59 PM | Report abuse

and one serious conservative fear is that if we go to a single payer system for example and hospitals are not reimbursed at rates they can afford they will go bankrupt and may eventually close. If that happens those that have to travel 30 minutes for an emergency will have to travel 45-60 minutes. How many people will die in that time frame?

A great example of the converse of over-saturation of the hospital market is Pascack valley hospital mentioned in the below article from the WAPO in June.

Its not needed. There are too many beds in NJ right now. They went through bankruptcy and existing hospitals in this suburb right outside of NYC tried to PAY $2 million to re-open it. It should stay closed. Now try to tell that to local residents and they'd have your head.

Think how much use this hospital's resources could be used in rural America.

Posted by: visionbrkr | October 1, 2009 2:02 PM | Report abuse

Because rural areas can't compete with urban areas for doctors, the government provides and incentives for foreign doctors to work in these areas.

Posted by: just_watching | October 1, 2009 2:04 PM | Report abuse

The oddity is that both Medicare payments for services and per-capita health costs are substantially higher in urban areas: people in non-urban areas are healthier and request, per capita, a lower dollar amount of government-provided health-care services.

The most accurate numerical analysis seems to come from Jefferson, who wrote extensively (back in the 1790's) about the growing cost of urban life and its effects on health, welfare, and longevity, and work ethics. His forecasts have proven surprisingly accurate (but I hope the ultimate outcome he predicted is inaccurate).

Posted by: rmgregory | October 1, 2009 2:11 PM | Report abuse

Even if the rural areas had all the newest technologies in MRI, CTscan, et. al, they wouldn't likely have the specialists able to interpret the results.

Why not rely more on air transport for specialized technology access? Each state could have a few copters and turboprops dedicated to medevac to nearby centers. They need these anyway, because some medical problems just can't be treated in small hospital/community clinic settings.

I'd have no problems with the Feds paying for some minimal level of air transport capability for low density states.

Second idea: hand-me-down equipment. Univ Med. Centers always have the latest and greatest. This happens often and regularly. Why not have a subsidized hand-um-down program to keep the replaced equipment within the state (instead of heading to recycling or whatever).

Posted by: JimPortlandOR | October 1, 2009 2:13 PM | Report abuse

i wonder how much bias against rural areas there would be if rural area senators voted for those provision of the healthcare bill that are near and dear to liberals like the public option. I'd imagine people's disgust for Senator Rockefeller isn't so great?? Isn't West Virginia mainly rural??? Oh gosh I wonder why??? Liberalism is just as transparent as conservatism.

Posted by: visionbrkr | October 1, 2009 2:13 PM | Report abuse

Thanks for a very clear exposition of the problem though you underplay the perversity of the representatives in these areas not speaking the truth about this situation to their constituents. Markets have almost always been unkind to areas in the economic "periphery" on a number of different fronts, not just health care. It is no accident that the Canadian single payer system started in Saskatchewan in the 1940's and spread from there.

You are making an argument for government intervention in the sacred market...did you know that? A government agency will have about as good a reason or more of a reason to serve these people than a profit-oriented medical industrial complex.

Posted by: michaelterra | October 1, 2009 2:16 PM | Report abuse

"It's a case where the market has succeeded, and we don't like its judgment."

You can make an IDENTICAL argument about pre-existing conditions, rescissions and many other elements in our healthcare system.

Posted by: kingstu01 | October 1, 2009 2:23 PM | Report abuse

As long as rural America keeps voting for an ideology that believes in a social order based on social darwinism nothing will change for them. They will continue to go without the most basic floor of health care and lack the most elemental resources. And rural Americans will predominate the 44,000 who die every year from lack of adequate health coverage according to Harvard Medical School.

Posted by: cmpnwtr | October 1, 2009 2:30 PM | Report abuse


of course I know that.

the difference between me and many conservatives is that I can realize our philosophies short-comings and I'll readiy admit them. Can you realize yours and understand that fraud and abuse are the reasons why I don't think government systems run well. Once profits are greater than fraud and abuse then you'll be right with your public option. until then you're only looking at one side of the debate.

Fraud and abuse of medicaid is about 32 billion dollars a year. Insurers profits aren't nearly that much.

Posted by: visionbrkr | October 1, 2009 2:35 PM | Report abuse

I've just finished TR Reid's book "The Healing of America" which mentioned that in Japan the cost of an MRI is much lower than in the US. Why?

They have invented smaller, much more affordable machines for many purposes. Why can't rural medical facilities purchase and use these for all but the greatest emergencies? And when there is a true emergency, having some flexible air service sounds like a good idea to me.

Posted by: t_seltzer | October 1, 2009 3:46 PM | Report abuse

1.) Representatives of rural areas are "big on cost control" until it comes to bringing goodies to their home regions, then they reverse field and and are all for raining dollars on the home folks. This is true regardless of party. I know this since I live in a rural area and have seen it at work.

If there is a chance to bring home bucks for improved access to high tech care, the representatives of rural areas will close ranks very quickly to vote for it.

2.) Those "cheap MRI machines" in Japan are also available here. In the US they exist almost exclusively in private doctors offices and in a few investor owned MRI centers.

The reason is that they can't do some of the fancy -- albeit often marginally useful -- things that bigger, more expensive scanners can do. For the same reason, many centers have thrown out perfectly good scanners and replaced (or upgraded to the point of essentially having replaced) them with the latest thing. This is what people like to call the "medical arms race."

In medical imaging, everyone likes to feel they have the biggest equipment.

Posted by: PatS2 | October 1, 2009 5:15 PM | Report abuse

Most people think "only 20%" of Americans live in rural areas. That means 50-60 million people which is more than just a drop in the bucket.

I have a couple of comments: First, the gov't does not spend massive amounts of money to keep health care services available in rural areas. Average Medicare spending per beneficiary is lower in rural areas than in urban areas. To give you an idea, in 2004 Medicare spent 14% less per beneficiary in rural areas than it did in urban areas. And, contrary to what rmgregory said above, people in rural areas aren't healthier than those in urban areas.

"While 20% of the United States population lives in rural areas higher rates of chronic illness and poor overall health are found in those communities when compared to urban populations."

And, contrary to what Ezra is implying, even Senators don't expect MRI machines in every rural hospital. The Critical Access Hospitals rusty spatula mentioned are limited service hospitals meant to keep an ER and other appropriate services available. They're not even doing OB in most of those hospitals. If other hospitals provided services at the same cost as rural hospitals, we wouldn't have a cost crisis.

Posted by: steveh46 | October 2, 2009 4:06 PM | Report abuse

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