Friday, October 27, 2017

Rural hospitals and universities forge partnerships

Medical Center Hospital in Odessa.
(Odessa American photo by Edyta Blasczyk)
Rural hospitals all over the country are struggling, but some have hit on a strategy in which hospitals and universities both benefit. For example, the Texas Tech University Health Science Center placed academic surgeons (i.e. surgeons who teach medical school classes and also do research) in five rural hospitals in western Texas. The university benefited because it relies on Graduate Medical Education funding to offset the cost of indigent care and education, Medical Xpress reports. Hospitals benefit because they often have difficulty recruiting surgeons in rural areas. Hospitals also enjoyed significant financial savings, in part because the need to transfer patients to another facility was drastically reduced, which brought participating hospitals an average increase of $4.7 million in net revenue.

One of the hospitals, Medical Center Hospital in Odessa, pulled the plug on the program in April 2016 because of a dispute among local and contract surgeons about the residency program, Jennifer Bruha reports for the Odessa American. "The move would have led to cost savings at Medical Center since Texas Tech does not get paid to take call because they are a teaching facility. The hospital would have also received money for allowing the residency program because the state pays Texas Tech and then the university reimburses Medical Center for the cost, Ector County Hospital District 5 candidate Julie Molland said in May."

Texas Tech presented findings from the program at the American College of Surgeons Clinical Congress this week. "Some of the results included a reduction in rural area surgical costs, improved quality of care and an increase in revenue for the academic surgical programs," Bruha reports.

Trump's opioid emergency declaration has no money, but could free up some and offer other aid

President Trump' declaration that the opioid epidemic is a national public-health emergency carries no extra money, but it "will help the government speed any available resources to communities, where the epidemic is playing out on the streets every day, and will eliminate some obstacles that stand in the way of providing assistance," Lenny Bernstein reports for The Washington Post.

One example: supplies of naloxone, branded as Narcan, which can stop an overdose in its tracks. "The emergency allows the federal government to speed more people and resources to the streets where naloxone is needed," Bernstein writes. "Acting Health and Human Services Secretary Eric Hargan could negotiate lower prices for government agencies. And he could put out model instructions for states and cities to issue 'standing orders' that make the antidote more readily available in pharmacies around the country."

The biggest need in rural areas is for treatment facilities, and greater access to them. "Barriers include a federal policy that prohibits Medicaid from paying inpatient facilities with more than 16 beds," Bernstein notes. "The emergency declaration would allow HHS to grant waivers to any state requesting one."

In an editorial, The Wall Street Journal says innovative approaches are needed: "Education for prescribers has improved in recent years but more is needed from within the profession. Beyond better prescribing, the problem gets complicated fast. FDA Commissioner Scott Gottlieb said in testimony at a House hearing this week that the agency is supporting the development of alternative painkillers with less addictive features. Another priority is expanding access to naloxone."

Congress should "consider the government’s role in allowing too-easy access to painkillers, particularly among society’s poor and vulnerable," the editorial says. "A 2016 Centers for Medicare and Medicaid Services bulletin noted that “'Medicaid beneficiaries are prescribed painkillers at twice the rate of non-Medicaid patients”' and are three to six times more at risk for overdose." In Medicare, "500,000 beneficiaries received more than 120 mg a day for at least three months—equivalent to 12 tablets a day of 10 mg Vicodin. That figure excludes patients with cancer or in hospice, who tend to need heavy pain meds. The only way to explain this cascade of pills is an epidemic of fraud."

Daily Yonder: Both parties to blame for failure to protect small meatpackers from corporate giants

"The U. S. Department of Agriculture announced last week that it was throwing out Obama administration rules that would have provided basic legal protections for poultry and livestock producers who are under contract with corporate meatpackers. The move illustrates the clear divisions within agricultural policy and shines a spotlight on the confusing and frustrating debate happening throughout farm country," Bryce Oates reports for The Daily Yonder. The Trump administration first delayed the implementation of the rules in March.

The Farmer Fair Practices rule would have updated how a USDA agency, the Grain Inspection and Packers Administration, handles anti-trust enforcement. That would have given small contract meatpacking outfits more power to compete with the huge agribusinesses that increasingly dominate the industry.

In what Oates calls the best analysis of the issue he's seen, The New Food Economy writes that the update to the GIPSA rules would have "made it a little easier for poultry and livestock farmers to sue processors or meatpackers over unfair treatment by updating language in the Packers and Stockyards Act of 1921 to clarify a stance USDA and GIPSA have long held: that farmers shouldn’t have to prove 'competitive injury' (that their buyers have done something to impact all farmers in their position, as a class) in order to pursue legal action." The rule change would have especially affected the chicken industry, where titans like Perdue and Tyson control most of the process.

Oates casts blame not only on the Trump administration, but on the Obama administration for delaying and watering down their proposals. "What is so galling is the lack of political representation on these issues by either party," he writes. "For Republicans of the current political moment, there’s an obvious hesitation to erect any rules and regulations whatsoever, even popular regulations that 'protect the little guy.' For Democrats, there is a lack of focus on actually fighting for and delivering on promises they make to family farmers."

This track record from both parties, he says, makes it easy for farmers to feel as though both parties have left them behind.

Wendell Berry says declining number of farmers limits grasp of economics, environmental policy

Wendell Berry (Photo by Guy Mendes)
In an interview with Time magazine's Sarah Begley, Kentucky writer-farmer Wendell Berry talks about why more people should live in rural areas and work the land through agriculture or animal husbandry. One big reason, he says, is that people who live in rural areas can better appreciate why we need to take care of our environment through policy -- an area in which activists have mostly failed.

"The more people who live in cities, the fewer there are who have knowledge of what I'm calling the economic landscapes. So that's the wrong way to get a lobby for better land care. There's nobody lobbying for the best use of farming and forest and mining landscape," Berry says. "For land use and land maintenance in those economic landscapes, we have done no good. We've not ever been able to put any meaningful restraints on the coal industry. They've done what they wanted to do. So-called farming has become increasingly dependent on toxic chemicals. There's still too much soil erosion."

Those who have never lived near a farm don't have that bone-deep knowledge of finite resources that comes from dealing with the vagaries of nature, Berry says: "This has been a dominant idea throughout our history: if you don't have it here, you can get it from somewhere else. If you use up this commodity here, you can't produce it here anymore, you've worn out the possibility here, get it from somewhere else. Or if you're short of labor or you're too good for certain kinds of labor, go to Africa and get some slaves. That recourse has haunted us, has plagued us to death." Read the whole interview here.

Illinois House rejects ban on 'bump stocks' in vote split along rural and urban lines, not party

In the wake of the deadly shooting in Las Vegas, politicians of both parties seemed interested in banning bump stocks, an accessory used by the shooter to make a semi-automatic weapon fire as rapidly as a fully automatic weapon. But the Illinois House rejected a ban on bump stocks Oct. 26, mainly due to votes from rural Democrats.

"State Rep. Martin Moylan's prohibition on 'trigger modifications' got only 48 of the 71 votes it would have needed to pass. Fifty-four members of the Democratic-controlled House voted against it," John O'Connor reports for The Associated Press. "Moylan's bill defined trigger modification as any after-market alteration 'intended to accelerate the rate of fire of a firearm,' which critics complained is virtually universal" and would hurt sports shooting, O'Connor reports.

O'Connor's story supports the theory that America's growing political divide is not just Democrats vs. Republicans, but also urban vs. rural.

Thursday, October 26, 2017

Trump picks Ky. engineer to run strip-mine agency

J. Steven Gardner
President Trump has nominated a Kentucky mining engineer, J. Steven Gardner, to head the Office of Surface Mining Reclamation and Enforcement in the Interior Department. OSM, as it is generally called, oversees state regulation of strip mining and the surface effects of underground mining. In a few states, it directly enforces the 1977 federal strip-mine law.

Gardner "was a frequent critic of environmental rules during the Obama administration, including those from the OSM," Devin Henry reports for The Hill. "In a February op-ed in the Lexington Herald-Leader, Gardner celebrated the repeal of an OSM rule protecting streams from coal mining waste. . . . When Gardner's name was floated for the position in August, the Sierra Club called him a 'horrible choice'." In Kentucky public-policy circles, he is known as an effective advocate who is willing to consider the other side's arguments.

Kentucky Resources Council Executive Director Tom FitzGerald, the state's leading environmental lawyer-lobbyist, told the Herald-Leader, “I think his great challenge will be stepping out of a role as a very visible pro-coal partisan, into the job heading an agency that was charged with protecting the public and the environment from the adverse effects of surface coal mining. I wish him every success in making that transition.”

Read more here:

Mining interests and Republican political leaders saluted the pick. Senate Majority Leader Mitch McConnell of Kentucky said, “Steve will be a strong leader and I look forward to the U.S. Senate considering his nomination.” The White House notice of Gardner's appointment said he was president of the Society for Mining, Metallurgy and Exploration. in 2015, was a member of the Kentucky Board of Licensure for Professional Engineers and Surveyors, and has served on the Kentucky Geological Survey advisory board.

In a statement issued by the Interior Department, Gardner said, "My whole life, I have been involved with mining on multiple levels, and I understand the importance of these issues to the communities we serve. I pledge to work every day on behalf of the men and women across this country who look to the OSM office as a partner in bettering life for all people on mining lands."

Family that brought us OxyContin, and arguably the opioid epidemic, is profiled in 2 magazines

Arthur Sackler (Wikipedia photo)
As President Trump prepared to declare a limited public-health emergency in response to the deadly opioid epidemic, Esquire magazine and The New Yorker published fascinating articles on the secretive family that made a fortune selling OxyContin and arguably spurred the epidemic: the Sacklers of New York.

If you've heard of the Sacklers, it's not likely in connection with drugs. The name is attached to art museums and university institutions all over the world. But the family has stayed mostly silent on the genesis of their multi-billion-dollar fortune. "The family’s leaders have pulled off three of the great marketing triumphs of the modern era: The first is selling OxyContin; the second is promoting the Sackler name; and the third is ensuring that, as far as the public is aware, the first and the second have nothing to do with one another," Christopher Glazek writes for Esquire.

Physician and pharmaceutical promoter Arthur Sackler bought Purdue Pharma in 1952 at the age of 39; his two brothers Mortimer and Raymond, also doctors, ran the business and bought out Arthur's share after he died in 1987. By that time, Purdue was in the process of developing OxyContin.

Purdue's aggressive advertising had helped Valium become America's most-prescribed medication in the 1960s. In the 1990s OxyContin succeeded partly for the same reason. OxyContin was popular for chronic pain sufferers because it didn't have the stigma of morphine. And though it was 50 percent stronger than morphine, many doctors incorrectly believed it was much less powerful -- a misconception Purdue actively encouraged. Doctors thought that addicts would stay away from a time-released narcotic, but it was the opposite: OxyContin had a breakthtaking amount of oxycodone in one pill, and addicts soon discovered they could access it all at once by crushing the pill and snorting it.

"The vehicle of that fortune was OxyContin, but its engine, the driving power that made them so many billions, was not so much the drug itself as it was Arthur’s original marketing insight, rehabbed for the era of chronic-pain management," Glazek writes. "That simple but profitable idea was to take a substance with addictive properties—in Arthur’s case, a benzo; in Raymond and Mortimer’s case, an opioid—and market it as a salve for a vast range of indications."

Patrick Radden Keefe writes for The New Yorker, "Sales representatives marketed OxyContin as a product 'to start with and to stay with.' Millions of patients found the drug to be a vital salve for excruciating pain. But many others grew so hooked on it that, between doses, they experienced debilitating withdrawal. Since 1999, two hundred thousand Americans have died from overdoses related to OxyContin and other prescription opioids. Many addicts, finding prescription painkillers too expensive or too difficult to obtain, have turned to heroin. According to the American Society of Addiction Medicine, four out of five people who try heroin today started with prescription painkillers."

In 2007, Purdue Pharma agreed to pay a civil penalty of $600 million for misleading doctors, patients and regulators about the addictive nature of OxyContin. That avoided a trial and testimony, but Richard Sackler had to give a deposition in a suit filed by the state of Kentucky, similarly charging the company with deceptive marketing that had created the epidemic, costing the state dearly. The suit was filed in Pike County, at the eastern end of the state; in a bid to get the case moved, Purdue Pharma did a survey that “was revealing in ways that Purdue may not have intended: according to the filing, twenty-nine per cent of the county’s residents said that they or their family members knew someone who had died from using OxyContin,” Keefe reports. “Seven out of ten respondents described OxyContin’s effect on their community as “'devastating.'”

The case was settled for $24 million, but not before Richard Sackler had to give a deposition, Keefe reports: “Tyler Thompson, the lead attorney, told me that Sackler’s demeanor during the session reminded him of Jeremy Irons’s portrayal of Claus von B├╝low, the aristocrat accused of murdering his wife, in the 1990 bio-pic 'Reversal of Fortune.'  "A smirk and a so-what attitude—an absolute lack of remorse,' Thompson said. 'It reminded me of these mining companies that come in here and do mountaintop removal, and leave a mess and just move on."” The deposition remains sealed; Purdue Pharma is appealing the judge's ruling, in a suit by the medical-and-science news site Stat, that it should be public.

There's much more in the two long articles, but here's a passage from Esquire with ironic resonance. In a memoir, Arthur's second wife Marietta Lutze said he became obsessed with collecting art: 
"Boxes of artifacts of tremendous value piled up in numerous storage locations," she wrote. "There was too much to open, too much to appreciate; some objects known only by a packing list." Under an avalanche of "ritual bronzes and weapons, mirrors and ceramics, inscribed bones and archaic jades," their lives were "often in chaos. . . . Addiction is a curse, be it drugs, women, or collecting."

Rural infant mortality rose 5% in 2014-15

New statistics from the federal Centers for Disease Control and Prevention show that infant mortality rose 5 percent in rural areas from 2014 to 2015, and the rural infant-mortality rate was 25 percent higher than it was in large urban areas. Infant mortality has long been higher in rural areas, especially for black infants, but these new figures show an across the board increase in mortality for all rural infants.
Overall infant mortality decreased from 2007 to 2015, but rural areas are still worse off
than other areas. (CDC chart; click on it to enlarge)
The figures are alarming, but must be considered in context. Infant mortality as a whole dropped in all areas from 2007 to 2015 and is low overall. So that means any increase in infant mortality can move the statistical needle a lot. In raw numbers, rural areas went from 6.55 deaths per 1,000 births in 2014 to 6.8 deaths per 1,000 births in 2015. In urban areas the rate stayed about the same at 5.4 deaths per 1,000 births in both years. Comparatively, the death rates from 2007 were 7.5 deaths per thousand in rural areas and 7.1 per thousand in urban areas.
CDC chart; click on it to enlarge.
Lack of access to adequate health care is the most likely reason for the discrepancy between urban and rural infant mortality; the fact that more and more rural hospitals are closing their doors, and over half of all rural hospitals lack obstetric units could be reasons for increased rural infant mortality from 2014 to 2015. Women who have difficult deliveries can't get to a well-equipped hospital in time to help save the baby, and women who have a hard time accessing general health care may not receive adequate prenatal care.

Trump OKs drone experimentation plan; could make use and deliveries easier in rural areas

An delivery drone. (Amazon photo)
"President Donald Trump launched a program on Wednesday to expand testing of drones to include flights over people, nighttime operations and flights out of sight of the operator," David Shepardson reports for Reuters.

"The pilot program aims to speed up the integration of unmanned aerial vehicles into the national airspace system and test drone detection and tracking while waiving some limits on their use." That could benefit rural areas, and make use of them in agriculture more practical. Drones also could be used to deliver life-saving medications to remote areas, and retail giants like Amazon could deliver packages for less. UPS and FedEx charge extra fees to deliver packages to some rural areas.

Trump's Oct. 25 memo means "states and local governments would be able to seek Federal Aviation Administration approval for testing and expanded use," Shepardson reports. "The White House stopped short of proposing new regulations that would allow broader nationwide use of drones or any timetable for new authority. The memo said the Transportation Department could allow drone flights at up to 400 feet with the goal of approving at least five pilot projects. The program would expire in three years."

The Transportation Department website said that the cost of the program will be revealed soon.

Wednesday, October 25, 2017

Tight-lipped, family-owned firm, started 3 years ago, is already 6th largest owner of U.S. papers

Adams Publishing Group, a newspaper firm that is barely three years old, has bought more than 100 small dailies, weeklies and shoppers in at least 15 separate transactions," Poynter Institute media-business analyst Rick Edmonds writes for the Iowa Newspaper Association's INA Bulletin and for Poynter. That makes it the nation's sixth-largest owner of newspapers, according to a March 2017 report by Visiting Professor Carol Wolf for the University of North Carolina's Center for Innovation and Sustainability in Local Media. About half its papers are in Minnesota, where it is based. UPDATE, Oct. 30: The company announced Oct. 26 that it had bought from Champion Media several papers in the Mount Airy, N.C., area, just east of an area where it has weekiles.
Center for Innovation and Sustainability in Local Media map; click on it to enlarge
"In contrast to other big consolidators, they often leave existing management in place, do not impose cookie-cutter content templates, and do not start by stripping down newsrooms of editors and reporters," Edmonds reports. One example is its purchase of Jones Media, a Greeneville, Tenn.-based chain that was in its fourth generation of family ownership until patriarch John Jones died in 2016 and his descendants forced a sale over the objection of CEO Gregg Jones. He "chose to stay and has nothing but good things to say about the company," Edmonds reports, quoting him: "I'm working harder and enjoying myself more than I ever have. . . . These are the kind of people we want buying newspapers."

CEO Mark Adams rarely speaks
publicly about the firm he runs.
Edmonds couldn't elicit comment from the company, and called it "secretive." The firm is part of a diversified portfolio owned by "billionaire investor Stephen Adams and his family," who "have flown largely under the radar, unknown to those outside the industry," the UNC report says. "The company looks to buy non-metro publications where the newspapers or groups have revenue of about $10 million, said Larry Grimes, of W.B. Grimes & Co., a Gaithersburg, Md.-based mergers-and-acquisitions advisory firm specializing in media properties. Adams Publishing looks for large niche markets and buys within a geographic region. So far, the company has focused primarily on purchasing papers in the Midwest, but it owns publications as far east as the Jersey shore."

Study looks at states' ambulance use to guide policy; many areas run short of paramedics, EMTs

Kentucky, Alabama, South Carolina, Tennessee and West Virginia were the top five states in the use of ambulances in 2012-14, with Alaska, Arizona, Colorado, Hawaii, Nevada and Utah at the bottom of the list, according to a study aimed at helping policymakers make better decisions about their ambulance services, which provide a vital service to communities.

The study, conducted by the Rural and Underserved Health Research Center at the University of Kentucky, looked at Medicare beneficiaries using both ground and air ambulance services, the number of miles they were transported per year and per day, and the number of days of services they used in a year. The researchers said they used Medicare data because the benefits are the same nationwide, making it easier to make regional comparisons.

Parsing data by regional census divisions, the study found found that 13 percent of Medicare beneficiaries in the East South Central division (Kentucky, Alabama, Mississippi and Tennessee) used a ground ambulance service and traveled almost 33 miles per year, on average -- the most of any division. The typical usage in the region was two days a year, with an average trip of 16 miles.

The study found that in 2014, Medicare beneficiaries in New England had the highest ground-ambulance usage and the Mountain division had the lowest. It found those in the Southeast (East South Central and South Atlantic) traveled further per year and per day, and received transportation more often than other areas of the U.S. The West North Central states (Kansas, Missouri, Iowa, Nebraska, Minnesota and the Dakotas) were transported more miles per day per beneficiary, but also traveled fewer days per year. Air transportation was most prevalent in the West (comprising the Mountain and Pacific divisions), but the report points out that the number of people using air ambulance service was small compared to ground transportation.

"From our study, we believe policymakers and researchers need to consider differences across the regions of the U.S. when evaluating reimbursement and rules about usage," the researchers wriote. "When looking at changes in the supply of ambulance services in an area, we need to consider the current rate of usage of those services. An area which relies more heavily on these services would react differently to a change in policy than an area with lesser usage."

The report says many ambulance services are at risk of scaling back or closing their doors because of finances. Mike Poynter, the executive director of the Kentucky Board of Emergency Medical Services, told Kentucky Health News that one of the profession's greatest challenges is that policymakers and the public don't really know "what we do or how we do it." He noted that the training to become a paramedic lasts at least 18 months, and many paramedics have advanced degrees in emergency care. "We've got to do better in educating the decision makers on what we actually do and how vital our role is in the community." For the KHN report on the study, click here.

On 3-2 vote, FCC kills Depression-era rule that TV and radio stations must have local newsrooms

On a 3-2, party-line vote Tuesday, the Federal Communications Commission eliminated a
requirement that local broadcasters must maintain newsrooms in the communities they serve, the culmination of a six-month process that "eliminated requirements that have kept local news broadcasting a mainstay of local television," Mitch Herckis reports for Route Fifty. "The outcome will likely be the elimination of many American communities’ primary lens for understanding the impact of local politics and policies, as well as a primary source of guidance when emergencies occur."

Pew Research chart: Poll respondents'
sources of local news in 2016 and 2017
The “main studio rule” required every station to “maintain a main studio located in or near its community of license … to ensure stations would be accessible and responsive to their communities,” Herckis writes. It was enacted in 1939 to ensure that stations would be “accessible and responsive to their communities. However, a local main studio is no longer needed to fulfill those purposes,” an FCC fact sheet says.

"Broadcast stations now interact with their communities of license online, and technology enables them to produce local news even without a nearby studio," the fact sheet says, and the FCC argues that broadcasters will also save money by consolidating media services and running them out of main offices in urban areas.

"Together, these actions could mean a significant change in local television programming and have significant implications for the future of policy discussions at the state and local level," Herckis writes. While local-news blunders are often the butt of internet memes and jokes, the local news does provide a significant service, and local media newsroom elimination would have significant implications for state and local governing and public awareness."

The FCC's ruling bears added significance after an April decision to allow the merger of Tribune Co. and Sinclair Broadcast Group, "which would put the local television news of 70 percent of U.S. households in the hands of one company," Herckis writes.

Large rural manufacturers (100+ jobs) are just as innovative as urban ones, if not more so

"Large manufacturing firms in rural America are at least as likely as similar urban firms to use innovative methods that can contribute to job creation and increased earnings," Bryce Oates and Tim Marema write for The Daily Yonder, citing a new report.

The Department of Agriculture's Economic Research Service looked at data for non-farm rural economic sectors like manufacturing and services in 2010-14, when the overall economy was recovering from the Great Recession. Most of the rural manufacturers studied were in chemicals, pharmaceuticals, computers, plastics and textiles.

The results? About 53 percent of rural manufacturers with more than 100 employees were 'substantive innovators', compared to 49 percent of similarly sized urban manufacturers. "That means those firms did things like reform their business practices based on customer feedback, create new products or significantly modify old ones, analyze data to evaluate progress and efficiency, and use trade-secret protections like non-disclosure agreements or non-compete clauses," the Yonder reports.
USDA graphic; click on it to enlarge.
High scores in innovation matter because, as the study also showed, job growth is faster in highly innovative rural industries. During the time period studied, innovative manufacturers added 153,736 jobs, while non-innovative manufacturers added 130,345 jobs. "The strongest employment growth in the rural innovation sector during the economic recovery period came from transportation equipment, beverages and tobacco, machinery manufacturing, scenic/sightseeing transportation, fabricated metals, and data processing. For the non-innovation sector, the strongest growth was seen in mining support activities, water transportation, oil and gas, and pipeline activities. Significant decreases were found in the rural communications sector, including publishing, broadcasting, printing, and telecommunications," the Yonder reports.

The results are preliminary and will need more study, but it challenges the assumption that urban employers channel advantages like better internet connectivity or more potential skilled workers into more innovative practices, the Yonder reports.

Park Service seeks big entrance-fee hikes, mostly in West, for infrastructure and maintenance

The National Park Service wants big increases in entrance fees "at 17 of its most popular parks, mostly in the U.S. West," reports Felicia Fonseca The Associated Press. "Visitors to the Grand Canyon, Yosemite, Yellowstone, Zion and other national parks would be charged $70 per vehicle, up from the fee of $30 for a weekly pass. At others, the hike is nearly triple, from $25 to $70."

Most national parks and other Park Service sites do not charge entrance fees, Fonseca notes: "The 118 that do keep 80 percent of revenue for things like fixing restrooms, signs, trails, exhibits and campgrounds and send 20 percent into a pot to help other free park sites." The only Eastern parks affected would be Acadia in Maine and Shenandoah in Virginia.

Interior Secretary Ryan Zinke endorsed the increases as a 30-day public comment period on the proposal opened Tuesday. "The Park Service says it expects to raise $70 million a year with the proposal at a time when national parks repeatedly have been breaking visitation records and putting a strain on park resources," Fonseca reports. "It comes not long after many of the parks that charge entrance fees raised them. The rationale is the same this time around — to address a backlog of maintenance and infrastructure projects."

Other interests said the hikes might reduce visitation at parks. Kevin Dahl, senior program manager in Arizona for the National Parks Conservation Association, told Fonseca that Congress, not vistors, should bear maintenance costs should fall to Congress, not visitors. “We’ve supported increases at the parks,” he said. “They are a huge value for the price of entrance. But we want to look closely at this, and we want local communities to look closely at this, to see if it would impact visitation because we don’t want to price people out of the parks.”

Canned and frozen food industries try to unseat fresh produce in school lunch program for the poor

The federal government spends more than $16 billion each year on school meals, and lobbyists for competing food industries want a piece of that pie. Or a piece of that fruit. At the center of contention is the Fresh Fruit and Vegetable Program, a successful $177 million initiative that makes sure kids in even the poorest schools get fresh produce every day. In 2008, Democratic Sen. Tom Harkin of Iowa got Congress to say that the produce must be fresh -- a move that displeased lobbyists for makers of processed food. "This fall, with Congress likely to take up legislation to reauthorize child nutrition programs, the canned and frozen lobbies believe it’s their moment to change the rules—and the retired Harkin won’t be there to stop them this time," Helena Bottemiller Evich reports for Politico.

The lobbyists insist that fruits and vegetables in all forms are healthy choices, which is mostly true, but supporters of the initiative say that kids are much more likely to make a habit of eating fruits and vegetables in any form if they're first introduced to the fresh version. "Harkin argues that the goal of the program is to introduce kids to fresh fruits and vegetables, period. Some kids, particularly in high-poverty areas, had never seen a fresh pear or carrots with the stems on, or even fresh grapes, before getting the snack program at their school," Evich reports. Federal expenditures on fresh produce are vanishingly small, accounting for less than 2 percent of the $670 million the Department of Agriculture spent on fruit and vegetable commodities in 2014.

The outcome of the jostling is uncertain, though the lobbyists have some supporters. "Reps. Bruce Poliquin (R-Maine) and Kurt Schrader (D-Ore.) this week introduced a bill that would expand the Fresh Fruit and Vegetable Program to include frozen, canned, dried and pureed fruits and vegetables," Evich reports. "The effort already has the support of a number of key Republicans and Rep. Marcia Fudge (D-Ohio), an influential member of the House Education and the Workforce Committee, which is working on a broader bill to reauthorize child nutrition programs."

Federal judge dismisses suit by New Mexico ranchers who cited families' centuries of grazing

Part of the grazing land in question. (Photo by Luke Jones)
"A group of Hispanic ranchers has been dealt a blow in their years-long feud with the federal government over grazing rights on land in New Mexico that has been used by their families for centuries," Susan Montoya Bryan reports for The Associated Press.

At issue is the Forest Service's 2010 decision to cut grazing permits by 18 percent in the Alamosa and Jarita Mesa historic land grants, despite acknowledging that descendants of Spanish colonists have a unique relationship with the land. The ranchers sued, saying that the agency didn't consider the social and economic harm that would result in the high-poverty region, where many depend on land subsistence. They say the agency has a responsibility to remember that Hispanics' property rights have been ignored and institutional bias has been allowed to continue over the years. 

But in a recent ruling, a federal judge "dismissed remaining counts against the government, finding that the National Environmental Policy Act does not require the Forest Service to consider social and economic effects that are a direct result of an agency's action," Bryan reports. He ruled that the law narrowly centers on effects to the physical environment.

"The Forest Service has argued that management practices by the ranchers contributed to overuse of meadows in the two allotments and that grazing conditions needed to be improved by limited livestock," another AP story reports. The decision may be a death blow to the ranchers' case, which was first filed in January 2012.

Mental-health help scarce in Appalachian coalfield

A story from Kaiser Health News highlights the difficulty many rural Appalachians face in trying to get mental-health care. The story zeroes in on Wyoming County, West Virginia, where a visit to the nearest psychiatrist can be time-consuming and expensive, and lengthy wait times between appointments are the norm. "There are no psychiatrists in Wyoming County. A handful of small, general medical practices, a small telemedicine program and a few behavioral health specialists handle services for the 21,763 residents. Patients’ issues — ranging from depression, anxiety, addiction and other mental health concerns — are aggravated by the local economic downturn," Vickie Connor reports.

Local general practitioner Joanna Bailey told Connor that about 30 percent of her caseload is mental health care, which is "way more" psychiatry than she's comfortable with, but does send patients who need specialized help to the closest psychiatrist in Beckley, W.Va.  But many patients don't drive and must rely on a van service or relatives to ferry them, and it can take more than a month to get an appointment.

A Wyoming native, Bailey says the economic downturn from the collapse of the Central Appalachian coal industry has caused a lot of the trauma her patients face. “We haven’t had growth, and a lot of people are unemployed right now," she told Connor. "That’s traumatic to families on every level."

Untreated mental health issues can cause a "vicious cycle" for parents and children. "Those children grow up with the same mental-health issues because they’ve watched the same unhealthy relationships their whole life," Bailey said. "It’s just a cycle of abuse and trauma." It can also contribute to other health issues such as chronic pain and substance abuse.

To help general practitioners treat mental health patients, West Virginia University has a program called the Extension for Community Healthcare Outcomes, which provides specialists from the college for rural health care providers to consult with. The university recently received a federal grant to provide psychiatric services through video conferences to residents in Wyoming and McDowell counties.

Tuesday, October 24, 2017

Blue Cross of Okla.'s rate cuts would be 'another nail in the coffin of rural hospitals,' one says

Sperling's Best Places map
Blue Cross Blue Shield of Oklahoma wants deep rate cuts that some rural hospitals say they can't afford. If the hospitals can't comply with the insurance company's demands, hospital officials say they can't remain in-network. "Don Buchanan, CEO of
Haskell County Community Hospital in Stigler, said BCBS intends to cut the hospital's reimbursements by 30 percent for all services, except those in the emergency room. The current contract runs out Oct. 31, and if BCBS doesn't change its intention by then, the hospital will have to stop taking that form of insurance, he said," Meg Wingerter reports for The Oklahoman.

BCBS wouldn't discuss the specifics, but told The Oklahoman that it makes "every effort" to keep insurance affordable and accessible while providing "fair and equitable reimbursements." If a hospital leaves the network, insured members can search for other options on the BCBS website. The trouble with that is two-fold for rural residents: going to an out-of-network hospital is usually much more expensive, and traveling long distances for medical care is difficult. Haskell County has only one hospital, so patients might have to drive 50 miles to find an in-network hospital. Buchanan said that many of the 6 percent of the county's patients with BCBS insurance are older and would have a hard time driving that far. It would also be a problem for women delivering babies.

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At Drumright Regional Hospital, CEO Tracy Byers says the proposed cuts range from 30 to 40 percent. About 15 percent of the hospital's patients have BCBS insurance, so he says the rate cut would cost the hospital $1 million every year. The hospital can't afford to offer services at a loss, and may stop accepting BCBS insurance.

Mike Murtha, president of the National Alliance for Rural Hospitals, said rural hospitals are already struggling, and the BCBS cuts could cause some to close. "Losing a hospital would have repercussions for the surrounding community, because businesses won't want to set up in a town without a hospital nearby, Murtha said. If BCBS doesn't change its intention, the alliance will start working on suggested regulations to protect rural hospitals, such as mandatory minimum payments, he said," Wingerter reports.

Buchanan said his hospital will keep negotiating with BCBS until the last second. If the cuts are enforced, he says "It's just another nail in the coffin of rural hospitals."

Repair of near-collapsed dam to cost $500 million; U.S. has thousands of aging, high-hazard dams

Construction crews repair the Oroville Dam
(Photo by Calif. Dept. of Water Resources)
"The costs to repair the nation's tallest dam after a nearly catastrophic failure of the spillways will top $500 million, nearly double the original estimate of $275 million," Jonathan Cooper reports for The Associated Press. When the spillways for the 770-foot tall Oroville Dam ruptured in February, nearly 200,000 people were evacuated while the dam was stabilized.

But that $500 million figure only includes repair costs by the main construction contractor, Kiewit Corp. The state will also have to pay for other contractors as well as the emergency responders who helped in the immediate aftermath of the disaster. Erin Mellon, a spokesperson for the California Department of Water Resources, said the cost for the emergency responders alone is estimated at $140 million to $160 million.

The Federal Emergency Management Agency has reimbursed some of the costs for the emergency response, but it's unclear whether it will fund long-term repair work. California state officials say they hope FEMA will pay up to 75 percent of that bill, Cooper reports.

The narrowly-avoided disaster calls attention to the nation's aging dam system. The U.S. has thousands of high-hazard dams, and visual inspections alone can't predict if a dam is in danger of failing. Even small dams can cause major damage when hit by powerful storms. And because of climate change, even more extreme weather is likely on its way. That's prompted calls for more federal involvement in design and operations parameters for dams, Jeremy Jacobs reports for Energy & Environment News. The federal Bureau of Reclamation has a program to do just that, but President Trump's 2018 budget proposal calls for eliminating the program's budget, which ranges from $1.5 million to $3 million.

Amid bumper soybean and corn crops, some Iowa farmers are looking at fourth straight year of losses

Roger Zylstra harvested soybeans on one of his fields near Kellogg, Iowa, Oct. 18.
(Des Moines Register drone photo by Rodney White and Michael Zamora)
Many Iowa farmers are looking at the fourth consecutive year of losses on their crops, Donnelle Eller reports for The Des Moines Register: "Here are some numbers worrying Nodaway farmer Bill Shipley: He could get $8.96 for each bushel of soybeans he brings to his southeast Iowa elevator. But the statewide average cost is over $9 a bushel. Corn prices are even more grim: Iowa farmers could potentially lose 30 to 40 cents per bushel, with prices around $3 at Iowa elevators, based on estimates from Chad Hart, an Iowa State University economist."

Iowa's soybean and corn crops, respectively, are expected to be the second and third largest ever, part of the largest-ever soybean crop and second-largest corn crop in the U.S. as a whole. "U.S. farmers are expected to see a 3.1 percent increase in profits this year, thanks largely to improved pig, cattle and other livestock returns," Eller reports. "But Hart says Iowa farms will be lucky to see a 1 to 1.5 percent increase, given the state's large grain production." He told Eller, "For a good number of Iowa farmers, it will be a fourth year of losses."

The downturn, which cascades to farm equipment, crop insurers, fertilizer and seed companies, has created a shortfall in the state budget. "Since 2013, Iowa farm income has dropped $5.72 billion to $2.6 billion in 2016, U.S. Department of Agriculture data shows. Corn and soybean prices have dropped between 50 and 60 percent from highs in 2012, when the nation was gripped in a widespread drought," Eller reports. Her story is accompanied by photos and video from drones.

Rural Indiana county ends syringe exchanges, with one official citing moral grounds

Lawrence County, Indiana
(Wikipedia map)
"A Southern Indiana county has become the second [in Indiana] to end its needle exchange program over concerns it enables addicts — and one county official expressed moral objections as well," Leigh Hedger reports for the The Indianapolis Star.

The Board of Commissioners in Lawrence County (population 45,000) voted last week to end the two-year-old program, which provides intravenous drug users with clean syringes and collects used ones to reduce needle sharing that can spread blood-borne diseases like HIV and hepatitis C. The opioid epidemic has led to a rise in hepatitis C. County health officials wanted to extend the plan, but county prosecutor Michelle Woodward told commissioners she couldn't support facilitating illegal drug use, the Herald-Times in Bloomington reports.

County Commissioner Rodney Fish said he objected to the law on both moral and practical grounds. NBC News reports that he quoted 2 Chronicles 7:13-14, in which God says that, if he sends a plague among his people, he will "forgive their sin and heal their land" if they turn back to him. Fish told Maggie Fox of NBC that his practical objections stemmed from his heavy research with community health professionals, and "Few, if any of the health care professionals that I personally spoke with believe that the needle exchange program was an effective way of getting people into treatment programs." He said he could support a hospital-based program, though.

"The Centers for Disease Control and Prevention, Johns Hopkins University, the World Health Organization and former Indiana State Health Commissioner-now U.S. Surgeon General Dr. Jerome Adams, however, back evidence that shows the programs are a proven way to prevent disease," the Star reports. Christopher Abert of the Indiana Recovery Alliance was more blunt: "People are going to die" without the needle exchange, he told NBC. The program has contributed to a 50 percent drop in hepatitis C cases in Lawrence County this year, he says, and the grant-funded program costs the county nothing. Getting rid of the needle exchange could trigger long-term costs for the county and its citizens, though. Preventing one case of HIV saves $450,000 in lifetime costs, and preventing one hepatitis C case saves $90,000, he says.

Madison County, Indiana, ended its syringe exchange this month after complaints from a prosecutor about "dirty needles left in public places," reports Haley Bull of WXIN-TV in Indianapolis. The health department agreed to make only one-for-one exchanges in August, but that apparently did not satisfy local officials in the county of 130,000 (seat: Anderson) northeast of Indianapolis.

Small electrical contractor from rural Montana tapped to rebuild Puerto Rico's power grid

Pedestrians duck under a downed power line in Puerto Rico. (Photo: Angel Valentin, Vox)
A relatively untested Montana energy contractor has signed a $300 million deal to rebuild some of the power grid in Puerto Rico, which is still largely without power a month after Hurricane Maria. Though Whitefish Energy is only two years old, company spokesperson Chris Chiames says the company's experience with rebuilding power lines in the mountains of western Montana translates well to Puerto Rico, Tristan Scott reports for the Flathead Beacon in Kalispell. Chiames says Whitefish has had crews on the ground since Sept. 26, with 265 workers and contractors in country right now. That number that could grow to 1,000 by the end of the job, which he estimates will take months. The company's specific assignment is to repair and rebuild 100 miles of transmission lines on the western side of the island. The island has about 2,400 miles of transmission lines, roughly 80 percent of which was damaged by the storm.

The Puerto Rico Electric Power Authority took the unusual step of hiring Whitefish and other private companies last month to rebuild the island. Often after disasters, U.S. states activate mutual aid arrangements with other utilities, but it's unclear why Puerto Rico didn't. Congress is scrutinizing the decision to hire Whitefish and others because of concerns about bankrupt Puerto Rico's ability to pay.

Another reason Congress is paying attention: Whitefish, Mont., is the home town of Interior Secretary Ryan Zinke, and he and Whitefish CEO Andy Techmanski acknowledge knowing each other--but only because it's a small town where "everybody knows everybody," Zinke's office told The Washington Post. Both Zinke and Techmanski deny that Zinke had any role in scoring the job for Whitefish. The House Committee on Natural Resources is examining Whitefish's hiring because "The size and unknown details of this contract raises numerous questions," committee spokesperson Parish Braden told the Post. "This is one of many things the committee is taking a close look at as it continues to work with the resident commissioner, governor’s office, and oversight board to ensure Puerto Rico’s recovery is robust, effective and sustained."

CHIP reauthorization could stall in Congress until December; some states running out of money

It's been 24 days since the federal government let funding lapse for the Children's Health Insurance Program, which provides coverage for 9 million low- and middle-income children, and there's no clear resolution in sight. "This is an unprecedented moment for the CHIP program," Sarah Kliff reports for Vox. " Giving health insurance to low-income children is not controversial. The program has never courted the same controversy that the Affordable Care Act has. Instead, CHIP typically has widespread bipartisan backing among legislators on both sides of the aisle. Bills to expand CHIP typically pass with wide margins."

A congressional aide told Sam Baker of Axios that CHIP funding may not be restored until December because "the House is still fighting over the substance of its bill and floor time in the Senate is limited." The delay is likely to disproportionately hurt rural counties.

Most states have leftover funding to keep their programs running, for varying lengths of time. No children have yet lost coverage, but that's coming soon if the program is not reapproved soon. Five states (California, Arizona, Oregon, Washington, and Minnesota) have already received emergency funding to keep state CHIP plans going through the end of December, Politico reports. They and 26 more states, along with the District of Columbia, will run out of funds by the end of March 2018. All 50 states and D.C. will run out by summer.

The Politico article has a detailed run-down of how the lack of CHIP funding will hurt 13 states in the near future. But in general: "If CHIP funding runs out, many enrollees would be shifted over to Medicaid coverage instead. But roughly 4 million CHIP enrollees live in states whose programs aren’t linked to Medicaid, so those enrollees are at risk of losing coverage. In certain states, pregnant women could also lose benefits."

A Politico map shows when each state is expected to run out of money:

Monday, October 23, 2017

Drug-overdose death rate in rural areas surpasses urban rate due to increase among women

Rates of drug overdose deaths are now higher than in urban areas, due to an increase in the rate among women, according to a report released Oct. 19 by the Centers for Disease Control and Prevention. A chart with the report (click on it to enlarge) shows that among women, those in rural areas once had the lowest overdose-death rate among the six types of population areas, but now have the highest. Among men, those in rural areas had the lowest rate in 2015, just as they did in 1999.

The study found that while rural and metropolitan areas both saw an increase in overdose deaths, the rural and urban death rates converged in 2004, and rural areas edged out urban areas the year after. In 2015, the rural rate of 17 deaths per 100,000 people was slightly higher than the urban rate of 16.2. In raw numbers, metropolitan areas saw six times more OD deaths than rural areas, which have about six times fewer people than metropolitan areas.

Both rural and urban areas experienced significant increases in rates of people who reported using illicit drugs within the past month. But there were also significant declines in the percentages of people with drug use disorders among those self-reporting illicit drug use in the past year.

"The drug overdose death rate in rural areas is higher than in urban areas," said CDC Director Brenda Fitzgerald, M.D. “We need to understand why this is happening so that our work with states and communities can help stop illicit drug use and overdose deaths in America."

One possible reason is less availability of naloxone, known by the brand name Narcan, is rural areas. The drug that stops overdoses "is less often administered by emergency medical technicians-basics (persons trained to provide basic-level life support), who are more common in rural areas than paramedics (who can provide advanced life support care)," the report says.

Bipartisan ACA plan would affect relatively few, but disproportionately in rural areas, Republican states

Amid the hot debate over the proposed Alexander-Murray bill to repair Patient Protection and Affordable Care Act marketplaces, Drew Altman of the Kaiser Family Foundation throws in a word of caution: The bill is a narrowly focused effort that aims to fix a problem only affecting relatively few Americans. The reality check is necessary, he believes, because a recent KFF poll indicates that some people have the wrong idea about who's affected by changes in ACA plans.
Kaiser Family Foundation chart; click on it to enlarge.
"Many people will think it affects their insurance when, in actuality, it will have no impact on the vast majority of Americans who get their coverage outside of the relatively small ACA marketplaces," Altman reports. Because of that mistaken impression, "The public will be susceptible to spin and misrepresentation against the limited goals of Alexander-Murray: a bipartisan effort to stabilize the marketplaces by funding the cost-sharing reduction subsidies, providing more resources for open enrollment outreach, and expediting state waivers."

Bloomberg map; click on it to enlarge.
It should be noted that, though changes to the ACA marketplace plans won't affect most Americans, those it does affect will be disproportionately rural. It may end up hurting Republicans more too, since nearly 70 percent of the people who receive the cost-sharing subsidies live in red states.

Trump kills EPA plan to reduce biofuel mandate

After intense pressure from Corn Belt lawmakers such as Republican Sens. Chuck Grassley and Joni Ernst of Iowa, the Trump administration has backed down on efforts to reduce mandatory biofuel percentages in the nation's gasoline supply. Reducing biofuel requirements (which mostly means ethanol) in the Renewable Fuel Standard would hurt corn-producing states, which inspired a bipartisan uproar: Grassley threatened to hold up EPA nominees, and Democratic Sen. Tammy Duckworth of Illinois did more than threaten, citing the RFS as one of the reasons she placed a hold on two key nominations.

"Trump told Pruitt in a phone call late last week he needs to keep Grassley happy, according to multiple people familiar with the call," Amy Harder reports for Axios. Environmental Protection Agency Administrator Scott Pruitt promptly wrote a detailed letter to the main Congressional dissenters, assuring them that he won't alter the biofuels mandate.

Why the about-face? Harder speculates that, with higher-priority issues like tax reform and health care on the docket, Trump "needs GOP support everywhere he can get it." Also, as we reported last week, Grassley is the head of the Senate Judiciary Committee and could hit Trump where it hurts by holding up judicial nominees. He also has a hand in investigating Russia's role in Trump's election.

The petrochemicals industry, which was the driving force behind the proposed alterations, was not happy. Axios reports that Chet Thompson, president and CEO of the American Fuel and Petrochemical Manufacturers said Oct. 20, "It's frankly been very embarrassing to watch the administration bend its knee to its will to King Corn and these handful of senators."

By Nov. 30, the EPA must issue quotas for how much biofuel that refineries must blend into the gasoline supply. The oil-refining industry will probably attempt to change Pruitt's mind before then, Harder reports.

Minn. seasonal cabin owners shoulder much of local tax burden, say they have little local voice

Some 124,000 people who own cabins in Minnesota's lake country, many of whom live in the Twin Cities area, are paying a big share of the property taxes for the scenic vacation area. "In 10 of Minnesota’s 87 counties, they shoulder more than 40 percent of the residential property tax burden, according to data from the state Department of Revenue. And in several counties, they pay more than 50 percent," John Reinan reports for the StarTribune in Minneapolis. But cabin owners "say they often don’t feel like they have much voice in how that tax money is spent. That frustration has prompted many property owners in lake country to question the fairness of a system where counties rely so heavily on taxpayers who live there only a few months of the year."

Local officials in lake country often fail to contact seasonal cabin owners about local plans, such as a controversial lakeshore hotel development approved by the city of Detroit Lakes in 2015. Morrie Lanning, a former state legislator who tried to provide tax relief for cabin owners, told Reinan, "Your voice doesn’t count nearly as much as those who can vote in that jurisdiction." He said cabin owners in Otter Tail County (he's one of them) are particularly irritated that local school officials "kind of sell their [school] bond issues with the argument that a lot of the taxes are going to be paid by people who don’t live here." Here's a screenshot of the StarTrib's interactive map, showing the county with the largest percentage of residential property taxes paid by cabin owners:

Kansas pastor says future of rural churches is tied to the future of their communities

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A Kansas pastor has written a book exploring how rural churches can survive in a changing world. Brad Roth is the pastor of West Zion Mennonite Church in Moundridge, and has spent much of his life in rural areas, from his childhood on a farm in central Illinois to past ministry jobs in Washington state and Peru. In God's Country: Faith, Hope and the Future of the Rural Church, Roth argues that rural churches can thrive by making sure the community around them is thriving too, Patricia Middleton reports for The Hutchinson News.

Brad Roth
"It’s a way of thinking about the rural church that starts with where the church is at, rather than kind of an idealized vision of the church,” Roth told Middleton. "It begins in that place, but then dreams about where can the church go and how do rural communities thrive and grow."

He may be onto something, since an increased sense of community can help rural residents cope with problems when government resources are scarce. "Plugging into the daily lives of their communities is vital for churches to reach out to both members and non-members," Roth told Middleton.

Quick hits: how opioids hook brains; how renewable energy affects Midwest, Great Plains; a young black man's struggle to leave Harlan County

Here's a roundup of stories with rural resonance; if you do or see similar work that should be shared on The Rural Blog, email us at

Ever wonder how a brain gets hooked on opiods? Read and learn from this article from Kentucky PBS affiliate KET.

You've read about how renewable energy sources are important in rural areas of the Midwest and Great Plains. But infrastructure built to channel that energy also impacts rural areas. Read how in this study from the Center for Rural Affairs.

West Virginia Public Radio follows one young African-American man's journey to leave his native Harlan County, Kentucky, somehow. It's the first of a three-part series. Read it here.