Feds' proposal could encourage cuts in Medicaid reimbursement, hurt rural hospitals and doctors' practices

A proposal from the Centers for Medicare and Medicaid Services to cut Medicaid rates without oversight could trigger soaring uncompensated-care costs and facility closures at hospitals and medical practices, Virgil Dickson reports for Modern Healthcare. The changes would especially hurt rural areas, which serve a higher proportion of Medicaid patients.

"The CMS in March suggested that states cutting Medicaid rates by up to 4 percent in one year or up to 6 percent in two consecutive years would not need to conduct an analysis to determine if the cuts harm access to care," Dickson reports. "Comments on the proposal were due Tuesday." The CMS said the proposed rule would reduce states' administrative burden and wouldn't likely diminish access to care.

Casey Dungan, senior vice president of the Tennessee Hospital Association, told Dickson that rural hospitals would suffer because they can't afford to leave managed-care networks and don't have the leverage to negotiate rates to cover the cost of providing care to Medicaid patients. Medicaid already has lower reimbursement rates than commercial insurance and Medicare, so rural hospitals are already dealing with thin or non-existent profit margins.

"The proposal also doesn't account for thin Medicaid patient margins for primary-care physicians," Dickson reports. "A primary-care physician's profit margin is usually less than 4 percent a year, which means they are just getting by. Even modest cuts would wipe those margins out, putting access to care at risk, according to Dr. John Meigs, board chair at the American Academy of Family Physicians."

Some states would also no longer have to assess how easy it is for fee-for-service Medicaid beneficiaries to receive primary care, pre- and post-natal obstetric care, and specialty and behavioral health care. Fee-for-service populations are the most vulnerable Medicaid patients, and are more likely to include people with disabilities and those who need long-term support, Dickson reports.

Rural entrepreneurship development needs more funds, attention, writes Center for Rural Entrepreneurship founder

Don Macke

Recently, Dell Gines of the Federal Reserve Bank of Kansas City asked why entrepreneurship isn't a more mainstream development strategy in America. The answer is complicated, writes Don Macke, the co-founder of the Center for Rural Entrepreneurship and director of Entrepreneurial Communities at the CRE.

In the 1990s Macke was the executive director of the Nebraska Rural Development Commission and saw how Nebraska, like many other states, tried to lure businesses with tax breaks. But other factors ultimately drove companies' decision to come to Nebraska. But most economic development funding still tends to go toward attracting businesses, not helping entrepreneurs, Macke writes.

"Even where there are commitments to entrepreneurship-led development, we find folks struggling with how to proceed," Macke writes. "In most cases they are attracted to higher-profile solutions focused on specific ecosystem elements – more capital, incubators, accelerators, workshops and the like. We continue to struggle to get communities to understand the entrepreneurial talent they have, to take the time to identify what these entrepreneurs need and to focus their efforts on networking entrepreneurs to relevant solutions whatever they might be."

And many communities, especially the more rural ones, lack the capacity to engage in basic entrepreneurship development work, Macke writes. A support system for such communities would help, but few organizations exist that can build it. State development agencies focus most of their resources on attraction and business retention. Regional developmental organizations are often project- and grant-management focused. Development financial institutions focus on deploying capital but not so much technical assistance or building community capacity. And though there are many organizations that support entrepreneurs, rural entrepreneurs may not know about them. 

"Fortunately," Macke writes, "there are a growing number of promising initiatives and organizations making good progress using entrepreneurship as a leading economic development strategy."

Rural seniors are less likely to be vaccinated for pneumonia; rural pharmacists could play a major role in closing that gap

Seniors in rural areas are less likely to be vaccinated for pneumonia, and those that do get immunized are more likely to get the vaccine from a pharmacist than seniors in urban areas. That suggests that rural pharmacists could play a major role in filling the vaccination gap, Melissa Patrick reports for Kentucky Health News.

A national study by the Rural and Underserved Health Research Center at the University of Kentucky found that vaccination rates for pneumonia among Medicare patients are 40 percent lower in rural communities than in urban areas: 2.81 percent and 4.66 percent, respectively. It found that 72.5 percent of seniors vaccinated for pneumonia got the shot from a primary-care provider and 22.2 percent got it from their pharmacist. In rural areas, the pharmacists' share was 29.4 percent; in urban areas, it was 21.1 percent.

Rosemary Smith, a co-owner of six Jordan Drug stores in Eastern Kentucky, told Patrick that the vaccination rate in rural areas is probably lower because they have fewer health-care providers and most of "our people" are not "wellness oriented" -- but almost every community has access to a pharmacist. "They may go to their physician two or three times a year," she said, "but we see them two or three times a month sometimes."

The researchers note that the death rate from pneumonia for seniors doubles, from 20 percent to 40 percent, between the ages of 65 and 85, and despite the recommendation that everyone 65 and older get vaccinated for the disease, fewer than two-thirds do. Smith told Patrick, "The opportunities are there to really move the needle on these vaccinations. . . . I had no idea there was such a difference in the vaccination rate between urban and rural. So I think we can do more and I think as an independent pharmacy group across the state, being the most accessible health-care provider, that we will do more and we will take this study to heart."

Senator calls for probe of billing schemes at rural hospitals

At yesterday's Senate Finance Committee hearing on rural health, U.S. Sen. Claire McCaskill, D-Mo., called for a federal investigation of a rural Missouri hospital after reports surfaced of possibly fraudulent billing practices. "McCaskill has requested the top watchdog at the Department of Health and Human Services examine billings that occurred when a management company, Hospital Partners Inc., used Putnam County Memorial Hospital in Unionville as a pass-through for millions of claims for out-of-state laboratory services," Jenny Gray reports for the Fulton Sun.

Florida resident Jorge Perez controls HPI, which bought Putnam in September 2016. Perez also owns a Florida-based laboratory services business. Soon after Putnam's purchase, Perez began issuing billing for laboratory services from all over the country from Putnam, since hospitals receive higher reimbursement rates for services than do urban ones, Dan Margolies reports for KCUR-FM in Missouri.

The issue came to light after Missouri State Auditor Nicole Galloway audited Putnam in 2016 and found $90 million in questionable laboratory billings, Margolies reports. "An investigation by KCUR, KBIA and Side Effects Public Media found that businesses linked to Perez had bought or acquired management rights to about 20 struggling rural hospitals across the country and pursued the same controversial lab billing arrangements to salvage them." McCaskill said there may need to be limits on such billings.

Without any supporting evidence, McCaskill said "the same group" apparently was involved in a similar purchase and billing scheme at Chestatee Regional Hospital in Dahlonega, Ga., the first such case reported by David Axelrod of CBS News/

Small dairy farmers in 7 states get another month to find buyers, but prospects are poor; Wendell Berry weighs in

A cow looks into the milking room at a Kentucky
farm. (Courier Journal photo by Pat McDonogh)

More than 100 small dairy farmers in Indiana, Kentucky, Pennsylvania, Tennessee and three other states are facing doom because they can't find buyers for their milk. Dean Foods informed them in late February that it was terminating contracts because "Walmart no longer will buy Dean’s milk for its Great Value house brand, cutting the production needed at Dean’s Louisville plant, which the company announced will be shut down soon," Grace Schneider reports for the Louisville Courier Journal. "Walmart has started its own production facility in Fort Wayne, Indiana." Dean also cited an increase in milk production and a decrease in milk consumption as reasons for the termination in its letter to the affected dairy farmers.

This week Dean extended its initial May 31 deadline until the end of June, but farmers are still searching for new buyers or talking about forming cooperatives, with no luck so far. Losing these dairy farms could hurt the surrounding communities. Maury Cox, executive director of the Kentucky Dairy Development Council, said each cow generates $14,000 a year in economic impact from veterinary bills, feed, fuel and equipment, Schneider reports.

In a column last month for the Henry County Local, the weekly newspaper in his county, Kentucky author and farmer Wendell Berry suggested farmers should form their own cooperative as tobacco farmers led by his father did decades ago. "The story of Dean Foods’ cancelled contracts is a representative piece of the story of rural America since the 1950s, when Eisenhower’s secretary of agriculture told farmers to 'get big or get out,'" Berry wrote. "And so the story of rural America has been the story of the dispossession of millions of farm families, the disintegration of rural communities, and the destruction of small businesses and small towns."

Quick hits: Rural folks worry more about money; bump stock bans hit bumps; there is a rural creative class . . .

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 heather.chapman@uky.edu.

Personal finance: Americans' anxiety about their finances is worsening across the board, but rural residents are even more pessimistic: according to a Pew Research Center report, only 36 percent of rural Americans believe their financial situation will improve in the future, as opposed to almost half of those living in urban and suburban areas, Jacob Passy reports for MarketWatch.

Guns: Months after a deadly Las Vegas shooting, seven states banned the sale and possession of bump stocks, which enable semiautomatic rifles to fire at the rate of fully automatic rifles, and several other states are expected to pass bans soon. But states that have passed the ban are having a hard time enforcing it. New Jersey residents were supposed to turn in or destroy their bump stocks by mid-April, but "So far, New Jersey State Police say, they have not received a single one," Matt Vasilogambros reports for Stateline.

Rural innovation: "One of the most persistent myths in America today is that urban areas are innovative and rural areas are not. While it is overwhelmingly clear that innovation and creativity tend to cluster in a small number of cities and metropolitan areas, it’s a big mistake to think that they somehow skip over rural America," Richard Florida reports for CityLab. A series of studies from the Department of Agriculture's Economic Research Service digs into the drivers of rural innovation, and finds that not only are innovative businesses common in rural areas, but that rural innovation gets a boost from the arts. Read more.

"For all the ways Americans are divided today along urban and rural lines, the two groups are at least united in this: Majorities of both, according to a new Pew Research Center survey, believe that everyone else is looking down on them," Emily Badger reports for The New York Times.

New studies confirm black lung surge for coal miners

According to a slew of studies released Tuesday or expected to be released soon, "more coal miners in central Appalachia have suffered the advanced stages of the deadly disease black lung than previous government research has found, and more miners working in the region today have earlier stages of the disease," Howard Berkes reports for NPR.

NPR research in 2016 had shown the disease's impact to be far worse than research from the National Institute for Occupational Safety and Health, though later NIOSH research confirmed NPR's work. Previous studies of black lung incidence relied on federal black lung testing and surveillance, which was voluntary and only tested working miners. Black lung can take a long time to show up, so NIOSH was missing cases. "From 2011 to 2016, NIOSH counted just 99 cases of PMF nationwide. NPR, meanwhile, conducted its own survey of black lung clinics and legal providers and has found more than 2,000 cases in the same time frame," Berkes reports.

Kirsten Almberg and colleague Robert Cohen at the University of Illinois, Chicago, found more than 4,600 severe cases of the disease while combing through black lung benefit claims filed with the federal government since 1970. More than half the cases they found happened in the past 16 years, and they found sharp annual increases in the disease in central Appalachian coal mining states, Berkes reports.

"So it is certainly not a blip. It's not just a small spike. It's kind of a relentless and increasing progression of disease," Cohen told Berkes.

Rural strategy helps former Marine fighter pilot win Democratic primary for Kentucky congressional seat

Lt. Col. (Ret.) Amy McGrath celebrated after Tuesday's primary win.
(Lexington Herald-Leader photo by Alex Slitz)

The victory of former Marine fighter pilot Amy McGrath in Tuesday's Democratic primary in Kentucky's 6th Congressional District was based in part on a strategy of appealing to rural voters, especially through rural newspapers.

That was the idea of campaign manager Mark Nickolas, who had quit political work more than a decade ago and "had never worked in a campaign in the digital era," reports Michael Tackett of The New York Times. With the Democratic Congressional Campaign Committee pushing Lexington Mayor Jim Gray to get into the race, Nickolas "saw the Washington rebuke as an opportunity to run the campaign his way, without having to hew to the DCCC playbook. That meant buying ad space in small-town newspapers for opinion pieces by Ms. McGrath, buying billboard space, and building a field operation in rural areas where few Democrats have dared to even campaign in recent years."

The outsider strategy also left McGrath free to push "the message that the national party has abandoned its voters here," Travis Waldron reports for the Huffington Post. “The Democrats here feel left behind by the national party,” McGrath told him. “The national party, to them, is Washington D.C. They don’t have the same values. They’re led by San Francisco and New York. They don’t see leaders from here or the Midwest. And they’re focused on the wrong things.” Nickolas told Waldron, a Kentucky native: “You can be a progressive and still do well in more conservative areas, as long as those rural voters get a sense that you’ll fight for them.”

McGrath had plenty of money from outside Kentucky, thanks to an announcement video that went viral, but she also sought out interviews with weekly editors like Ben Carlson of The Anderson News, who complimented her in a column and then did a long story about her. Carlson told Waldron, “I haven’t sensed, in a congressional race, this kind of enthusiasm for a candidate in the 12 years I’ve been running the paper. For either party. She’s brought that kind of excitement to it.” McGrath won the county by more than 2-1 over Gray and got 61 percent of its vote, her highest county share. The primary had four other Democrats seeking the nomination to face three-term Republican Rep. Andy Barr. She carried every county but Fayette, Gray's base, and won 49-41.

The 6th District covers most of Kentucky's
Bluegrass Region. (National Atlas map)

"Still, for much of the race, the DCCC seemed to have made the right calculation," Tackett reports. "In March, a survey for Mr. Gray, which his campaign released in April, showed he was up by 25 points with a little more than a month left in the race. It was sobering — but [McGrath] was campaigning aggressively in rural areas, and followed through on her plan to stay positive. . . . Nickolas continued his quirky tactical moves, which included making yard signs for individual counties, and one for rural areas in Marine red rather than Democratic blue."

In the time between Gray's poll was taken and released, McGrath was catching up to him, breaking into the lead in mid-April. Waldron reports, "In a direct appeal to the rural parts of the district, she’s advocated for an expansive role for the federal government, arguing that it should invest heavily in broadband, infrastructure, and job and economic development in areas left behind by the decline of manufacturing and the collapse of the coal industry," which has a very small footprint in the district but many transplants from the Central Applachian coalfield.

McGrath's win sets up "a November election that will attract national money and attention as Democrats try to make Kentucky part of a possible blue wave in 2018," Daniel Desrochers, Lesley Clark and John Cheves wrote for the Lexington Herald-Leader in Lexington. They called her a "candidate who fits the Democratic moment . . . a political newcomer at a time Democrats across the country are looking for a fresh response to the 2016 election of President Donald Trump."

Wyoming approves hunting of grizzlies near Yellowstone

"State wildlife officials approved plans on Wednesday for Wyoming’s first season of grizzly bear hunting in 43 years, a move cheered by sportsmen but decried by Native Americans and conservation groups fighting to restore Endangered Species Act protections to the bears," Laura Zuckerman reports for Reuters.

Last June the U.S. Fish and Wildlife Service announced that grizzlies would no longer be listed as a threatened species around Yellowstone National Park, which left management of the bears to the governments of the three states bordering Yellowstone: Wyoming, Idaho and Montana. 

Hunters in Wyoming will be allowed to shoot and kill as many as 22 grizzly bears during hunting season, which begins Sept. 1. Two weeks ago, Idaho approved a more conservative plan that allows hunters to take only one grizzly during its hunting season, which also opens Sept. 1. Montana decided not to open a grizzly season because of worries about the long-term recovery of the bear population, which brings in money in ecotourism.  

"Grizzlies also are at the heart of a cultural divide between Native Americans, who revere the bears, and ranchers and others who see the creatures as potential threats to livestock and impediments to more mining, logging and fossil energy development," Zuckerman reports.

How six small papers joined forces to cover the opioid crisis in Long Island with the East End News Project

Six newspapers, including dailies and weeklies and representing three different media companies, came together recently to cover the impact of the opioid epidemic on eastern Long Island in New York. Their coverage of a candlelight vigil in Hampton Bays last week launched the East End News Project, with about a dozen journalists spread out in the crowd, capturing the stories of people who have been hurt or lost loved ones.

Participating papers include "the Times Review Media Groups’ weekly Suffolk Times and Riverhead News-Review and the Shelter Island Reporter; the Press News Group’s weeklies, The East Hampton Press and the eastern and western editions of The Southampton Press; the weekly The Sag Harbor Express and journalism students at Stony Brook University," Kristen Hare reports for Poynter.

The scope of the story was too big for the papers to cover on their own, so the papers decided to band together, despite their normal attitude of friendly competition. "With the East End News Project, the goal is not just to tell bigger and more personal stories, but to confront the opioid epidemic as a community," Hare reports. "They want to offer resources, help humanize and destigmatize people dealing with addiction and examine the medical industry’s role and response to the crisis."

The Stony Brook University students have been able to pitch in thanks to a three-year, $150,000 grant, which Stony Brook Journalism School's founding dean Howard Schneider told Hare will put "more boots on the ground" and add "an influx of talent, enthusiasm and ambition and also multimedia capabilities that some of our other partners might not have."

The project will continue for the rest of the year, but they're considering future partnerships. "We are competitors, but we’re all in this together," said Joseph Shaw, executive editor of the Press News Group. "The future for us as an industry is about doing good work, and if we can pull together to do better work together than we do individually, I think that’s crucial."

Bills filed to boost telemedicine, help opioid addicts

A bipartisan group of senators has introduced five bills to increase access to telemedicine treatment for patients with substance-abuse disorders; the proposed bills will likely be included in a larger legislative package by the Senate Finance Committee. "The new bills look at everything from breaking down geographical restrictions of telemedicine to setting best practice for treating kids with substance abuse disorder through telemedicine," Laura Lovett reports for MobiHealthNews. Telemedicine is a boon to rural areas, which generally lack the resources urban areas have in treating substance abuse problems. 

The five bills include a proposal that Medicaid eliminate originating-site geographic restrictions for telemedicine. Another calls on the comptroller general to evaluate access to telemedicine and remote monitoring services to treat pediatric Medicaid patients with substance-abuse disorders. And another bill would require the Department of Health and Human Services to advise states on federal reimbursement for substance-abuse treatment under Medicaid using telemedicine, Lovett reports.

"In addition to the telehealth-focused bills, the legislation package is expected to include . . . a change to the Social Security Act so that a screening for potential substance use disorders and a review of current opioid prescriptions would be part of the initial preventive physical exam and annual wellness visit in the Medicare program," Lovett reports. It will also include a proposal that "the HHS secretary provide guidance to states about Medicaid items and services for non-opioid pain treatment and management."

The Senate Finance Committee met for a 9 a.m. hearing today to discuss hospital closings, Medicare payment programs and other challenges facing rural providers, reports Politico. More on that tomorrow.

Florida retirees increasingly moving to Appalachia

Florida is a well-known destination for retirees, but increasing numbers of Florida transplants, dissatisfied with life in the Sunshine State, are retiring in Appalachian communities in North Carolina, northern Georgia and eastern Tennessee. "These retirees are reshaping local economies, boosting everything from tax revenues to restaurant receipts to sales of electric chair lifts for the elderly," Cameron McWhirter reports for The Wall Street Journal. "Along the way, they are chafing locals who say the migration is pricing them out of homes and bringing in a sort of big-city brusqueness.

The "halfback" phenomenon — so called because retirees are moving halfway back up north — was already popular in the early 2000's, but halted during the Great Recession and returned slowly afterward, as many retirees weren't able to sell their Florida homes. Today it's back in full force: though net migration to all U.S. retirement-destination counties increased 67 percent from 2010 to 2017, net migration to Appalachian retirement destinations in Georgia, North Carolina and Tennesse increased 169 percent, according to University of Virginia demographer Hamilton Lombard, McWhirter reports.

Former New Yorker Marty Stefanelli and his wife initially retired to West Palm Beach, Fla., but decided to move to rural North Carolina. "I need to find time to wind down, and Blue Ridge forces you to wind down," he told McWhirter. The Stefanellis said they like the area's moderate weather, lack of traffic, and lower cost of living and taxes.

Farms increasingly owned by non-farmers and rented out

U.S. Department of Agriculture map

Farmland is a kind of currency: valuable because of what it can do, and because it's finite. And though rental of farmland isn't increasing -- the number of acres rented has been around 40 percent for the past 40 years, according to the the U.S. Department of Agriculture -- what's changing is the landlord. "The landowner is increasingly not the farmer next door or a landlord intimately involved in the farming operation," Erin McKinstry reports for The Midwest Center of Investigative Reporting. "Instead, many farmers rent from multiple owners who may have little to no connection to farming or the local community and who may own land strictly for investment purposes."

In the Midwest, about 46 percent of the farmland is rented; around 81 percent of those landowners do not farm. Some see that as a good thing, saying it puts more capital into rural communities and makes arable land affordable for farmers who could not outright buy it. "Others see it as one more barrier for farmers trying to access land or expand their operations," McKinstry reports. "They worry that the trend has driven up farmland prices, led to irresponsible conservation practices and drained money from rural economies."

It's difficult to assess trends, since statewide and USDA data can be spotty, but the phenomenon of absentee farm owners appears to be increasing, especially in the most fertile parts of the Midwest. It may continue to increase as more land-owning farmers retire and pass their farms down to their children. Some may not want to farm and rent it out, and some may sell it to investors.

Annual National Rural Assembly focuses on civic courage in the building of an inclusive nation, offers lots of stories

The annual three-day conference of the National Rural Assembly ends today in Durham, N.C. It's a network of organizations and individuals focused on improving conditions in rural America, coordinated by the Center for Rural Strategies. This year's discussions centered around "how we build a more inclusive nation, viewed through a lens of civic courage," says the assembly's website.

Carol Blackmon and Anita Earls embodied that theme and spoke at this year's assembly, Bryce Oates reports for The Daily Yonder, published by the center. Blackmon helped black voters register in the Deep South in the 1960s and is still a civil-rights activist. Earls, an attorney who founded the Southern Coalition for Social Justice in 2007, successfully challenged North Carolina voting laws that disenfranchised minorities, and is running for a seat on the state Supreme Court.

The conference also featured several "Firestarter" speakers who shared how they sparked change in rural communities. Chris Poore of Yonder profiled several and shared videos of their talks, including:

• Liz Shaw, who organized the Appalachian Ohio and West Virginia Connectivity Summit in an effort to bring broadband to Appalachian regions of both states. Read more here and see the video.
• David Toland, the CEO of rural revitalization advocate Thrive Allen County in Kansas, who said one of the biggest obstacles to bringing positive changes to rural areas is the notion that most efforts will fail. He urged listeners to ask community members what changes they'd like to see, start small if necessary, and build on what community members suggest. Read more here and see the video.
• Magaly Licolli, executive director of the Northwest Arkansas Workers Justice Center, who fights for labor rights for immigrant workers in Arkansas. "Southern politeness" can be one of the biggest obstacles to justice and fairness, she advised, and said it's important to challenge comfort zones. "We will not effect change by caring about the feelings of people with privilege," she said in her talk. Read more here and see the video.
• Anita Earls, mentioned above, said she worries about what she sees as a trend of ignoring many community voices. "What I see us facing right now is a true threat to our democracy, " Earls said. "We now have forces that don’t believe in the importance of having every voice at the table." Read more here and see the video.

As drug makers lobby policymakers with advertorials, Trump plan to cut drug prices is short on details

Trudy Lieberman

Veteran health journalist and columnist Trudy Lieberman is back with another "Thinking About Health" column for the Rural Health News Service after enduring her own health crisis that kept her from writing for four months. In her latest column, she ponders the Trump administration's plan for dealing with America's high drug prices. The pharmaceutical industry is reportedly relieved at the proposal, which a Wall Street Journal story described as falling short of "more far-reaching ideas."

"The plan continued the current system under which the government does not negotiate the prices it pays for medicines under the Medicare program, a far-reaching solution that I’ve discussed before in this space," Lieberman writes. "The 2003 law that gave seniors a drug benefit under Medicare prohibited such negotiations, which pharmaceutical manufacturers loudly and forcefully opposed. They feared that allowing the government to use its muscle to bargain over drug prices might slow their escalating increases."

Drug prices didn't increase much for a few years after the 2003 law was passed, but that has changed dramatically in the past few years: one diabetic told Lieberman that the price of an insulin pen increased from $73 in 2014 to $123 in March 2018, though insulin is a well-established drug.

"The pricing practices of all the players in the drug distribution system are responsible for the confusing pricing system we have," Lieberman writes. "Pharmaceutical manufacturers and pharmacy benefit managers – third-party administrators brought in to help insurers manage their drug costs – bear responsibility. So do the pharmacies themselves, when they offer coupons to consumers to lower their out-of-pocket costs, easing some individual burdens but doing nothing to solve the larger problem."

Lieberman says Trump's plan is short on details and doubts it will bring greater clarity or lower prices to consumers. She notes that the pharmaceutical industry has been lobbying hard to revamp its image and cast doubt on its role in ballooning health care costs. 

"Almost daily, a drug company or a related business sponsored content in several online health newsletters that are read by Washington lobbyists, health experts, congressional staff members, and journalists," Lieberman writes. "Sometimes the sponsored messages looked like the regular content of the newsletter. Even though they were flagged as paid content, the format often made me think I was reading a legitimate news story. One 'story' sponsored by the pharmacy benefit management industry said they were not the ones to blame for higher prices. With clout like this, is it any wonder the industry has managed to keep drug price negotiation out of the picture?"

This should serve as a warning to newspapers that sometimes fill their news hole with advertorial or "sponsored content," or those that allow "native advertising," essentially the digital version of editorial. "Such messages should be clearly and prominently identified as sponsored," said Al Cross, director of the Institute for Rural Journalism and Community Issues, publisher of The Rural Blog. "Readers always deserve to know who is producing all the material they are reading."

Free Rural Health Journalism Workshop June 8 in N.C.; deadline to apply for a travel stipend is today

The Association of Health Care Journalists is hosting a free one-day workshop on covering rural health on June 8 in Research Triangle, N.C.

The conference is free for AHCJ members, but registration is required by May 25. Members who need financial assistance should apply for a limited travel stipends by the Wednesday, May 23 deadline.

The keynote speaker will be Hannah Koch, a research and technical assistance associate at the Mental Health Program, Western Interstate Commission for Higher Education. Koch will tentatively discuss key behavioral health issues in rural communities.

Five workshops will cover a variety of topics, including "What reporters should know about rural residents and rural health," featuring Alan Morgan, chief executive officer of the National Rural Health Association and Dr. Jeffrey Heck, president and chief executive officer of the Mountain Area Health Education Center. 

Another workshop, "Will your local hospital survive?" includes George Pink, deputy director of the North Carolina Rural Health Research Program and Dana Weston, president of the University of North Carolina Rockingham Health Center. 

The "Addressing rural health workforce hurdles" workshop includes Mark Holmes, director of the North Carolina Rural Health Research and Policy Analysis Center and the director of the Cecil G. Sheps Center for Health Services Research and Dr. Robert Bashford, associate dean for the Office of Rural Initiatives at the University of North Carolina School of Medicine. 

The "Rural opioid crisis: Access to treatment and harm reduction" workshop includes Regina LaBelle, visiting fellow, Duke-Margolis Center for Health Policy and a former chief of staff in the White House Office of National Drug Control Policy and Donald McDonald, executive director, Addiction Professionals of North Carolina. 

Wrapping up the day is a workshop, "Can telemedicine transform health care in rural communities?" featuring Latoya Thomas, policy director for the American Telemedicine Association. 

To register for the event, click here. To request a travel stipend, click here or send an e-mail to membership coordinator Tina England at Tina@healthjournalism.org.

Fleeing the suburbs for the farm saved this writer's marriage

Schmitt and her husband Jason on their New York farm.
(Photo by Bennett Schmitt)

When Kristen Schmitt and her husband bought an old house in the Detroit suburbs, they planned to stay forever. But restoring the house depleted their savings and strained their marriage and so they decided to move to rural Vermont, barely scraping by for four years as they tried to rebuild their finances.

It was hard going at first, especially in the winter, but they loved it. "While the house was small, it sat on eight acres, and the land was both exciting and overwhelming," Schmitt writes for Salon. "There were mature blackberry and blueberry bushes — some wild and some planted — and fresh bear tracks along the dirt path through the woods that made me nervous. An 11-acre pond, which we shared with a seasonal neighbor, was filled with wood ducks, mallards and Canada geese. The forest cadence was loud without any automotive traffic; coyote howls rippling through the night air seemed both close by and far away at the same time."

Making the move brought Scmitt and her husband closer together, and with a lower cost of living, she was able to stay home with their young daughter and work on her freelance writing career. They eventually swapped their Vermont farm for one in northern New York, and still love farm life.

"Whenever someone asks me if I miss the city or the suburbs, I think about the experiences we’ve gathered over the course of only a few short years," Schmitt writes. "We’ve learned how to heat our own house with wood chopped, split and stacked by hand. We’ve learned the beauty of planting seeds and harvesting food from our land. We’ve watched fluffy chicks blossom into laying hens that peck cracked corn from our hands. We’ve also reclaimed our lives for ourselves and each other, focusing on our own priorities and values rather than those we were told were important."
Read more here.

U.S. lost nearly 31 million acres of farmland to development between 1992 and 2012, according to new report

A new report from the American Farmland Trust, the nation's leading farmland-preservation group, says that America has been losing twice as much farmland as the group thought. That's a problem because In Farms Under Threat: The State of America's Farmland warns that "by 2050, the demands on agriculture to provide sufficient food, fiber and energy are expected to be 50 to 70 percent higher than they are now."

The leading cause of farmland loss is low-density residential development, the report found. Between 1992 and 2012, nearly 31 million acres of agricultural land were lost to development, which is the almost the size of Iowa. Almost 11 million acres of that was prime land for intensive agriculture that would bring high yields with little environmental damage. Less than 17 percent of the total land area of the continental U.S. is suitable for intensive agriculture, so its loss is especially troubling.

Improvements in data and projection models are helping AFT more accurately keep track of the threats to America's agricultural lands and forecast trends. "This first report, Farms Under Threat: The State of America’s Farmland, examines the nation’s irreversible loss of agricultural land to development between 1992 and 2012," the report says. "A subsequent report will analyze state-level data on past farmland conversion and the effectiveness of state-level farmland protection policies. In a third report, Farms Under Threat will assess a range of future threats, forecast potential impacts to 2040 and recommend effective policies that help conserve agricultural land."

AFT plans to offer specific policy suggestions for farmland preservation. In general, counties can preserve farmland by purchasing development rights to farmland, or put farms under a conservation easement. AFT president John Piotti said at a recent press conference that preserving farmland not only helps existing farmers and encourages tourism, but it helps keep land prices down so more young people can get into farming, Al Cross reports for the Midway Messenger in Kentucky. Cross is the director of the Institute for Rural Journalism and Community Issues.

Facebook puts newspapers' promotions of news stories on politics into same category as posts of political advocates

By Al Cross
Director, Institute for Rural Journalism and Community Issues, University of Kentucky
May 22, 2018

For more than a year now I have been warning journalists, and supporters of journalism's role in democracy, that journalism is under threat -- from forces that don't fully understand that role, or fear it. Now there is a new threat, apparently driven by lack of understanding and appreciation of our role by people running the world's primary information platform, Facebook.

Today, the leading social-media network is scheduled to implement a new policy that will undercut the ability of major newspapers, the primary finders of fact in our democratic republic, to promote their work and compete with less reliable sources of information.

The policy will "treat ads promoting political news coverage the same as political advocacy ads," report Mike Snider and Jessica Guynn of USA Today. For the sake of "combating the spread of political misinformation, all Facebook ads featuring political content will get a 'Paid for by' label and carry a disclaimer. . . . These political messaging labels would also appear on 'sponsored' posts that news organizations buy to amplify the reach of an article or video on the political news of the day."

So, a promotion of a deeply reported package of stories about the evolving views of Trump voters in the Upper Midwest, like chief correspondent Dan Balz of The Washington Post did recently, would get the same treatment on Facebook as promotions of the daily "throw it up against the wall and see what sticks" from liberal or conservative interest groups. It's ridiculous.

The policy "is a fundamental mischaracterization of journalism," David Chavern, head of the News Media Alliance, the main lobby for newspaper publishers, told Facebook CEO Mark Zuckerberg a letter. "Newsgathering and reporting about politics is not the same thing as advocacy or politics. By lumping journalism and issue advocacy together, Facebook is dangerously blurring the line between real reporting and propaganda, and threatening to undermine journalism’s ability to play its critical role in society as the fourth estate."

Chavern suggested negotiations and an alternative: "require disclosure from all advertisers on all advertising; exempt news in the ad-archiving and labeling process for political content; or label and archive news independently from politics and advocacy."

Campbell Brown, the former CNN reporter who heads up Facebook's news partnerships, initially defended the policy but "later said that the company recognized "news content about politics is different and we are working with publishers to develop the right approach," USA Today reports.

Let's hope those negotiations produce a different policy than Facebook plans to implement today. In a world where citizens increasingly have difficulty deciding what sources of news and information are trustworthy, "This treatment of quality news as political, even in the context of marketing, is deeply problematic," Chavern told Zuckerberg. "You are forcing publishers to make a choice between labeling that is fundamentally counter to who we are and what we do, or to walk back our presence on a dominant platform for news consumption and discovery. This will have the effect of elevating less credible news sources on Facebook, the exact opposite of your stated intent."

Rural students face backlash after supporting gun control

Marshall County student Hailey Case
wearing an "Enough is Enough" shirt.
(NYT photo by Andrea Morales)

Recent school shootings have inspired a wave of gun-control activism, some of it from students, and a few of those students from rural areas. "In a more liberal city like Parkland, Fla., or at a rally in Washington, these students might have been celebrated as young leaders," Jack Healy reports for The New York Times. "But in rural, conservative parts of the country where farm fields crackle with target practice and children grow up turkey hunting with their parents, the new wave of student activism clashes with bedrock support for gun rights."

Some students in Benton, Kentucky, began speaking out for gun control after the deadly January shooting at their high school. Soon afterward, friends started shunning them, locals on social media made fun of them and said they should have died during the Marshall County High School shooting, Healey reports. Debate and action in Benton has largely focused on how detect potentially dangerous students and keep schools safer instead of limiting gun rights: After the shooting, the high school hired more armed officers and locked many of the school's doors. Every morning, students are scanned with metal detector wands and have their backpacks searched. 

"Speaking out in a place like Marshall County, Ky., carries a price — measured in frayed friendships, arguments with parents and animosity within the same walls where classmates were gunned down," Healy reports.

Ten high school students from Campbell County High School in Gillette, Wyoming, faced similar backlash when they marched downtown to demand tighter gun laws in solidarity with the survivors of the Parkland, Florida, shooting. The protest was a hard sell in a state with more guns per capita than any other state and rising sales in each of the past five years. "More than 80 percent of adults in Campbell County have firearms in their homes," Eli Saslow reports for The Washington Post.

Moriah Engdahl waits to address the school board.
(Washington Post photo by Jabin Botsford)

"In the days since the march, the 'Campbell County Ten' had become the object of profane graffiti, the inspiration for a rival Freedom March and the favorite target of a new Instagram account, 'Campbell County Students for America,' which shared memes comparing gun protesters to Hitler," Saslow reports. One of them is Moriah Engdahl, 16. Her father, Alan, had more than 250 guns until he lost the right to own firearms after committing a drug felony in 2006. 

Moriah's support of gun control has been a source of tension between the two, with Alan teasing her frequently, asking her if she'd managed to get everyone's guns yet. Though Moriah, a student journalist, had an independent streak, she had never questioned gun rights until the Parkland shooting. The more she researched online, though, the more she became convinced that the problem in Parkland and at home in Gillette (which has one of the nation's highest suicide rates) is unfettered access to guns. 

Moriah spoke to the school board recently in an attempt to dissuade them from arming teachers. She went alone, since the original 10 students protesting in Gillette had eroded to four: one student's furious mother pulled her daughter into the car during the protest, and in the days afterward a few students said they wanted to focus on less controversial issues like remembering victims or discouraging bullying. The remaining four included Moriah and the outspoken editor of the school newspaper, and two others. At a meeting at Starbucks to plan their next steps, one lamented that "Even my dad has started calling me a gun-control libtard," Saslow reports.

U.S. and China step back from threatened tariffs; Trump tweets at farmers worried about trade war

After two days of negotiation between Chinese and U.S. officials in Washington, D.C., the Trump administration has announced the framework of an agreement between the two countries in their ongoing trade dispute, leading both to step back from threatened tariffs that would hurt American farmers, David Lynch reports for The Washington Post. But the deal's lack of specifics has left interested parties dissatisfied and led many to question whether President Trump, who prides himself on his negotiating skills, is giving away too much to the Chinese.

Trump had earlier demanded a $200 billion reduction in the $375 billion U.S. trade deficit with China, but while the tentative agreement apparently does not meet that goal, he has halted tariffs he had threatened to impose on $150 billion worth of Chinese products. A joint statement issued on Saturday said the U.S. would send a team to China to hammer out the details, "which also may include expanded trade in manufactured goods and stronger 'cooperation' in enforcement of intellectual property protections," Lynch reported in an earlier story for the Post.

On Friday, China's Ministry of Commerce announced it would halt the investigation into U.S. sorghum exports and remove the 178.6 percent anti-dumping tariff it had imposed on U.S. sorghum one month ago. The announcement could be construed as a goodwill gesture in ongoing trade talks. "Chinese officials also said the price of domestic pork in China was falling and restrictions on imported sorghum would increase feed costs on pork producers as well," Chris Clayton reports for DTN/The Progressive Farmer.

The trade war was undermining Trump's agricultural base, to which he appealed on Twitter. He tweeted, "China has agreed to buy massive amounts of ADDITIONAL Farm/Agricultural Products," but that does not appear to be true, since there is no agreement. Two hours later, he tweeted, "Under our potential deal with China, they will purchase from our Great American Farmers practically as much as our Farmers can produce." That remains to be seen; as he clarified, the deal is "potential."

Defeat of Farm Bill in House may push renewal into 2019, which might not be bad politics for Republicans

The defeat of a new Farm Bill in the House on Friday may push the renewal process past the Sept. 30 expiration date of the current law, much like what happened in 2013. Then the fight was over big cuts in the Supplemental Nutrition Assistance Program, once called food stamps. This time it's not only SNAP, it's immigration, an issue that divides Republicans.

"A revolt by Republican conservatives defeated a new Farm Bill calling for stricter work requirements for food-stamp recipients and looser payment limit rules for farmers. Once again, the delay may stretch into the new year," Chuck Abbott reports for Successful Farming. Rep. Collin Peterson of Minnesota, ranking Democrat on the Agriculture Committee, told him that "What we'll end up with is an extension" of the current law: “Our side is not going to live with this work requirement stuff.” But committee chair Michael Conaway of Texas told Abbott that SNAP work requirements “absolutely” must be part of the bill. The Senate is not expected to accept them.

Conaway's bill would require “work capable” adults ages 18 to 59 to work or take job training at least 20 hours a week, and tight eligibility rules. "Democrats said the combination would push 2 million people off of SNAP," Abbott notes. Economist Vince Smith of Montana State University told Abbott, “In many ways, no bill is the better outcome for many Republicans. Instead, they can just vote for an extension through, say, March 31 of next year. That way, the House Republicans with urban constituencies can avoid being tarred with a vote to reduce the scope of food stamps.”

Abbott reports, "Meanwhile, on the farm side of the bill, an array of fiscal hawks, good-government advocates, environmentalists, and libertarian think tanks attacked provisions to make cousins, nieces, and nephews eligible for up to $125,000 a year in farm subsidies and to remove payment limits on some forms of corporate farming."

States of Senior Hunger report says food insecurity among those over 60 is worst in the Deep South and Southwest

A new report about the state of hunger among American seniors reveals that more than 15 million faced food insecurity at varying levels in 2016, the year with the most recent national and state-level data from the U.S. Census Bureau's December Supplements to the Current Population Survey. Food insecurity was found to be greatest among those living in the South and Southwest, racial or ethnic minorities, people with lower incomes, and younger seniors (ages 60-69).

Food insecurity is measured in three tiers, as established by the U.S. Department of Agriculture: marginal food insecurity, food insecurity, and very low food security. Each category had fewer people in 2016 than 2014. The study's top findings:

• "13.6 percent of seniors are marginally food insecure, 7.7 percent are food insecure, and 2.9 percent are very low food secure. This translates into 8.6 million, 4.9 million, and 1.8 million seniors, respectively.  
• From 2015 to 2016, there were statistically significant declines in the percentage of marginally food-insecure seniors. However, there were no statistically significant changes in food insecurity or very low food security. Looking at demographic categories, there were sizable and statistically significant declines for several categories among the marginally food insecure; however, only two groups – those with incomes above 200 percent of the poverty line and white seniors—experienced significant declines in food insecurity. 
• Across all three measures, from 2014 to 2016 there were statistically significant declines of 2.2 percentage points, 1.2 percentage points, and 0.5 percentage points for marginal food insecurity, food insecurity, and very low food security. 
• Compared to 2001, the fractions of marginal food insecure, food insecure, and very low food secure seniors increased by 27 percent, 45 percent, and 100 percent, respectively. The number of seniors in each group rose 90 percent, 113 percent, and 200 percent, which also reflects the growing population of seniors. "

The State of Senior Hunger in America 2016: An Annual Report was researched by professors James Ziliak of the University of Kentucky and Craig Gundersen of the University of Illinois, and was prepared for Feeding America and the National Foundation to End Senior Hunger. 

Lung transplants rise along with black-lung cases

A new study published in the American Journal of Industrial Medicine shows that, as black-lung cases have surged in the Central Appalachian coalfield, so have lung transplants. The expensive surgery can be risky, and most transplant recipients die within five years. The study, conducted by researchers from the National Institute for Occupational Safety and Health, "found that 62 black lung patients had lung transplant surgery over the past two decades, and most of the miners lived in Kentucky, Virginia, and West Virginia," Benny Becker reports for Ohio Valley ReSource. "The study also found that more than two dozen patients were placed on a wait list for transplants. Of those, 11 died while waiting."

The study's lead author, David Blackley, said that the rate of lung transplants for black-lung patients increased nearly threefold in the last decade. "That suggested pretty strongly to us that this is a problem that's getting worse," he told Becker.

Insurance from coal companies and other private sources paid for about one third of the lung transplants. Nearly two-thirds were paid for with public insurance, including 26 percent paid for by Medicare and up to 24 percent paid for by the federal Black Lung Disability Trust Fund. "That fund has paid more than $45 billion to cover benefits for miners who can’t seek benefits from their employer, because the responsible company has either gone bankrupt or can’t be identified," Becker reports. A federal study is looking into how long the fund can stay solvent given the rise in cases.

The researchers who conducted the study had also recently discovered that the spike in late-stage black lung in Central Appalachia is the largest cluster of the disease ever recorded.

Signs of more drought ahead for Colorado River basin

National Oceanic and Atmospheric Administration map of drought conditions

Runoff levels in the Colorado River from melting snowpack peaked early last week, the earliest peak in the past 50 years. It's also the fourth lowest volume of peak runoff recorded in 85 years. Peak runoff's early appearance and modest height predict a drought that experts say will be more common, Allen Best reports for Route Fifty.

Several parts of the U.S. already face drought conditions, mainly the Southwest. That will likely hurt the nearly 40 million people and 5 million acres of farmland that depend on the Colorado and its tributaries.

"If you ask why there is so little runoff in the Colorado and other rivers this year and why it has come so early, the No. 1 reason is we didn’t get much snowfall. That explains the bulk of this anomaly,"  Jeff Lukas, a research integration specialist with the University of Colorado’s Western Water Assessment, told Best. "But the temperature, much warmer than normal, especially from November to January, is a part of the story."

Lukas noted that runoffs have been unusually low for the past 16 years and that droughts are now more common than they were in the past, which he said "may speak to the contribution of human-caused warming."

Increased temperature is the main cause of the drought, with precipitation a secondary contributor, according to a 2017 paper by Jonathan Overpeck, dean of the School for Environment and Sustainability at the University of Michigan. "Temperatures in the region have increased, and as they do, the warming atmosphere needs more moisture.," Best reports. "Overpeck and his co-researcher, Brad Udall of Colorado State University, concluded that the moisture is being induced into the atmosphere through increased evaporation and transpiration." 

"This turns out to be the very biggest consequence of the temperature-induced drought in the Colorado River Basin,” Overpeck said. "Wildfire is going crazy in the Southwest, and it’s for the same reason."

'Buckwild' makers filming another West Virginia reality show

The original cast; Gandee is at left

The executive producers of MTV's reality series "Buckwild" are returning to West Virginia to shoot a new series in Charleston and Morgantown called "West Virginia Wilder." Morgantown native and executive producer J.P. Williams says it will be similar to "Buckwild" but will be funnier and have a stronger female cast, Max Garland reports for the Charleston Gazette-Mail.

"I think this show will be a completion of what we got started," Williams told Garland. "There’s a lot I’m excited about, frankly."

"Buckwild" ran for one season and scored well with the coveted age 12 to 34 demographic, but was canceled after one of its stars, Shain Gandee, was killed in an all-terrain vehicle accident in 2013.

Some West Virginians, such  U.S. Sen. Joe Manchin, disliked "Buckwild", saying it played to negative stereotypes, but Williams said his shows are about "laughing with — not at," which he says is a "huge distinction that needs to be made," Garland reports.

The new show may not be on MTV; the show's producers say they're considering multiple offers on broadcast rights and will announce a decision soon.