U.S. physician shortages expected to increase dramatically as older doctors retire or quit because of heavy workloads

Lack of doctors will mean a sicker population.
(Photo by J.C. Gellidon, Unsplash)

U.S. physician shortages are expected to increase substantially as aging doctors retire or extreme workloads push them out. "As the aging population's need for care grows, retirement and burnout are both driving swaths of health care workers out of the field, fueling a crisis that shows no signs of stopping,"  reports Alejandra O'Connell-Domenech of The Hill. "The country is expected to suffer a shortage of up to 124,000 physicians in the next 12 years, according to a 2019 report from the Association of American Medical Colleges." American Medical Association President Jesse Ehrenfeld told O'Connell-Domenech: "When people don't have access to routine primary care and preventative services [due to no physician access], they live sicker and die younger. . . . These are things that are only going to get worse as we put more pressure on the physician workforce." In many rural areas, the lack of doctors is already a stark reality.

If there aren't enough physicians, those who are working will have to work longer hours with sicker patients, which leads to burnout and more doctors deciding to retire or leave medicine altogether. "A 2022 study found that nearly 63 percent of physicians experienced symptoms of burnout by the end of 2021, representing a 19 percent increase from 2017," O'Connell-Domenech reports. "Another 2022 study determined that one out of five doctors said they were likely to leave their current practice within two years, citing burnout and workload as two major reasons."

The numbers explain another reason for the shortage. "There are about 55.8 million people aged 65 and older in the United States, according to Census Bureau," O'Connell-Domenech explains. "Their numbers are growing and will continue to do so. . . . Almost half of working physicians in the United States are 55 and older, according to the AMA. Thirty-five percent of the physician workforce will reach retirement age within the next five years."

Possible solutions include lessening student loan debt and increasing the number of physicians allowed to train. "The Resident Physician Shortage Reduction Act of 2023 could help by lifting the cap on residency programs," O'Connell-Domenech adds. "The bill. . . would expand the number of Medicare-supported medical residency positions by 14,000 over seven years. . . . Another piece of legislation that could help stem the shortage is the Conrad State 30 and Physician Access Reauthorization Act, according to Ehrenfeld. Under the bill, international doctors could stay in the U.S. after their residency programs as long as they committed to practicing medicine in parts of the country with physician shortages. . . . Easing medical student debt could also potentially increase the amount of doctors willing to work in underserved areas, Ehrenfeld said."

Few Americans know much about the First Amendment; survey shows only 3% can name all 5 protections

In 2006, 22% of polled Americans could name all 5
Simpsons family members. (Image via NCC)

Americans' understanding of the First Amendment is not getting better with time. In 2006, the McCormick Tribune Freedom Museum commissioned a poll, which revealed that many Americans knew more about the Simpsons than the First Amendment, reports the National Constitution Center. "The phone survey found that only 28% of Americans could name more than one of the freedoms guaranteed by the Constitution's First Amendment, but more than half of Americans could name at least two members of the fictional Simpsons family. In addition, 22% of Americans could name all five Simpsons family members, while just 11% of folks knew that freedom of the press was guaranteed under the First Amendment."

Fast forward 17 years: Americans have a breadth of information at their fingertips that 2006 did not offer. Do we know more about the First Amendment? "Survey says: No," reports Sean Stevens of the Foundation for Individual Rights and Expression. "In a recent AmeriSpeak panel conducted by the National Opinion Research Center at the University of Chicago, FIRE asked 1,140 Americans if they could name any of the specific rights protected by the First Amendment. . . . Almost a third of Americans could not name a single enumerated right protected by the First Amendment, and another 40% could name only one — usually freedom of speech. Among Americans who named one or more enumerated rights, roughly two-thirds named freedom of speech, about a quarter (26%) named freedom of religion, 20% named the right to assemble, 15% named freedom of the press, and 8% named the right to petition. Only 3% of Americans could name all five and, on average, could name 1.33 First Amendment rights."

Fire's survey also revealed that older Americans and citizens with a bachelor's degree had more First Amendment knowledge. But what can be done to help the rest of the country? "Americans cannot protect, preserve, and exercise their rights if they don't know what those rights are," Stevens writes. "But, there exists a ray of hope, as the Freedom Forum has also consistently found that high school students who have taken classes that include content about the First Amendment are more supportive of free speech rights. This suggests that a culture of free speech can be fostered by increasing knowledge of the First Amendment."

FIRE image

To help support First Amendment learning, FIRE offers a variety of free courses on the First Amendment, including "The History of Free Speech," "Can I Publish This?" and "The Case for Radically Free Speech," Steven reports. "We provide college orientation materials and maintain a syllabus database of courses that focus on freedom of expression. We also provide teaching resources to help K-12 teachers enrich and supplement their existing instruction on the First Amendment. We even send out complementary copies of our comic book, "Finding Your Voice," which shows teens the empowering effects of knowing and using their First Amendment rights."

Pandemic gave workers 2 weeks sick leave; now many are back to work with no paid leave and few options for care

Photo by Aron Visuals on Unsplash

For many American workers, the days of two weeks paid sick leave, mandated in the first year of the pandemic, have ended. They have been replaced with hard decisions, which weigh disproportionately on rural residents, reports Jazmin Orozco Rodriguez of Kaiser Health News: "Workers in rural areas face even more challenges than those in cities, including greater distances to hospitals and fewer medical providers, exacerbating health and income disparities. Companies in rural areas may be less likely to voluntarily offer the benefit because they tend to be smaller and there are fewer employers for workers to choose from."

Some jurisdictions have implemented time-off laws, but "Most states where more than 20% of the population is rural haven’t, leaving workers vulnerable," Rodriguez writes. "Vermont [the most rural state by population, 65%] and New Mexico [the 29th most rural, at 25.5%] are the only states with a sizable rural population that have passed laws requiring some form of paid sick leave. . . . Experts say the gaps in paid leave requirements mean workers in rural areas often struggle to care for themselves or loved ones while making ends meet."

The two weeks of sick leave mandated by the 2020 Families First Coronavirus Response Act ended at the end of that year, and its "expiration left workers to rely on the Family and Medical Leave Act of 1993, which requires companies with 50 or more employees to provide them with up to 12 weeks of unpaid time off to care for themselves or family members. But many workers can’t afford to go that long without pay," Rodriguez reports. "Advocates say a stronger federal policy guaranteeing and protecting paid sick and family leave would mean workers wouldn’t have to choose between pushing through illness at work or losing income or jobs."

Rural Americans support paid sick and family leave, "according to the National Partnership for Women & Families, which found in 2020 polling that 80% of rural voters supported a permanent paid family and medical leave program, allowing people to take time off from work to care for children or other family members," Rodriguez writes. "But lawmakers have been divided on creating a national policy, with opponents worrying that requiring paid leave would be too big a financial burden for small or struggling businesses."

San Francisco was the first city to order paid sick leave. Rodriguez reports: "Since then, 14 states, the District of Columbia, and 20 other cities or counties have done so. Two other states, Nevada and Maine [the second most rural state, at 61% of population], have adopted general paid time off laws that provide time that can be used for illness. . . . The patchwork of laws nationwide leaves workers in several mostly rural states — places like Montana [46.6%], South Dakota [42.8%], and West Virginia [55%] . . . without mandated paid sick and family leave."

Unemployed Americans face benefits delay under relief bill; states demand money back for mistaken benefit payments

Millions of Americans have lost their jobs because of the pandemic, but many are still getting inadequate unemployment benefits, and even if the bipartisan relief bill passes, they'll likely see a lag in payments.

The new bipartisan bill includes $300 in weekly unemployment benefits, but it could be weeks after the bill is signed before unemployed workers start seeing that money, The Washington Post reports.

The last relief bill, passed in March, included an extra $600 in weekly unemployment benefits though the end of July. Other measures added to that. The bill also created two programs to help unemployed independent contractors, both of which are set to end in December, Emily Stewart reports for Vox. 

"In designing these programs, Congress made a lot of assumptions about how the U.S. would handle the pandemic — mainly, that it would do a better job than it did of getting the virus under control so that people could get back to work," Stewart reports. "But nine months later, America still has 10 million fewer jobs than it did pre-pandemic, and as the coronavirus continues to spread, many places across the country are facing shutdowns once again, threatening further job losses."

Meanwhile, many states are demanding that recipients pay back thousands of dollars after mistakenly issuing too much in benefits, Ava Kofman reports for ProPublica. The new bill might stop that.

House passes bipartisan bill to fund government through Dec. 11; deal includes expanded farm aid, food assistance

In a 359-57 vote on Tuesday night, the House passed a bill to keep the government funded through Dec. 11, following a compromise on farm aid and food assistance.

"The bipartisan agreement between House Speaker Nancy Pelosi (D., Calif.) and Treasury Secretary Steven Mnuchin, reached just hours before the vote, is expected to smooth the bill’s passage in the GOP-controlled Senate and avert a partial shutdown when the government’s funding expires next Thursday," Kristina Peterson and Lindsay Wise report for The Wall Street Journal. The Senate is expected to vote on it this week.

The bill "would add to the spending bill $21 billion sought by the White House for the Commodity Credit Corp., or CCC, a Depression-era program designed to stabilize farm incomes that permits borrowing as much as $30 billion from the Treasury to finance its activities. The agreement prohibits any payments from going to fossil fuel refiners and importers, a concern of Democrats, and includes roughly $8 billion in additional nutrition funding," Peterson and Wise report. "President Trump has tapped the CCC program to finance both trade relief and coronavirus-related aid for farmers, a second round of which he announced at a campaign rally in Wisconsin last week. But the program has traditionally been used to send out payments established under bipartisan farm bills, some of which the Agriculture Department had said could be subject to delays as soon as October."

The bill also adds $8 billion for food assistance. "That includes a one-year extension of a program expiring at month’s end that would provide funding to families of school-age children to buy groceries, replacing the free or reduced-price meals they would have received at school, "Peterson and Wise report. "They also expanded the program to include children at child-care centers affected by the pandemic."

Controversial nominee pulled, but he will keep running BLM

William "Perry" Pendley

"The Trump administration withdrew the controversial nomination of William 'Perry' Pendley to head the Bureau of Land Management on Saturday amid signs that the choice would hurt the re-election prospects of Republican Sens. Cory Gardner (Colo.) and Steve Daines (Mont.)," Steven Mufson reports for The Washington Post. "Earlier this month, the Senate Energy and Natural Resources Committee received the materials needed to hold hearings on the nomination. But Democrats were planning to press Daines, who sits on the committee and is in a tight race with Montana Gov. Steve Bullock (D). It was not clear whether Gardner or Daines would vote for Pendley."

Senate Republicans have taken pains to help Gardner and Daines' re-election prospects, including passing a bill they co-sponsored that permanently protects public lands and addresses part of the national park system's maintenance backlog. Public-lands preservation has been a major campaign platform for both senators.

Pendley, BLM's deputy director for policy and programs, has been acting director since July 2019. He has been criticized for controversial views about public lands, the environment, and other issues. Before his tenure at BLM, he was the longtime president of the conservative Mountain States Legal Foundation. During that time, he wrote that there should be no public lands and said repeatedly that climate change lacks credible scientific evidence. Also while at the MSLF, "he had sued the Interior Department on behalf of an oil and gas prospector, sought to undermine protections of endangered species such as the grizzly bear, and pressed to radically reduce the size of federal lands to make way for development," Mufson reports.

However, just because Pendley's nomination has been withdrawn, he isn't out of the picture. "White House and Interior officials said that Pendley would continue to serve in his current, lower-level deputy director position at the Interior Department, a job that effectively lets him continue to act as head of the BLM. Pendley was the only person nominated to head the BLM under Trump," Mufson reports. "Several federal agencies are being run by the Trump administration using similar arrangements."

Poultry workers' unions sue USDA over line speed waivers

"The union representing workers at chicken processing plants in six states sued the U.S. Department of Agriculture on Tuesday, saying its policy of allowing companies to slaughter birds more quickly endangers workers and makes it more difficult to protect against spread of the coronavirus," David Pitt reports for The Associated Press. "The United Food and Commercial Workers International Union and local unions representing 10 plants in Alabama, Arkansas, Indiana, Kentucky, Mississippi and Missouri joined with nonprofit consumer advocacy group Public Citizen to file the lawsuit in federal court in Washington, D.C."

The U.S. Department of Agriculture allowed plants to waive line speed caps in 2018, after it said the issue had been studied via pilot programs for 25 years. However, "the unions said in court documents that an average of eight workers per year died on the job between 2013 and 2017 in poultry processing plants, and that workers commonly suffer sprains, lacerations, and contusions," Pitt reports. "They contend that research and worker experience shows work speed is a major contributing factor to the high injury rates suffered by poultry workers."

Senate Democrats introduced a bill on Tuesday that would block faster line speeds at meatpacking plants during the pandemic and suspend line-speed waivers already issued, Chuck Abbott reports for Successful Farming.

Quick hits: Appalachian New Deal offered; rural homelessness could rise after federal pandemic aid runs out

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 heather.chapman@uky.edu.

A coalition of left-leaning environmental and economic policy groups have published an "Appalachian New Deal" meant to give federal lawmakers ideas on how to bring more jobs and clean energy to the region as they consider the next stimulus bill. Read more here.

Drillers are increasingly declaring bankruptcy and sticking taxpayers with the cleanup costs, while executives pocket millions and workers lose jobs. Read more here.

Will rural homelessness hit after benefits and eviction moratoriums end? Read more here.

Because rural physicians are older on average, they could be at an increased risk of severe outcomes if they catch covid-19. Read more here.

Rural families struggle with finding child care

Rural families are more likely to live in child-care deserts, meaning areas where demand for licensed child-care programs far outstrips local supply, according to a newly published data analysis by University of Minnesota researchers and the liberal-leaning Center for American Progress.

"The first-of-its-kind nationwide portrait shows that . . . rural families nationwide had the fewest child-care slots relative to demand across all categories, the researchers found," Amanda Becker reports for The Washington Post. The study also found that, on average, areas with large Latino populations and households with a combined income of $75,000 to $85,000 were the most likely to be in child-care deserts.

"The analysis comes as the coronavirus pandemic has upended an already tenuous child-care landscape," Becker reports. "Industry groups predict that one-third to half of child-care programs may close permanently without significant public investment, and many economists warn as much as $50 billion may be needed to assist the industry as parents attempt to return to work."

Congressional Democrats and Republicans have proposed bills with billions in funding for the Department of Health and Human Services' already-existing Child Care and Development Block Grant, which gives states and tribes funding to help lower-income workers access child care, Becker reports.

Bill headed to Trump's desk would force FCC to do a better job collecting and publishing rural broadband data

A bipartisan rural broadband bill has cleared the House and Senate and is on its way to President Trump's desk. The Broadband Deployment and Technological Availability Act (styled the DATA Act, but don't confuse it with the 2014 DATA Act) is intended to provide funding for rural utilities to build out high-speed internet, Jeff Postelwait reports for T&D World, a trade publication for utilities.

The bill is more about laying the groundwork for gathering better rural broadband data than it is about funding. The Federal Communications Commission has been criticized for relying on internet service providers' self-reporting to assess rural broadband coverage. ISPs have an incentive to overstate their rural reach; it may help them qualify for federal funds. That and other issues have led to maps that could be more accurate. Though FCC data shows only 6.5 percent of the population lacks broadband access, crowdsourced data shows that the number is higher.

Under the DATA Act, the FCC would have to to create better rules to gather, monitor, verify and disseminate detailed broadband coverage data. "According to the National Rural Electric Cooperative Association, the bill also would make it illegal to provide false information to the FCC and allows cooperatives, consumers, local governments and others to challenge FCC maps with data of their own," Postelwait reports.

Congress aims to curb surprise air ambulance bills

Use of air ambulances has declined over the past decade, and prices for their runs have soared, so many customers are stuck with massive, unexpected bills when their insurance fails to cover the ride. Complaints from constituents have prompted lawmakers at both the state and federal level to try to curb the surprise bills, Alma Almendrala reports for NPR.

An estimated one in six insured Americans are hit with surprise bills after a hospital stay, and air ambulances are a big offender. Tom Saputo, of Thousand Oaks, Calif., ended up paying more for a post-surgical ride back to the hospital than he did for the surgery itself, a double lung transplant. The air ambulance company, Mercy Air, charged his insurance company more than $51,000 for the 27-mile flight, leaving Saputo responsible for more than $11,000, Almendrala reports. Mercy Air blamed Saputo's insurer for not covering more of the bill, but forgave the bill after it caught the attention of ABC's "Good Morning America."

"The median cost of a helicopter air ambulance flight was $36,400 in 2017, an increase of more than 60 percent from the median price in 2012, according to a Government Accountability Office analysis. Two-thirds of the flights in 2017 were out of network, the report found," Almendrala reports. "The air ambulance industry justifies these charges by pointing out that the bulk of its business — transporting patients covered by the public insurance programs Medicare and Medicaid — is underfunded by the government."

Critics argue that market saturation is the real reason behind increasing air ambulance prices. "While the number of air ambulance helicopters in the U.S. has increased — rising more than 10% from 2010 to 2014 — the number of flights hasn't, which means air ambulance companies seek to raise prices on each ride," Almendrala reports.

State-level efforts to eliminate or limit surprise "balance billing," as it is called, have been generally unsuccessful; federal judges usually strike down such laws because they violate the Airline Deregulation Act of 1978, which prohibits states from regulating air traffic. Congress is considering several bills to limit or ban balance bills. "One measure by Sens. Lamar Alexander, R-Tenn., and Patty Murray, D-Wash., would ban balance bills from air ambulance companies," Almendrala reports. "The bill passed committee and is now headed to the Senate floor for a vote, pending approval from Senate Majority Leader Mitch McConnell of Kentucky."

New Yorkers offer bills to revamp, raise rural funding, create Rural Future Corps to send youth to rural areas, maybe stay

Sen. Kirsten Gillibrand of New York, who recently gave up her Democratic presidential bid, has introduced legislation meant to revamp and increase federal funding for rural areas. Rep. Antonio Delgado, also of New York, will introduce a House version, Cara Chapman reports for the Plattsburgh Press-Republican in the state's northeastern tip.

The Rebuild Rural America Act would establish a new $50 billion Rural Future Partnership Fund that would provide flexible, multi-year block grants for regional rural revitalization projects. "Rural regions that work together to become certified would automatically receive a commitment of five-year, renewable funding to support progress on the region’s locally developed goals and objectives," says Gillibrand's summary of the bill.

Gillibrand told Chapman that the bill is needed because "Federal grants are often too narrow and inflexible to support the development needs of rural communities." Rural communities can find it difficult to apply for grants because they often don't have enough staff and expertise, and shouldn't have to employ lobbyists or dedicated grant writers to access funding, she said.

Eligible projects would include entrepreneurship, infrastructure, public services, skills training and job placement, and improving disaster response. Gillibrand's summary of the bill promises a new, streamlined approach to disaster response and recovery that can help aid arrive sooner. 

The bill also proposes launching a "Rural Future Corps," which would be a joint effort of the Department of Agriculture and AmeriCorps to expand services like child care, health care, nutrition assistance, education and job training. Another aim of the program: persuade corps members to stay in the rural areas where they've served after they're done with their stint.

The act would be funded one of two ways, Gillibrand said. "Should a hoped-for bipartisan infrastructure bill come about — the senator noted President Donald Trump's frequent statements that he wants to invest $1 billion in that sector — a $50 billion piece would be dedicated solely to rural America," Chapman reports. "That would be combined with other infrastructure bills the senator has written to make for a comprehensive approach."

Air ambulances offer rural residents iffy memberships

Rural residents rely disproportionately on air ambulances to reach distant medical care in emergencies, but many have been hit with huge, unexpected bills since many such services aren't in insurance networks. To combat fears about such bills, ambulance services have been increasingly advertising prepaid subscriptions that promise patients free use of their helicopters in an emergency. 

"Nationwide, though, state insurance leaders, politicians and even one of the nation's largest air ambulance companies have raised concerns about the slickly marketed membership campaigns," Sarah Tribble reports for NPR. "The memberships often don't include every ambulance company in an area, and the choice of which medevac service answers a call is out of a consumer's hands."

Meanwhile, the cost of air ambulance services has soared in recent years. The median price for an air ambulance trip increased from $22,100 in 2012 to $36,400 in 2017—a 65 percent jump. Medicare and Medicaid patients pay lower fees or even nothing for such trips, but those with private insurance often find their plans don't cover the entire cost of the service, leaving them saddled with "balance bills" for the uncovered portion, Tribble reports.

States can't regulate air ambulance rates, routes or services, but several, including North Dakota and Montana, have introduced or passed bills to limit air ambulance memberships or decrease the likelihood that subscribers would get stuck with balance bills, Tribble reports.

The federal government does have the power to regulate air travel, though; Congress formed a committee last year to look into air ambulance bills. Air ambulance lobbyists blamed inadequate Medicare and Medicaid reimbursement for the high rates and asked that the federal government reimburse them more, Harris Meyer reports for Modern Healthcare.

Explainer details history of background-check debate

Gun control is the subject of increasing debate, especially the question of whether to expand background checks for people seeking to buy firearms. A particular note of contention: Background checks are required for purchases from gun stores, but most states do not require them for gun-show purchases, which account for 22 percent of all gun purchases in the U.S. today. It's a fraught subject in rural America, where guns are part of the local culture.

Dan Freedman of the Times Union in Albany, N.Y., provides a great explainer on the history of the background-check debate that reaches back to 1986. Congress passed the Firearms Owners Protection Act that year, which banned the production and possession of most fully automatic machine guns. The act didn't make many headlines, "but in retrospect, this innocuous-sounding piece of legislation contained the seeds that sprouted into the debate over expanded background checks underway yet again on Capitol Hill in the aftermath of mass shootings in Ohio and Texas," Freedman reports.

That's because the FOPA Act specified which gun sellers needed a federal firearms license and which didn't. Gun owners who buy, sell, or exchange firearms only occasionally for a hobby or personal collection do not need a license. The National Rifle Association and the act's supporters in Congress (many Democrats from pro-gun rural districts) counted this as a major win, Freedman reports. With the legal blessing of the FOPA Act, gun shows became more popular.

Gun shows became even more popular after the Brady Handgun Violence Prevention Act passed in 1993. It mandated background checks for anyone who bought a firearm from a federally licensed dealer, but preserved the gun-show loophole. That encouraged more people to buy and sell at gun shows or online. Background checks are required for online sales across state lines, but not if the sale is within a state that doesn't require background checks as a matter of state law. Only 12 states require background checks on all sales, including private ones, Freedman reports.

The NRA opposes expanded background checks as an infringement on constitutional rights, and also because, its leaders argue, expanded background checks would not have prevented recent mass shootings. "But that equation may be changing with news reports saying the shooter in Midland-Odessa, Texas, was able to purchase a weapon privately after failing a background check because of a mental condition," Freedman reports.

A bill to expand background checks has passed the Democratic-controlled House but has stalled in the Republican-controlled Senate. Senate Majority Leader Mitch McConnell, R-Ky., has said he will only bring a bill to the floor if President Trump says he will sign it, but "so far, Trump has not firmly committed himself in either direction," Freedman reports.

Horse trainer won top walking-horse prize despite imminent suspension for soring, a 'sad state of affairs,' activist says

Rodney Dick riding I'm Mayhem
(Shelbyville Times-Gazette photo by Gary Johnson) 

The trainer and rider whose horse was named Tennessee Walking Horse World Grand Champion on Aug. 31 was allowed to compete even though he will soon begin a mandatory suspension for serial violations of the Horse Protection Act. Rodney Dick rode the horse I'm Mayhem to victory during the 81st annual Tennessee Walking Horse National Celebration in Shelbyville, John Carney reports for the local Times-Gazette.

In December 2018 the U.S. Department of Agriculture disqualifed Dick from all involvement in the horse industry from Oct. 1, 2019, to March 31, 2021, and ordered him to pay a $2,200 penalty for engaging in the practice of "soring" Tennessee walking horses. The technique involves harming a horse's front hooves and legs to encourage the high step that wins competitions. 

The Horse Protection Act has long banned sored horses from competitions, exhibitions or sales, but the rule is widely ignored and spottily enforced. In July, the U.S. House passed a bill called the Prevent All Soring Tactics Act to ban other soring techniques, increase penalties for violations and expand the USDA's enforcement of the HPA, but it faces an uphill battle in the Senate. 

Many horse competitions have shunned Tennessee walking horses because of the abuse associated with soring, activist Marty Irby writes in an op-ed for the Memphis Commercial Appeal. Irby is now the executive director at Animal Wellness Action, but is a former eight-time world champion rider and a past president of the Tennessee Walking Horse Breeders' & Exhibitors' Association. He urges senators to pass the PAST Act: "The Tennessee Walking Horse breed can remove the label of being the most abused horse on earth, but only with legitimate change." 

The fact that Rodney Dick was allowed to compete is a "sad state of affairs" that shows how necessary the PAST Act is, Irby wrote in an email to The Rural Blog.

Democrats seek to regain traction in rural areas, but are presidential candidates' proposals what rural voters want?

Mindful of Hillary Clinton's failure to connect with rural America in 2016, the current crop of Democratic presidential hopefuls are expending considerable energy on reaching out to rural voters in hopes of closing a long-time gap.

"Democrats are climbing out of a deep hole in rural America. In 2008, Obama lost rural voters by 17 points, and by 23 points in 2012. Rock bottom arrived in 2016, when Clinton ran 34 points behind Trump among voters, according to data collected by Catalist, a Democratic data platform," Elena Schneider and Catherine Boudreau report for Politico. "Democrats clawed back some gains in rural counties in the 2018 midterm elections, and they want to build on that momentum in 2020."

Democratic candidates' plans include things like broadband expansion and expanded or universal Medicare. But are these policy proposals, which include greener farming practices, what rural people want? The Daily Yonder and its affiliated Rural Assembly talked to a dozen experienced rural-policy advocates about what top measures they would like to see 2020 presidential candidates address. "New or increased funding for rural programs is on the agenda, the Yonder reports. "But other themes include a call for inclusion, cultural parity, redirecting programs for more community impact, and holding large institutions accountable for the way they serve rural America." Here are a few highlights from what the rural-policy advocates told the Yonder:

Federal housing policy mostly benefits cities and suburbs right now, and must be revamped to help rural areas. That means investing heavily in local non-profits that know local housing issues best, and funding community development finance institutions to deploy in places banks can't reach, according to David Lipsetz, executive director of the Housing Assistance Council.

Increased access to health care is critical in rural America, where more than 100 hospitals have closed since 2010 and more are in danger of closing, according to Alan Morgan, president of the National Rural Health Association. Medicare cuts and the lack of Medicaid expansion contribute to rural hospital closures. Three in five rural voters say they would be more likely to vote for a candidate who makes rural health care access a priority.

Rural areas need significant funding to support arts programming, better broadband to share that art with the world, and spaces dedicated to showcasing the arts. Making space for rural people to create and share art validates their identities and helps instill pride, according to Carlton Turner, the director and lead artist of the Mississippi Center for Cultural Production.

For a complete list of issues and rural advocate recommendations, read the Yonder story here.

House passes bill to protect Tennessee Walking Horses from harmful practices; Senate will have much say-so

Photo by Esther Roberts

The House of Representatives passed a bill Thursday that would strengthen protections in the 1970 Horse Protection Act against the practice of "soring" Tennessee Walking Horses. "Soring is a technique used by some trainers to improve walking horses' naturally high gait," reportAndrew Wigdor and Matt Reynolds of the Tennessean. "The technique is accomplished by exposing horses to chemicals, putting foreign objects into a horse's hooves or placing heavy chains" on their lower front legs.

The HPA already bans sored horses from competing in shows, exhibitions or sales, but advocates say the provision is being largely ignored, is rarely enforced, and is subject to loopholes.

The PAST (Prevent All Soring Tactics) Act, which passed 333 to 96, "would ban large stacked shoes and ankle chains used on horses, heighten penalties for violations and expand the Department of Agriculture's enforcement of the Horse Protection Act," Wigdor and Reynolds report. "The new penalties would increase from $3,000 to $5,000 and extend prison sentences from one year to three years. The legislation must still win Senate approval, where it faces an uphill battle. U.S. Sens. Lamar Alexander and Marsha Blackburn of Tennessee have sponsored competing legislation.

The House bill has 308 cosponsors, led by Reps. Kurt Schrader, D-Ore., and Ted Yoho, R-Fla. Animal-rights activists have long promoted the PAST Act, but it has taken six years to get a vote on the House floor, Wigdor and Reynolds note.

One representative, Scott DesJarlais, R-Tenn., said during floor debate that he opposed the bill because horse inspectors were "abusing the process" and arbitrarily disqualifying horse owners from shows. He said inspection methods are "subjective" and the bill fails to change this, and makes the stakes higher with increased fines and even possible prison time, Wigdor and Reynolds report.

DesJarlais "said a bill he's introduced, the Horse Protection Amendments Act, would be a better solution. He said his bill would require that all inspections be 'objective and science-based.' Desjarlais' bill would also amend 1970's Horse Protection Act to provide increased protection to horses participating in shows, exhibitions and sales," the reporters write. "Under his bill, inspection methods would have to be the subject of testing and would have to produce "scientifically reliable, reproducible results;" be peer-reviewed; and be accepted in the veterinary and other applicable scientific communities."

Overhaul of foster care, which will limit children's stays in group homes, may strain rural areas short of such homes

A new federal law that overhauls the nation's system of care for foster children tightens rules on group-home placement. The homes say there aren't enough foster parents to care for all the children in need, which have increased in recently, especially in rural areas, because of the opioid epidemic.

The Family First Prevention Services Act was included in an omnibus spending bill signed in February 2018; when it takes effect in October, the federal government won't pay for a child to stay in a group home for more than two weeks, with a few exceptions for children with special needs, Teresa Wiltz reports for Stateline: "The law had overwhelming support from nearly every state and the U.S. Congress. Many child welfare experts say that group homes, even the homiest among them, are far from an ideal place for a child to grow up. Research shows that foster kids in group homes face worse outcomes, from lower educational attainment to increased rates of homelessness and criminal-justice involvement."

The law puts a greater emphasis on trying to prevent children from needing foster care, and allows the federal government to reimburse states for more preventive services to children deemed "foster care candidates," generally those who have been abused or neglected but haven't been removed from home. "Under the new law, states may use matching federal funding to provide at-risk families with up to 12 months of mental health services, substance abuse treatment and in-home parenting training to families. Eligible beneficiaries are the families of children identified as safe staying at home; teen parents in foster care; and other parents who need preventive help so their kids don’t end up in the system. States must also come up with a plan to keep the child safe while remaining with parents," Wiltz reports in a different Stateline story. States can ask for a two-year delay to implement the group home restrictions in the new law, but that means forgoing federal funding for preventative services.

Baptist Children's Homes of North Carolina, which operates dozens of group homes in the state, kept the law from passing for years with the help of Sen. Richard Burr, R-N.C.. The organization's leaders protest that there aren't enough foster homes to care for all the children in need, and that the two-week time limit is too short -- it can take two weeks for a child to have their first family court appearance after being removed from their parents, Wiltz reports.

Karen McLeod, the director of Benchmarks, an alliance of statewide child-welfare agencies, said group homes in North Carolina aren't against the law because they're motivated by profit. Most are run by religious organizations, lose money and raise funds to make up for the shortfall, Wiltz reports.

Group homes are particularly suited to housing sibling groups and teens, both of which often have a harder time being adopted or placed in foster homes. Some teens choose to stay in group homes because they're tired of moving around. While most children have been placed there by courts, a few have been privately placed by parents, usually because the parent is having trouble managing the child or because the parent is incarcerated. The typical stay is six to nine months. Some children are reunited with their families, and some are adopted, Wiltz reports.

Study that showed increasing air-ambulance charges may bolster Senate bill that cracks down on surprise medical bills

In 2016, nationwide median charges for air ambulance services, which are used disproportionately in rural areas, were 4.1 to 9.5 times what Medicare paid for the same services, according to a recently published study. The billing disparity is much higher than for physicians or ground ambulance services. "Median charges for air ambulance services compared to Medicare rates soared by 46% to 61% from 2012 to 2016," Harris Meyer reports for Modern Healthcare. "For Medicare patients, the median charge per trip increased from $24,000 to $39,000."

Since many air ambulance providers aren't in insurance networks, patients get stuck with unexpected "balance bills" for thousands (or tens of thousands) of dollars for services they believed were in-network. The study may bolster a new Senate bill that would crack down on surprise bills. "Last month, the Senate health committee shocked the air ambulance industry, which is made up heavily of private equity-owned companies, by including a balance-billing ban for air ambulance services in its broader legislation to regulate surprise out-of-network billing," Meyer reports.

Because of a federal law that governs air carriers, courts have blocked states from regulating air ambulances, so experts say only the federal government can address the problem. "Congress last year ordered creation of an advisory committee of stakeholders to examine air ambulance price-transparency measures and consumer protections against excessive charges," Meyer reports.

"The Association of Air Medical Services, the industry's lobbying group, blamed inadequate Medicare and Medicaid payment rates for the out-of-network billing controversy," Meyer reports. "It said air ambulance services are essential for Americans, particularly in rural areas, and that the federal government needs to conduct a study to develop rates that cover actual costs in order to preserve these services."

Bill to use accumulated coal-tax revenue for Central Appalachia moving again in House, under Democrats

U.S. Rep. Hal Rogers, R-Ky.

A bill to bring more than $100 million to the Central Appalachian coalfield passed the House Committee on Natural Resources Committee Wednesday. The Revitalizing the Economy of Coal Communities by Leveraging Local Activities and Investing More (RECLAIM) Act Of 2019, "written by U.S. Rep. Hal Rogers of Kentucky’s 5th Congressional District, would pay for the reclamation of abandoned mine lands and, advocates hope, would foster growth in areas suffering from a sharp decline in coal production in recent years,"  Will Wright reports for the Lexington Herald-Leader. 

The bill would distribute $1 billion of unappropriated money from the Abandoned Mine Reclamation Fund to coal-producing states and Native American tribes over five years for mine reclamation projects, Wright reports. One of the bill's sponsors, Rep. Matt Cartwright, D-Pa., noted, "This is money that’s already collected and sitting in the federal treasury."

Though the bill has bipartisan support, it may face the same obstacles it did when introduced in years past. The idea was originally part of President Obama's PowerPlus plan, included in his 2016 budget proposal, and most Republicans were leery of supporting it. Rogers, a Republican, filed the RECLAIM Act as a stand-alone bill in 2016. It failed to pass the Natural Resources Committee that year; in 2017 it passed the committee but didn't get a full vote in the House, Wright reports.

But now the House is controlled by more free-spending Democrats, and the Senate is managed by Majority Leader Mitch McConnell, R-Ky., who introduced his own version of the legislation last year but has been cagey about whether the other bill. Spokesperson Robert Steurer said McConnell "remains committed to ensuring funding is secured to reclaim abandoned mine lands as well as for economic development efforts in Central Appalachia" and said McConnell's office "continues to discuss the issue with constituents and colleagues," Wright reports.

The bill has been blocked by representatives from Western coal states. Wyoming, which produces 40% of the nation's coal and thus pays a plurality of the taxes for the AML Fund, and Sen. John Barrasso of Wyoming is in the Republican leadership with McConnell. But some of the states that get AML funds don't have any more eligible coal sites to reclaim and are spending the funds on non-coal projects. That could trigger resentment, since that means high-producing coal states like Wyoming aren't getting money they need to spend on their greater share of mine reclamation projects.