Grocers and SNAP recipients face perplexing set of rules restricting 'junk food' purchases

In Idaho, candy is banned, unless it contains flour or requires 
refrigeration. (Photo by Denny Mueller, Unsplash)

States that no longer allow Supplemental Nutrition Assistance Program money to pay for "junk food" have left retailers and SNAP recipients confused about which foods are allowed for purchase with SNAP dollars, reports Rachel Roubein of The Washington Post. The new rules may disproportionately impact rural residents, who are more likely to participate in SNAP than their urban counterparts.

Health Secretary Robert F. Kennedy Jr. and his supporters have led the charge to keep highly processed foods off of American tables, beginning with the SNAP program. Roubein explains, "They argue federal dollars shouldn’t help people buy products increasingly linked to poor health and obesity. Trump administration officials have pushed states to bar the use of food stamps for soda and candy."

In response, 10 states received federal waivers to restrict SNAP food choices and rolled out their own unique set of restrictions. "In Iowa, anti-hunger advocates recently sought to highlight how some cold sandwiches and granola bars may not qualify," Roubein reports. "In Idaho, legislators had attempted to clarify the state’s candy ban, since it allows KitKats and Twix because they contain flour."

The fact that each state has its own rules "has led to a complicated and at times counterintuitive maze of new restrictions, according to more than two dozen interviews with trade groups for independent grocers and convenience stores, store owners, anti-hunger advocates, SNAP participants and others," the Post reports.

Fearing the loss of their SNAP licenses, some grocers have banned additional products from SNAP purchases to ensure compliance, Roubein explains. But that change has left SNAP-spending customers not just trying to figure out what their state allows, but also what the store they are shopping in allows.

While most anti-hunger activists oppose the restrictions as further marginalizing and punishing people for "being poor, nutritionists and nutrition advocates have mixed opinions," the Post reports. "Others say they have long sought to test SNAP changes, and want to see data showing whether the new rules impact consumer behavior and improve health." States with restriction waivers have two years to pilot their programs.

Food manufacturers tell Trump and Republican lawmakers to choose sides

NAM's report works to explain the food industry's many moving
parts. (National Association of Manufacturers graphic)

After months of trying to avoid direct conflict with  U.S. Department of Health and Human Services Secretary Robert F. Kennedy Jr. or drawing ire from President Donald Trump, the food industry decided it's done dodging the battle.

"America’s food-makers have a message for Trump and Republican lawmakers: You must choose between Robert F. Kennedy Jr.’s agenda and ours," reports Amanda Chu of Politico. At its core, Kennedy's "Make American Health Again" plan includes more regulation, and manufacturers say that will increase costs, potentially limit food supplies or consumer access to certain foods.

To drive their message home, the National Association of Manufacturers (NAM) released a video and report titled Manufacturers Feed America, which "warns the food industry is 'under increasing strain,'" Chu writes. The video explains that American consumers won't benefit from a state-by-state "patchwork" of rules that don't account for food production dynamics and challenges. The report points out that regulation will inevitably increase food prices.

NAM wants national uniform standards along with "a seat at the table on policies stemming from Kennedy’s MAHA agenda," Chu adds. NAM CEO Jay Timmons called Kennedy's policies and tactics "a business killer." Timmons maintains that Kennedy's attacks on U.S. manufacturers don't align with Trump's promise to reinvigorate U.S. manufacturing. 

Meanwhile, Kennedy has given food-maker concerns "little deference," Chu adds. "He said he thinks the deference policymakers have shown them in the past was a byproduct of the Washington swamp."

The timing of NAM's publicly shared report and video reflects the industry's awareness of "Republican vulnerabilities on the economy in an effort to push their agenda ahead of the November midterm elections," Chu writes. Midterm outcomes will "shape Trump’s influence for the remainder of his term."

Whatever the agenda, American consumers are weary of increasing food costs. Chu reports, "November’s Politico Poll with Public First found Americans across demographics rank cost of living as the nation’s top problem, with 45% naming grocery prices as their 'most challenging' expense, surpassing housing and health care costs."

Texas A&M study, supported by Texas Pecan Board, says pecans help prevent obesity and many other health issues

Pecans have thin shells and lots of meat. (Texas A&M)

"Daily consumption of pecans has been shown to prevent obesity and a host of related health issues like fatty liver disease and diabetes, according to a collaborative study by Texas A&M AgriLife scientists," the university reports, citing a study also funded by the Texas Pecan Board and the Texas Department of Agriculture. 

“Obesity and diabetes numbers are increasing in modern society worldwide, and the trend in high fat diet consumption is one of the main reasons, besides lifestyle and genetic predisposition,” said Luis Cisneros-Zevallos, a professor of horticulture and food science. “People are searching for healthier options, and we have now shown pecans are a healthy tool consumers have in their hands.”

Cisneros-Zevallos was principal investigator for the study, which provides scientific evidence supporting traditional knowledge in the Americas that pecans are highly nutritious, said Amit Dhingra, head of the Department of Horticultural Sciences at Texas A&M. The study also involved a team at the National Institute of Medical Sciences and Nutrition Salvador Zubiran in Mexico.

“We now know what potential mechanisms underlie that nutritional benefit,” Dhingra said. “Our department is focused on the areas of sustainability, wellness and food security, and this research illustrates the relevance of horticultural crops for human health.”

 
Researchers applied pecans and high-fat diets to mice models and found that pecans increased energy expenditure, reduced inflammation and imbalances of microbes, and helped with digestion, liver function and muscle function.

Cisneros-Zevallos said pecans reduced low-grade inflammation that leads to chronic inflammation and the development of a range of prevalent diseases, as well as maintaining body weight and preventing diabetes even with a high-fat diet.

America's high obesity rates made the pandemic deadlier, but Vilsack is only high-level Biden official voicing concern

Percentage of obese adults, 2019 (Politico map, CDC data) 

High rates of diet-related issues such as obesity and diabetes have made the pandemic deadlier in the U.S., especially in rural America, where such diseases are more prevalent. "Yet there has been very little attention to the connection at the highest levels of government," Ximena Bustillo reports for Politico's Weekly Agriculture. "The problem is deeply entrenched and staggering in scale: More than 42 percent of American adults — about 100 million people — had obesity before the pandemic began, according to the Centers for Disease Control and Prevention. Nearly three-fourths of American adults are overweight or have obesity, and roughly one in five children now have obesity. Researchers estimate that nearly two-thirds of Covid-19 hospitalizations in the U.S. were related to obesity, diabetes, hypertension and heart failure."

But the federal government has "no national strategy, no systems-wide approach, even as researchers increasingly recognize that obesity is a disease that is driven not by lack of willpower, but by a modern society and food system that’s almost perfectly designed to encourage the overeating of empty calories, along with more stress, less sleep and less daily exercise — setting millions on a path to poor health outcomes that’s extremely difficult to break from," Bustillo reports. "The only high-level Biden administration official who routinely talks about the issue is Agriculture Secretary Tom Vilsack — and he brings it up often. Vilsack likes to point out in his speeches, for example, that the government now spends more treating diabetes than the entire budget of the USDA, which is about $150 billion."

Pandemic roundup: ACA enrollment booming; what we don't know about 'long Covid'; National Guard opening vax clinics

Here's a roundup of recent news about the pandemic and vaccination efforts.

As more people get vaccinated, more Americans are relaxing social-distancing precautions and returning to normal life, according to a new poll. Read more here.

More than 200,000 people have signed up for health insurance plans under the Affordable Care Act's online marketplace during a special enrollment window that President Biden opened, which one health policy reporter says is "a sign that those who lost insurance during the pandemic remain in desperate need of coverage." Read more here.

The National Guard is opening coronavirus vaccination clinics in rural counties to increase access to underserved areas. Read more here.

Vaccination sign-ups prove daunting for speakers of other languages. Read more here.

Visually impaired people face extra difficulties in getting vaccinated. Read more here.

Communities and organizations are working to get the vaccine to homebound people. Read more here and here.

A 70 percent vaccination rate doesn't ensure herd immunity, some experts caution. Specifically, if residents in some areas can't or don't get vaccinated and social distance, they can harbor the coronavirus and allow it to mutate and spread to other areas. Read more here.

American adults gained an average of half a pound for every 10 days spent under stay-at-home orders, according to a new study. Read more here.

What we know and don't know about "long Covid," or symptoms—sometimes debilitating—that persist for months after catching the virus. Read more here.

Toolkit aims to help rural communities plan, create and fund early childhood health promotion programs

The Rural Health Information Hub has launched a toolkit to help rural communities learn how to plan, create and fund early-childhood health promotions.

The toolkit has seven detailed modules that break down how to create, develop and implement a program, evaluate its effectiveness, plan for long-term sustainability, and best practices. 

The toolkit is designed to supplement and expand on other rural community health toolkits dealing with food access, health promotion and disease prevention, obesity prevention, oral health, services integration, social determinants of health, telehealth, tobacco control and prevention, and rural transportation.

From the website: "For more information about rural community health programs, including how to develop and implement a program, please visit the Rural Community Health Toolkit. Visit the Rural Health Promotion and Disease Prevention Toolkit for information about implementing a health promotion program for people of all ages."

Quick hits: Local journos face QAnon quandary in election coverage; Paradise, Calif. once again threatened by wildfire

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.

Local journalists face a quandary in how to cover politicians promoting QAnon conspiracy theories during election season. Read more here.

A Wisconsin farmer just outside Kenosha planted sunflowers and wildflowers over 22 acres in hopes of bringing a little sunshine to visitors' lives in a stressful time. Read more here.

September means ripe pawpaws if you live in Appalachia. Learn more about this delicacy (which looks and tastes like a banana-mango hybrid) and why you don't see it in groceries . Read more here and here.

Doctors study why obesity may be tied to worse outcomes for covid-19 patients. Read more here.

Residents in Paradise, Calif., a town destroyed by the Camp Fire in 2018, are once again threatened by wildfire. Read more here.

The Environmental Protection Agency is cracking down on illegal devices that bypass vehicle emissions controls for diesel pickup trucks. Read more here.

Index shows counties most vulnerable to covid-19 due to underlying health issues; many of them are rural

Covid-19 health risk by county, compared to the national average. New York Times map; click on the image to enlarge it.

Many areas of the U.S. that haven't yet seen major pandemic outbreaks could still be hard-hit in the coming months because of higher chronic health issues like obesity, diabetes, high blood pressure, and other ailments. Many of those counties, are rural.

"Large parts of the South and Appalachia are especially vulnerable, according to a health-risk index created for The New York Times by PolicyMap, a company that analyzes local health data," Nadja Popovich, Anjali Singhvi, and Matthew Conlen report for the Times. "The index for the first time identifies counties with high rates of the underlying conditions that increase residents’ risk of becoming severely ill if they are infected with the coronavirus. Even in lower-risk counties, a significant proportion of the population is living with these conditions."

The index's top 11 highest-risk counties where coronavirus cases are growing are all in rural, heavily African American counties in the Black Belt and the Mississippi Delta. Among them, Dallas County, Alabama, has the highest population, at about 44,000.

Study: Rural women with ovarian cancer more likely to be diagnosed at Stage IV, but not because of distance to doctor

Rural women who have ovarian cancer are more likely to find out about it when it's already at stage IV than women who live in metropolitan areas, according to a study in The Journal of Rural Health. That matters because detecting cancer earlier makes for a higher survival rate. From 2000 to 2015, the five-year survival rate of stage IV ovarian cancer was only 29 percent. The American Cancer Society estimates that 23,000 women were diagnosed with ovarian cancer in 2019, and about 14,000 died or will die from it.

Researchers from the University of Iowa and the Centers for Disease Control and Prevention studied a sample of about 1,000 women in Iowa, Kansas and Missouri who had been diagnosed with ovarian cancer in 2011-2012. At the time of diagnosis, 111 had stage IV and 889 had stages I-III. The stage IV patients were more likely to be older, rural, and have other health problems.

It is tempting to attribute that difference to poverty, or difficulty in accessing health care, but the study controlled for those factors. Rural women were more likely to be diagnosed with late-stage ovarian cancer regardless of their census tract's socioeconomic status or the distance to their primary care provider.

The diagnosis-stage disparity also isn't likely related to lifestyle factors such as smoking, obesity, or lack of physical activity; though such factors are more prevalent in rural areas, they aren't prominent risk factors for ovarian cancer. And though it's possible those lifestyle factors could create a higher incidence of cancer, they aren't likely to create geographic survival or diagnostic disparities.

Rural cancer patients overall have poorer outcomes than non-rural patients, including a lower survival rate. That's true of rural ovarian cancer patients too, probably because of lower access to specialty care and treatment after diagnosis.

The researchers suggest that better access to gynecological specialists in urban areas could make a difference, since those doctors are highly trained and may be able to recognize the symptoms of ovarian cancer sooner than other health care providers.

Some state legislatures tackle rural health access problems

Stateline map; click to enlarge it.

As state legislatures begin their 2020 sessions, more are grappling with how to increase access to medical care in rural areas.

Most rural areas have significantly worse health outcomes than cities and suburbs. Rural mortality rates for the top five causes of death (heart disease, cancer, accidents, low respiratory disease and stroke) and the gap has been growing at least since 2009, Michael Ollove reports for Stateline. Rural areas also have higher suicide rates. And though urban areas have a higher overall rate of deaths from drug overdoses, rural areas have higher overdose rates for some drugs, such as methamphetamines and oxycodone. Rural women are also more likely to die from a drug overdose than their suburban and urban counterparts.

The health gap has multiple reasons: poverty (which reduces access to health insurance and nutritious food), higher rates of smoking and obesity, and lower rates of exercise. Another big reason: "Since 2005, at least 163 rural hospitals have closed, more than 60 percent of them since 2012. Nineteen rural hospitals closed in 2019, the most in a year," according to the Rural Health Research Program at the University of North Carolina, which tracks rural hospital closures, Ollove reports. Rural health clinics are faring poorly, too: 388 clinics closed between 2012 and 2018, leaving 4,245 in operation.

Partly because of hospital closures, rural areas have a hard time attracting and keeping medical professionals. "Nearly 80% of rural counties are short on primary-care doctors, and 9% have none, according to the National Rural Health Association’s Policy Institute," Ollove reports. "The shortage of providers is likely to only get worse. More than 25% of primary care physicians in rural areas are 60 or older, compared with 18% in urban areas.

Though Medicaid expansion and the Patient Protection and Affordable Care Act have helped many rural residents get health insurance, rural areas are still grappling with these systemic problems. "Many states are focused on making improvements, both large and small, to address the deficiencies," Ollove reports. "Among the ideas: creating private-public partnerships to increase access to care, sending mobile medical units into remote areas, expanding telemedicine and encouraging young people in rural communities to go into health professions."

Several Republican-run states are fielding initiatives to expand Medicaid, which would increase rural coverage and thus rural hospitals' revenue. "Some states are trying to help rural hospitals deliver preventive care and chronic illness management beyond their walls, improving the collective health of the community while reducing health care costs," Ollove reports.

Pennsylvania, for example, has an initiative in which it guarantees 13 participating rural hospitals the revenue they'll receive in the coming year and rewards hospitals for keeping patients healthy and out of hospitals. The hope is that hospitals will be better able to focus on prevention and treatment without having to worry so much about the budget, Ollove reports.

"Brock Slabach, senior vice president of the nonprofit National Rural Health Association, said big ideas are needed to truly change the trajectory of rural health. The good news is that because of scale, rural areas are promising places to test out innovations in the delivery and financing of health care." But, he told Ollove, "we don’t have the luxury of having years to spend finding solutions."

Low-carb diet advocates aims to alter feds' nutrition advice

A group of people who advocate low-carbohydrate diets is trying to persuade the federal government to lower the recommended daily intake of "carbs." The Department of Agriculture and the Department of Health and Human Services are set to update federal nutrition advice in 2020.

"The Low-Carb Action Network — launched on Wednesday by a small group of doctors, researchers and consumers . . . said scientific research shows the diet can help prevent diseases, particularly Type 2 diabetes, and should be included in the Dietary Guidelines for Americans," Ryan McCrimmon reports for Politico's Morning Agriculture. "The network does not receive funding from industry and plans to set up a donation page on its website to raise money, a spokesperson said."

Nutrition guidelines are updated every five years, based on a scientific report from an independent 20-member committee. The guidelines shape federal nutrition programs like school meals and the Women, Infants and Children nutrition program, McCrimmon reports.

"The committee last year signaled it would review low-carb (and high-fat) diets, a move welcomed by a disparate group of nutrition experts, Atkins and keto followers, and the livestock sector," McCrimmon reports. "The research on low-carb diets that the advisory committee includes in its review is a top concern among the leaders of the Low-Carb Action Network."

Proponents of low-carb diets say they're a good way to lose weight and can help reverse and prevent diseases. The American Diabetes Association seemed to support this view with a report earlier this year saying low-carb diets have been shown to reduce the need for diabetes medication, McCrimmon reports. However, some nutrition experts say the long-term health impacts of low-carb diets are unclear and that research on them is so new that it's too early to base firm recommendations on it.

Rural doctor's weight-loss clinic sees big results with old-fashioned methods: eat better food, less of it, and exercise

Dr. Carol Peddicord holds a model representing five
pounds of body fat. (Clinton County News photo)

A doctor and a pharmacist in rural Albany, Kentucky are seeing big results in the fight against obesity after opening a weight-loss clinic. Since The Doctor's Health and Weight Loss Clinic opened in January, its 433 patients have lost a collective 4,079 pounds, and most have maintained their weight loss, Brett Gibson of the Clinton County News reports.

Dr. Carol Peddicord and pharmacist Arica Collins of Dyer Drug Co. came up with the idea for the clinic after seeing how many patients came in looking for a quick fix to lose weight. But the best way to do that is to live a healthier lifestyle, not through a pill or a crash diet, the News notes.

The emphasis is on healthier, Peddicord told the News: "We don’t want people to be skinnier, we want them to be healthy and live longer."

Obesity is a significantly bigger problem in rural areas than in suburban and urban areas, according to the Centers for Disease Control and Prevention. Among adults, 34.2% of rural residents are obese, compared with 28.7% in metropolitan counties.

Though the duo first conceived of the clinic because they were worried about children's health, most of their patients are women between 35 and 58. There are a few high schoolers, though, and they're starting to see more men coming in. That's good, Peddicord told the News, because men typically have heart disease earlier in life.

Albany, in Clinton County, Kentucky
(Wikipedia maps)

The clinic, which takes insurance, offers individually tailored wellness plans for patients, depending on whether they have high blood pressure, diabetes, and/or heart disease. They offer diet plans and will soon have plans for meal replacements such as shakes, the News reports.

Though Peddicord was glad to note that the clinic's patients had lost 680 pounds last month, she told the News that pounds aren't the only thing that matter. Patients have seen other "non-scale victories," such as being able to stop taking insulin for diabetes. "People are losing weight, feeling better and are able to exercise," Peddicord said.

The bad news about rural America, and ways to deal with it

Illustration by Sarah Grillo, Axios (cropped vertically from original)

The online news service Axios specializes in smart, short reads of 300 to 600 words, pretty much the range for typical post on The Rural Blog, so we're running verbatim a 583-word piece headlined "The rural America death spiral," with our commentary below. We invite you to post your own comments, by clicking on the comment link at the bottom.

By Stef W. Kight and Juliet Bartz

Many of the nation's current pathologies are taking a heavy toll on the majority-white population living in rural America, which was severely impacted by the opioid crisis and has dealt with falling populations, job losses and rising suicide rates.

Why it matters: The malaise and discontent that President Trump has tapped into goes beyond the racism we've seen over the past few weeks and includes anger at a changing world and frustration at dwindling opportunities close to home. These trends are further entrenching the rural-urban schism that came to light in the 2016 election.

The big picture: Political and economic power is shifting to the cities, and 20 percent of the population — 46 million people — is being left behind in the middle of America. These communities face increasingly difficult barriers to education, wealth and health. And if you're African American or Hispanic, your chances of success and survival at every turn are even worse.

Let’s say you were born, grew up and now reside in rural America. Throughout your life, you have been more susceptible to poverty, lower education, illness and even death than your urban counterparts. As a kid, chances are, you lived farther away from a doctor or hospital and got less exercise. You were more likely to live in a school desert — having to travel long distances to make it to school, if you were able to attend at all. Your school might have shuttered, as school consolidation has become more common in many rural areas, per The New York Times.

You had a greater likelihood of getting your high school diploma than the national average, but were far less likely to go straight to college than your urban and suburban counterparts, as The Atlantic reported. If you did graduate with a college degree, you'd likely end up so saddled with student debt that returning to your rural hometown wouldn't be an option if you hoped to get a job that would enable you to pay it off, according to research by the Federal Reserve. Even if you stay, some of the brightest people you grew up with would leave, contributing to the rural "brain drain."

As an adult, you’re more likely suffer from obesity, mental health issues, diabetes, cancer and opioid addiction. You are more likely to know people who took their own lives. If you keep working in your hometown, your job is more likely to be taken over by artificial intelligence, according to a study by the Brookings Institution — especially if you live in Indiana, Kentucky, South Dakota, Arkansas or Iowa. Your community's economy still hasn't fully recovered from the 2008 recession, according to Fed data.

As you get older, you are more likely to die from a preventable death, according to the Centers for Disease Control and Prevention. If you do make it into old age, you may not have a place to grow old near your friends, family and the place you called home your whole life.

What's next: Technological advancements such as 5G and automated vehicles won't directly make life harder for rural America, but instead will fuel inequality by making life that much easier for urban America. The rural-urban divide will continue to play a central role in politics and elections for the next several years — unless and until rural America's population declines enough that its political power dwindles.

The bottom line: States, municipalities and the federal government have spent billions to draw jobs and prosperity to stagnant rural areas. But not much has changed.

COMMENT: One of our wiser advisers at the Institute for Rural Journalism and Community Issues, the late Dr. Gil Friedell, liked to say, "If there's a problem in the community, the solution is probably in the community." In other words, governments and philanthropies can help, but communities must leverage their own assets to create progress. Rural communities have much in common, but each one is a distinct place, with its own potential solutions. We try to provide information that helps rural communities deal with their problems; or, as our mission statement puts it, "help rural journalists define the public agenda in their communities."

Articles like the one above tell troubling truths, but there are other truths. We need to remind our urban cousins that rural America is where the nation gets its food, its fiber and most of its water; it’s where Americans find recreation and relief from the urban environment, many of them in second homes. But the value of rural America to the nation is more than just economic. Most Americans have some rural heritage, and elements of rural culture still run through our lives. Its values of neighborliness and self-reliance – which are complimentary, not conflicting – are too often forgotten in urban America. We need to point out and exalt the good things about rural America and not let it be reduced to stereotypes. –Al Cross, director and professor, IRJCI, University of Kentucky

Study shows rural residents are driving global rise in obesity

A newly published study found that rural residents are driving the global rise in obesity, contradicting previous research that linked obesity to sedentary urban dwellers, Doyle Rice reports for USA Today.

That's especially true in high-income and industrialized countries such as the United States, according to the study, which measured body-mass index averages in 200 countries from 1985 to 2017. "Researchers determined that BMI averages are rising for everyone," Rice reports. "However, they were rising more quickly for people who lived in rural areas."

The researchers wrote: "The lower urban BMI in high-income and industrialized countries reflects a growing rural economic and social disadvantage, including lower education and income; lower availability and higher price of healthy and fresh foods; less access to, and use of, public transport and walking than in cities; and limited availability of facilities for sports and recreational activity, which account for a significant share of overall physical activity in high-income and industrialized countries."

Diabetes is less deadly than it once was, but improvement in rural areas has faded in recent years

Diabetes mortality over time by rurality. The study grouped categories according to the National Center for Health Statistics' system. (Texas A&M chart; click the image to enlarge it.)

"The life expectancy of Americans with diabetes is diverging based on geography, with metropolitan areas seeing improvement in mortality rates while rural areas do not," Tim Marema reports for The Daily Yonder. That's according to a recently published study by researchers from the Southwest Rural Health Research Center at Texas A&M's School of Public Health.

Rates for diabetes mortality were very similar in rural and urban areas as recently as 1999, but urban areas have improved since then. Rural areas, especially in the South, have seen little improvement though. "From 1999 to 2016, diabetes mortality rates improved by 5.1 points in the central counties of metros larger than 1 million residents. In 'non-core' counties – the most 'rural' category in the study – the mortality rate improved by only 0.85 points during the same period," Marema reports.

The decline in diabetes mortality wasn't because fewer people have the disease; diabetes mortality declined in some areas where the incidence of diabetes remains high. "Possible causes are advancements in diabetes treatment or education, which may have been adopted at different rates in different regions," Marema reports. "The study also said future research should look at the possible roles played by the Affordable Care Act or Medicare Part D, the prescription drug benefit that went into effect in 2006."

Research shows which states, and which kinds of towns, have rural hospitals at most risk of financial distress

University of North Carolina map; click on the image to enlarge it.

The North Carolina Rural Health Research Program has released three new findings briefs about financial distress in rural hospitals. The program is administered by the Cecil G. Sheps Center for Health Services Research at the University of North Carolina at Chapel Hill.

The first brief compares the percentage of rural hospitals at high risk of financial distress in each state. The map above shows each state's percentage range and number.

The second brief outlines the characteristics associated with communities served by hospitals at high risk of financial distress. Those communities tend to have higher minority populations, lower high school graduation rates, higher unemployment rates, and more adults who are obese, use tobacco, and/or suffer premature deaths.

UNC map; click the image to enlarge it. Refer to the third brief for definitions of different CMS reimbursement types.

The third brief shows trends in financial distress among rural hospitals from 2015 to 2019. It found that the proportion of rural hospitals predicted to be at high risk of financial distress increased from 7.1% in 2015 to 9.2% in 2019, especially in the South and especially among hospitals that rely more on Medicare reimbursements.

The brief also shows that hospitals with a Prospective Payment System now tend to be at greater financial risk than Medicare-dependent hospitals, though both types are at increasing risk (as shown above). In a PPS, the government reimburses hospitals for Medicare and Medicaid patients' care with a predetermined, fixed payment. A Medicare-dependent hospital is a small rural hospital that has at least 60 percent of its inpatient days or discharges attributable to Medicare beneficiaries and is not the sole hospital in a community.

W.Va. manufacturers oppose clean water measure, arguing that West Virginians are fatter and thus harder to poison

The West Virginia Manufacturers Association opposed in November a state measure to tighten water quality standards on the grounds that Mountain State residents are fatter than average and thus more resistant to poisons. Nonetheless, the state House of Delegates passed a bill that included the provision, Erin Beck reports for Community Newspaper Holdings Inc.

The state Department of Environmental Protection released a proposal last year to update about 60 water quality standards, based on recommendations made in 2015 by the U.S. Environmental Protection Agency. The measures addressed pollutants known to cause health problems, but the WVMA asked the joint rule-making committee not to implement the new standards, Beck reports.

The manufacturers argued that "the EPA encourages states to incorporate state-specific science, and that because West Virginians are heavier, their bodies can handle more pollutants, and that because they drink less water, they are less exposed to the pollutants," Beck reports. "They have commissioned a worker to gather that state-specific information."

The Senate Judiciary Committee voted last month to give the WVMA until October to gather that information and present it to the DEP, Beck reports.

Register for rural obesity webinar set for 2 p.m. Oct. 11

The Rural Health Information Hub will present a free webinar Thursday, Oct. 11, discussing how the National Health and Nutrition Examination Survey assesses the health of adults and youth across the U.S. to create nationally representative estimates of obesity. Participants will also hear about the latest trends in obesity and severe obesity in rural areas.

The webinar will take approximately one hour and will begin at 2 p.m. ET. A recording will be available on the RHI website afterward. Though the webinar is free, advance registration is required. Click here to register or for more information.

Rates of severe obesity have increased much faster among rural adults and children than among urban counterparts

Centers for Disease Control and Prevention chart

Obesity has long been more common in rural areas; now two studies from the U.S. Centers for Disease Control and Prevention show the scope of obesity in among rural adults and children. One shows that rates of severe obesity have increased much faster in rural America than in urban areas.

And there are differences between rural men and women: 39 percent of rural men and 47 percent of rural women were obese, compared to 32 and 38 percent among urban men and women, respectively. And while severe obesity doubled among rural women in 2013-16, it more than tripled among rural men during that time period, Dennis Thompson reports for CBS News.

The second study, which looked at children and adolescents aged 2 to 19, found no significant differences in obesity between rural and urban areas (both were around 17 percent), but 9.4 percent of rural children were severely obese compared to just 5.1 percent of their urban counterparts, Thompson reports.

Aaron Kelly, co-director of the University of Minnesota's Center for Pediatric Obesity Medicine, said he was troubled by the relatively high percentage of severely obese rural children. These kids with severe obesity really need to have access to specialized medical care to treat their obesity, in the form of weight management services," Kelly told Thompson, but noted that access was a barrier to many rural patients: "They just aren't going to be able to reasonably drive to the bigger cities where these obesity specialists are who can help them."

Bariatric surgery is out of reach in the heaviest states

In red states, Obamacare plans don't cover bariatric surgery.
(Bariatric surgery society map; click  the image to enlarge it.)

The reasons for obesity, which hits rural areas hardest, are many: lack of nutrition education, inability to afford or otherwise access healthy foods, cultural preferences, or an inactive lifestyle. And it can lead to a host of health problems, from diabetes and heart disease to early death. A combination of diet and exercise is theoretically the best way to take the weight off, but the morbidly obese who use only that strategy tend to gain it all back. Bariatric surgery is the most effective approach for such patients because it shrinks the stomach and changes the body's level of hunger hormones, but hundreds of thousands of patients in the nation's most obesity-prone areas can't access it because it isn't covered on their health-care plans.

In red states, state-employee plans don't cover the surgery.
(Bariatric surgery society map; click the image to enlarge it.)

Though the surgery cuts obese people's risk of death in half, "experts and surgeons say the procedure is treated by insurance companies less like a life-saving treatment and more like a nose job: frivolous and optional. According to the American Society for Metabolic and Bariatric Surgery, many states don’t cover the procedure in their state-employee, Obamacare, or Medicaid plans," Olga Khazan reports for Route Fifty.

Jon Gould, a surgeon at the Medical College of Wisconsin, notes that insurance companies could save money in the long term by covering bariatric surgery, since it often fixes expensive chronic health conditions like diabetes. "But state budgets, which help fund Medicaid, are often pinched and need immediate returns on investment, not savings on insulin and doctors’ visits that may not add up until five or 10 years later," Khazan reports.

Plans that do cover bariatric surgery often impose high barriers to qualify for it, such as requiring patients to quit smoking, not gain any weight for three months before the surgery, or fail at following a structured diet program for six months.

Outdated ideas about obesity as a personal failure may also be a factor. In Mississippi, where more than 37 percent of adults are obese, a bill to help bariatric patients pay for surgery in Mississippi stalled out in 2015 after it became known locally as the "belly-band bill."

"Adding a bariatric benefit in a conservative state where there is a prejudice or bias against morbidly obese people . . . so many people think you're enabling them," said David Dzielak, Mississippi's former Medicaid director.