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Hundreds of people - living without running water every day. We aren't talking about a third world country, these are people right here in Alabama.

In the Lamison area of Wilcox County, many people have to dig wells to get water. Those who can't - live without running water at all.

In an Alabama News Network Extra, news anchor Stefanie Hicks traveled there to find out why they are living without the most important natural resource, and spent time with a family to see what it's like to raise their children this way.

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Extra: No Running Water in Wilcox County - WAKA 8

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Hundreds of people - living without running water every day. We aren't talking about a third world country, these are people right here in Alabama. In the Lamison area of Wilcox County, many people have to dig wells to get water. Those who can't - live without running water at all.

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Give clean, running water.

I believe every American has a human right to clean, running water.

I believe in an America where every family can clean their hands, bodies and homes.

I believe American families shouldn't have to choose between buying clean water or putting food on the table.

I believe that tribal nations, rural communities and people of color deserve running water.

I believe young Americans shouldn't have to drive to truck stops to use the bathroom or take a shower

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On a typically steamy Alabama summer day in 1970, a three-judge federal panel that had convened in Montgomery reluctantly ordered rural Sumter County, a farming community some 133 miles west in the Black Belt, to desegregate its schools immediately.

"Each member of this court is acutely aware of the customs and traditions of the people of this section of our country," U.S. Circuit Judge Richard Rives, and U.S. District Judges Frank M. Johnson Jr. and H.H. Grooms wrote in their ruling, according to a United Press International wire service report. "We enter this order in this case with the full realization that [ . . .] the student body in the Sumter County school system will, in all probability, be composed of only Negro students."

Total desegregation - not a process of gradual integration that would keep open some all-black schools, as Sumter County had proposed - was the only way to comply with the Department of Justice's mandates, the judges wrote. But, they warned, it would only lead to white flight.

"Of course, this is not good for either race," the panel wrote. "We have searched for a solution and found none."

For nearly five decades, their prediction held true. Finally, on Monday morning, University Charter School, Sumter County's first integrated school, opened its doors.

The date was Aug. 13, 2018.

"More than half of the school's 300-plus students are black, while just under half are white," AL.com's Trisha Powell Crain reported. "While not fully representative of the county's split - 76 percent black, 24 percent white, no public school in the county has come close to reaching the percentage at UCS, according to historical enrollment documents."

That's because when a new school year started in the fall of 1970, Sumter County's response to forced integration went exactly how the federal judges who ordered it had feared. Rather than enroll their children in schools whose student body reflectedthe county's majority-black population, white parents simply sent them to Sumter Academy, a newly opened private school, instead.

Nicknamed "segregation academies," similar all-white private schools cropped up across the South in the years after the Supreme Court's desegregation ruling in Brown vs. Board of Education. An unknown number remain open - in 2012, the Hechinger Report identified more than 35 in Mississippi alone.

The result was that public schools, though technically no longer segregated, were almost entirely black. The U.S. Commission on Civil Rights would later note that in 1968, before the court order, Sumter County had three predominantly white public schools that only a handful of black students attended. In 1970, one counted only four white students in attendance, while another had no white students at all. The third had closed down.

"Although Sumter County government officials maintain that the private academies have no race restrictions for students, they admit that no blacks attend them," the Commission on Civil Rights pointed out in a 1983 report. That year, whites made up roughly 30 percent of the population in the county, yet only 2 percent of students enrolled in public schools were white.

In 1987, the Montgomery Advertiser reported Sumter County was one of several Alabama communities where integration had plainly failed. In the Black Belt, which gets its name both from the dark topsoil found in the region and the fact that the majority of residents are African American, the few white students enrolled in public schools were only there because their parents couldn't afford $1,000 a year for private school tuition, the paper found.

"I know one white man who sent his child into our system," David Jones, the black superintendent of the Sumter County Board of Education, told the Advertiser. "It lasted a year. The pressure on him was unreal."

White parents - some of whom taught at public schools themselves - were largely unwilling to explain why they sent their children to all-white private schools. "That's nobody's business but mine," one man told the paper, insisting that he remain anonymous. "It's my choice to make, and I don't have to answer to anybody for it."

The racial breakdown didn't look much different 20 years later. During the 2015-2016 school year, Sumter Academy reported having 170 students, none of whom were black. By contrast, 1,562 of the 1,593 students enrolled in Sumter County public schools were black, according to statistics from the Alabama State Department of Education.

"We shop in the same place. We eat at the same restaurant," Julene Delaine, a member of the school board, told WBHM in 2016. "So why can't our kids go to school together?"

Then, in June 2017, Sumter Academy closed for good, citing the area's population decline. Enrollment had gradually been shrinking, and only 50 students had been signed up for the following school year, the Tuscaloosa News reported.

"The sad part about it is there's always been a need for this school in Sumter County," headmaster Glenn Sanders told WTOK. "And now, it's not here and quite honestly, it's almost like someone died."

University Charter School, which became the county's first integrated public school when it opened this week, may have also played a role. "It all got started back when they said they would have a charter school," Joe Nettles, Sumter Academy's head football coach, told the Tuscaloosa News in 2017. "I think people could see the end in sight with this."

Although charter schools are frequently accused of furthering racial segregation, the exact opposite seems to have happened in Sumter County. The K-8 school has no admission requirements, according to AL.com, and 70 percent of students qualify for free and reduced-price meals, suggesting that the school community is economically as well as racially diverse.

One parent, Markeitha Tolliver, told AL.com that the school "will work wonders for the community."

"Change is good," she said. "It's been a slow process, but it's happening,"

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Sumter County, Ala., just got its first integrated school. Yes, in 2018.

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In 1970, federal judges predicted that desegregating the rural Alabama county's schools would lead to white flight. They were right.

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Corydon Ireland Harvard Correspondent DateFebruary 15, 2016April 1, 2019

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The costs of inequality: Education’s the one key that rules them all

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When inequality is baked into public educational systems from kindergarten through the 12th grade, it usually extends through other aspects of life later, Harvard analysts say.

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Rural Americans-who make up at least 15 to 20% of the U.S. population-face inequities that result in worse health care than that of urban and suburban residents.

These rural health disparities are deeply rooted in economic, social, racial, ethnic, geographic, and health workforce factors. That complex mix limits access to care, makes finding solutions more difficult, and intensifies problems for rural communities everywhere.

"When you don't get your health care taken care of, you wind up with disease presentations that are much farther along. People with cancer show up with metastatic cancer, people with diabetes show up with end-organ damage," said Joseph Florence, MD, professor of family medicine and director of rural programs at Eastern Tennessee State University Quillen College of Medicine.

Consider one patient who came to a rural clinic affiliated with Quillen. The man had a large abscess that needed draining to help treat the infection. Although rural patients are less likely to have health insurance, he was insured. Yet, like many in rural areas, he couldn't find a plan provider within an hour or two of his home.

"We just happened to have a free clinic that night, so we took care of him there," said Florence. "But that's just a once-a-month event, to give medical students some experience, not a way to provide health care."

Challenges to rural health

U.S. rural communities-from Appalachia and the Deep South to the Midwest and western states to Alaska and Hawaii-share common risks for poorer health. These challenges, including few local doctors, poverty, and remote locations, contribute to lack of access to care.

Compared with urban areas, rural populations have lower median household incomes, a higher percentage of children living in poverty, fewer adults with postsecondary educations, more uninsured residents under age 65, and higher rates of mortality, according to a 2017 report by the North Carolina Rural Health Research Program (NC RHRP) at The University of North Carolina at Chapel Hill.

Rural residents who live on farms, ranches, reservations, and frontiers often must travel long distances to reach a health care provider. That means taking hours off from work for an initial appointment or follow-up, which causes many to delay or avoid care.

Greater distances also result in longer wait times for rural emergency medical services (EMS). That can endanger patients requiring EMS treatment. "If you're bleeding, in that extra 15 minutes (before help arrives), you can die," said Gary Hart, PhD, director of the Center for Rural Health, University of North Dakota School of Medicine and Health Sciences, in Grand Forks.

"Access to providers, even family physicians, is a problem. If you want to go to an OB/GYN, depending on where you live in the country, you may have to go 200 miles."

Gary Hart, PhD
University of North Dakota School of Medicine and Health Sciences

Physician shortages contribute to many rural health difficulties. Primary care doctors are stretched thin, and specialists, including mental health and substance abuse providers, are a rarity [see sidebar].

"Access to providers, even family physicians, is a problem," Hart said. "If you want to go to an OB/GYN, depending on where you live in the country, you may have to go 200 miles." In a study published in September 2017 by researchers from the University of Minnesota School of Public Health, as of 2014, 54% of rural counties did not have a hospital with obstetrics services.

According to the U.S. Department of Veterans Affairs (VA), 25% of U.S. veterans live in rural areas. Compared with 36% of urban military veterans, more than half of rural-dwelling veterans are enrolled in the VA health system, yet many live far from the nearest VA medical center.

Some medical schools are deliberately preparing students to meet the needs of rural populations. Quillen was founded to meet regional needs and looks for students who might be likely to "go back into a rural area and do primary care," Florence said. Students receive rural exposure during training, including through rural immersion experiences and learning from faculty with backgrounds in rural care. They conduct physicals for children in rural elementary schools and Head Start programs, gaining insight into differences with urban children.

Quillen's curriculum builds students' cultural sensitivity to rural patients. For example, said Florence, when a rural patient has gastrointestinal pain, the doctor needs to ask, "Do you have well water? Is it a drilled well or a dug well (which is at greater risk of contamination)? Are you working in the fields, out where it's hot?"

"You have this textbook of medicine that you have to cover," he said, but the school presents that knowledge to reflect "taking care of patients in the context of where they're coming from, where they're living."

The diversity of rural America

While rural communities share common challenges, their residents may be racially and ethnically varied, with distinct health inequities. "We look at differences through rural-urban classifications, but when you layer in the issues of race and ethnicity, you find even greater disparities [within rural populations]," said Alana Knudson, PhD, codirector of the NORC Walsh Center for Rural Health Analysis at the University of Chicago.

African Americans are the largest rural minority. In the Deep South, once centered on the use of slaves in agriculture, some rural counties have large or majority African American populations. "There's not a lot of migration out of state. It takes a lot to leave a place you've grown up in," said Monica L. Baskin, PhD, a professor in the Division of Preventive Medicine at The University of Alabama at Birmingham (UAB) School of Medicine.

Rural African Americans have higher rates of cancer morbidity and mortality than other rural residents and have higher rates of comorbid conditions. "These are the same disparities you see nationally, with African Americans tending to have higher rates of these conditions," Baskin said. "But in the rural communities we work with [in Mississippi and Alabama], there's an even greater likelihood for them."

"We look at differences through rural-urban classifications, but when you layer in the issues of race and ethnicity, you find even greater disparities [within rural populations]."

Alana Knudson, PhD
NORC Walsh Center for Rural Health Analysis, University of Chicago

The most recent U.S. census, which measured population changes from 2000 to 2010, showed that rural diversity has been increasing. Non-Hispanic whites were about 80% of rural dwellers in 2010 but accounted for only 25% of rural population growth. Over that same decade, rural Hispanics increased about 45% to 3.8 million people, almost equal to rural African Americans. Native Americans increased by 8%. The number of Asians rose by about 37%, although remaining a small part of the total rural population.

In his Central Appalachian area, Florence said, the Hispanic community has grown considerably in the past 15 years, with a smaller Haitian population arriving more recently. Some are migrant workers, for whom health care is "pretty sporadic," he said. "When I see a migrant tomato farmer, he might have been without his blood pressure medicine for six months. Yet he continues to work every day."

The NC RHRP reports that at least 80 rural hospitals in 26 states have closed since January 2010. Many are in communities with significant black or Hispanic populations. One such Alabama hospital closed in September and was located in a county where 72% of residents are African American. The nearest hospitals are now about 50 minutes away.

To increase access to specialists, UAB connects patients with physicians through its telehealth program. Using technology eliminates what can be, for some patients, a four-hour drive to Birmingham, said Baskin. Some areas without internet or broadband coverage are reached through conference calls and DVDs.

Higher disease incidence, worse outcomes

The rural-urban health care divide manifests clearly in breakdowns of conditions and outcomes. According to the Centers for Disease Control and Prevention (CDC), rates for the five leading causes of death in the United States-heart disease, cancer, unintentional injury (including vehicle accidents and opioid overdoses), chronic lower respiratory disease, and stroke-are higher in rural communities.

While overall mortality rates have been declining nationwide, rural areas have had a much slower decrease. They have higher infant mortality and greater rates of mental, behavioral, and developmental disorders in children. Rural youth and rural veterans have higher rates of suicide than their urban peers.

Rural residents are also more likely to have cancers related to modifiable risks, such as tobacco use, human papillomavirus (HPV), and lack of preventive colorectal and cervical cancer screenings.

UAB has a rural cancer prevention program that trains local residents and nonprofit organizations to deliver health promotion activities and evidence-based programs. "We make sure the interventions we're doing are scalable and sustainable," Baskin said.

Although smoking has greatly decreased in much of the United States, "adults in rural counties are still smoking at the same rate, or somewhat higher, than they were 10 years ago," said Knudson. Twice as many rural youth smoke as do their urban peers, so she expects the higher rural rates of tobacco-related diseases and mortality to continue.

The CDC also cites opioid overdose deaths as 45% higher in rural areas, yet urban patients have easier access to treatment facilities. In Central Appalachia, "we're just devastated by it," said Florence. From 2008 to 2014, rural communities saw an increase of infants born with neonatal abstinence syndrome -a condition related to maternal opioid use-that was about two and one-half times higher than in urban areas.

The factors involved in rural health disparities are "not just something that our physicians can deal with," Knudson said. "We need to figure out how to use these data to target resources and interventions to make a meaningful difference in improving the health of rural America."

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Health Disparities Affect Millions in Rural U.S. Communities

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Lack of access to care providers is a big part of the urban-rural health divide. Why addressing the physician shortage won't be enough to fix the problem.

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This story is a part of Ask Alabama, a weekly interaction with our readers, where you ask the questions, you vote to decide which questions we answer, and then we investigate. One reader, who identified himself as Michael from Mountain Brook, asks, "How will Alabama help improve access to health care in its rural counties that are closing their hospitals?"

On September 1, a rural hospital serving one of Alabama poorest counties will close its doors after 60 years. The J. Paul Jones Hospital in Camden, Wilcox County, the birth county of Alabama Governor Kay Ivey, will become one of seven rural hospitals that has closed over the last eight years, placing Alabama near the top of the list for rural hospital closures nationwide, according to experts who spoke to AL.com.

Georgia has closed six rural hospitals while Texas has closed nine, the highest in the nation.

"Alabama is without doubt facing a rural health crisis," said Jim Carnes, policy director at Alabama Arise, a non-profit advocate group for low-income residents. "The hospital closures, along with other medical facilities, have already had and will continue to have dire consequences for residents in rural areas."

Michael's question comes during a time of uncertainty across the U.S. healthcare sector. The Republican controlled Congress tried to pass numerous bills that would repeal and replace Obamacare, while President Donald Trump has threatened to cut federal funding for Medicaid, which would likely hurt rural communities in Alabama and across the country.

While the GOP failed to scrap Obamacare and Trump has yet to follow through on his threat, the closure of J. Paul Jones Hospital in Wilcox County is the latest chapter of how healthcare in the country is changing, and has become a cautionary tale for rural communities.

In hospital chairman George Alford's press release, explaining the hospital's closure and transition to an urgent care facility, he said that the county's high poverty rate of 40 percent, unemployment rate of 15.3 percent (June) and the declining population of the region - currently at its lowest level since 1840 -meant the hospital has very few sources of income other than Medicaid.

Wilcox County's population was predicted to hit just under 11,000 in 2016. It was 9,548 in 1840, but has been in decline since hitting 36,000 in 1900, according to Census statistics. Dale Quinney, Executive Director of the Alabama Rural Health Association (ARHA), a non-profit organization dedicated to preserving and enhancing the health of rural Alabama citizens, told AL.com that 41 out of 67 counties are projected to have less population in 2040 than they had in 2010.

What's more alarming he said was that 46 rural hospitals that report annual income, 34 were operating at a loss.

'These counties need people if hospitals are to survive," said Quinney. "They are magnets of economic opportunity. Why would people or businesses move to a county without adequate medical care?"

The Medicaid payments haven't come close to footing the bills of people who benefit.

Between Oct. 1, 2016 and May 31, 2017 the Camden-based hospital had $3,880,000 in charges through the Emergency Room alone, explained Alford. Of that total, around $850,000 was recouped during that time period. $129,000 of that came from Medicaid.

"If you have an item for sale in a retail situation that cost you $50.00 and you are required to sell it for $5.00-$10.00, you wouldn't be in business very long," said Alford in his Aug. 3 press release. "I believe these figures speak for themselves."

Alford said the hospital was losing roughly $1 million a year. As many as 40 staff members are expected to lose their jobs while locals will have to make the 50 minute drive to hospitals in Monroeville, Greenville, Selma and Grove Hill. But that might not be so easy.

According to the ARHA, up to 16 percent of households in 14 of Alabama's rural counties do not have access to a vehicle.

Medicaid battle

"Alabama's rural hospitals are paid among the lowest for Medicaid in the entire country,' he said. "Only about three or four U.S. territories have lower payments, so it's no wonder they are struggling to survive."

Medicaid payments are calculated using a complex mathematical formula based on the average wage of hospital workers, according to the American Hospital Association. Known as the Medicare Area Wage Index, it currently pays rural Alabama hospitals $6,900 per $10,000 of the cost of an operation. The Alabama Hospital Association (ALAHA) said the formula, originally designed to reflect market-to-market differences in healthcare costs, has become manipulated. Some states are paid up to $18,000 for the same operation.

"As a state like California receives higher payments, it has more resources to increase wages, driving its wage index higher and small rural states' wage index lower," said a 2014 fact sheet from ALAHA. "Low wage index states typically have lower margins, decreasing their ability to add staff or increase wages in order to increase their wage index."

"Without a more equitable wage index, some hospitals will be forced to close their doors, cut jobs or reduce services."

And when the Medicaid payments don't pay the bills, healthcare costs are spread to patients with private insurance. "Unfortunately," said Quinney, "there are allegations that rural hospitals receive significantly less reimbursement that their urban counterparts."

But the story doesn't end there for residents of rural counties. While all but seven of the 54 rural counties in Alabama will continue to have a hospital, many are cutting back on expensive procedures and services. For example, in 1980, 45 rural hospitals had obstetric services, loosely known as the field of medicine that deals with childbirth and childcare once the child is born. Today only 16 of the 54 rural counties offer that service, according to ARHA. In the Black Belt's 12 rural counties, where poverty and health issues are most acute, the number of hospitals offering obstetrics has gone from 10 in 1980 to 1 in 2017.

"There is no indication that these trends are reversing," said Arise's Carnes.
Remedies
Carnes claims the solution to the "funding gap," as he calls it, is quite simple, but extremely unpopular. Alabama needs to expand its Medicaid.

"A lot of people don't realize that the option to get heavily subsidized Medicaid is still there," he said. "The state would have to pitch in a small amount, I think about 5% now and then 10% by 2020. So you would have healthcare for hundreds of thousands of Alabamians for a dime on the dollar.

"Just a terrific bargain that we passed up there, but we can still turn it around and prevent more hospitals from being forced to close their doors."

It was Gov. Robert Bentley, a doctor, who passed up that opportunity. He said in his 2014 State of the State Address that "it is not my goal to put more people on Medicaid but to have less. It is not my intent to put able-bodied individuals on a government dependency program."

Quinney also said Alabama should follow the lead of neighboring states and allow nurse practitioners to take on more of the tasks that doctors would normally do. "Alabama has a very restrictive policy on what nurse practitioners can do," he said. "So that also restricts the care people can get in rural communities where there aren't many doctors."

Coosa County, north of Montgomery, does not have a physician, said Quinney, who has travelled to 51 of the 54 rural counties to study all aspects of health in those areas.

Another solution, claims both Carnes and Quinney, is Telehealth, the use of electronic information and telecommunications technologies to support and promote long-distance clinical health care, according to a Health Resources and Services Administration (HRSA) description. The technology involved includes videoconferencing, the internet, store-and-forward imaging, streaming media, and terrestrial and wireless communications.

However, two issues prevent Alabama from fully embracing the innovative idea.

"Unlike Georgia, Tennessee and Mississippi, we do not have legislation that mandates private insurance coverage or reimbursement for telemedicine,' said Quinney. "And also we need universal broadband coverage. You cannot offer telemedicine in many rural areas because of the terrible cell and internet access."

This issue of rural broadband access is a topic that Ask Alabama has covered in the past.

The last solution is the creation of hospitals with fewer beds. Many rural communities in Alabama have hospitals that operate with empty beds - because Medicaid, Medicare and private insurance companies have limits on how long a patient can be an inpatient before being shown the door. So the turnover is quick, meaning smaller hospitals with fewer beds would be ideal, said Quinney. However, under Alabama law, all hospitals in the state must have at least 15 beds, which use up more resources and requiring greater staffing levels.

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As Alabama's rural communities experience a major decline in population, its hospitals are closing faster than nearly every state in the country. Most are now operating at a loss, while vital services such as obstetrics are being cut.

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Dr. George Pink is a professor who studies rural health, not a doctor who tries to provide it. For the sake of his own blood pressure, he's grateful.

"Not a day doesn't go by that I don't thank God I'm an academic and not the CEO of a rural hospital," Pink, a health policy professor and deputy director of the rural research program at the University of North Carolina at Chapel Hill, said recently. "Recruiting providers, finding money, dealing with payers and lawsuits, dealing with the poor health outcomes, opioid addiction."

It's a lot.

Rural residents are in poorer health than those living elsewhere and have less access to treatment, partly because so many rural hospitals and health clinics have shuttered in recent years. As state legislatures begin their 2020 sessions, many lawmakers are struggling to find answers.

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.

"They have defined populations and identifiable characteristics," said Slabach, who used to be an administrator at a rural hospital in Mississippi. "That means when you are trying an intervention, you can see whether it's working without all the variables you might have in urban areas. In that way, rural areas are the perfect laboratories."

"But," he added, "We don't have the luxury of having years to spend finding solutions."

While the Affordable Care Act and Medicaid expansion brought health insurance to millions more Americans, including many rural residents, it has not ended many of the health care problems in rural areas: disparities in health outcomes, lack of access and an insufficient number of providers.

Many states are focused on making improvements, both large and small, to address the deficiencies. 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.

Initiatives also are underway in several conservative states this year to join the 36 states that have expanded Medicaid, which would increase coverage in rural areas and increase revenue to rural hospitals.

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.

Pennsylvania, for example, is engaged in what Slabach describes as "the boldest" state rural health initiative in the country. Other states are watching closely.

Called the Pennsylvania Rural Health Model, it prospectively guarantees its 13 participating rural hospitals the revenue they will receive in the coming year.

The idea is that by giving hospitals certainty about their budgets, hospitals can focus on preventive care and chronic illness treatment in the community, said Dr. Rachel Levine, the Pennsylvania secretary of health. The model rewards the hospitals for keeping patients healthy and out of the hospital.

"Over time the idea is to devote more resources to population health measures and put less emphasis on trying to fill their beds," Levine said.

One participant, Endless Mountains Health Systems, is deploying its personnel in new ways, said CEO Loren Stone, by monitoring patients in their homes, helping them with transportation to medical appointments and providing health education to cardiopulmonary patients and soon, he hopes, to patients with diabetes and heart disease.

Why the Disparity?

By most measures, the health of those living in rural areas is significantly worse than elsewhere. Mortality rates for the five leading causes of death - heart disease, cancer, unintentional injury, low respiratory disease and stroke - are all higher in rural areas, as is the overall mortality rate. And the gap is growing.

The suicide rate is higher in rural counties. Although the overall rate of death from drug overdoses is higher in urban areas than in rural ones, the reverse is true for certain drugs such as oxycodone and methamphetamines. Also, women in rural areas are more likely to die from overdoses than those in cities.

Health policy analysts cite multiple reasons for the rural disparities: poverty, and therefore less access to both health insurance and nutritious foods; higher rates of smoking, especially among young people; higher rates of obesity; and lower rates of exercise.

A contributing factor is the notoriously hard time rural areas have 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.

"Many people have to travel 100 miles or more for specialty services," said Oklahoma Commissioner of Health Gary Cox, adding that he hopes to develop a state fleet of rural mobile health clinics with help from a private partner.

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, according to a 2019 article in the New England Journal of Medicine. Few clamor to replace them.

"It is an unsustainable situation," said Ann Peton, director of the National Center for Rural Health Works, a research organization in Blacksburg, Virginia.

Peton said that rural areas are trying to recruit health professionals from other regions and persuade local high school and college students to stay nearby and work in health professions.

Preserving Rural Hospitals

One of the main pillars in rural health also is in extreme peril.

Since 2005, at least 163 rural hospitals have closed, more than 60% of them since 2012. Nineteen rural hospitals closed in 2019, the most in a year, according to Pink's Rural Health Research Program at UNC-Chapel Hill, which tracks the rural hospital closures.

Rural health clinics are faltering too. Peton's center reports that 388 clinics closed between 2012 and 2018, which left 4,245 in operation.

In Ashland, Kentucky, last week, Bon Secours Health Systems announced it was shutting Our Lady of Bellefonte Hospital, a 214-bed hospital. An estimated 1,000 people will lose their jobs. If history is a guide, the closure will hurt surrounding businesses and decrease local tax revenue.

About 2,200 rural hospitals are in business today, according to statistics from the Sheps Center for Health Services Research at UNC-Chapel Hill, but most survive on the slimmest of operating margins. Michelle Mills, CEO of the nonprofit Colorado Rural Health Center, said 22 rural hospitals in her state are operating in the red, double the number from the year before.

Tim Putnam, CEO of Margaret Mary Health, a 25-bed rural hospital and health system in southeastern Indiana, noted that rural hospitals like his serve populations that are older, poorer and sicker than urban ones. More patients rely on Medicare and Medicaid, public health plans respectively for the elderly and the poor, which reimburse at rates that usually do not cover expenses.

"Very few businesses would survive if they were getting back only 90 cents on the dollar," said Stone, the Endless Mountains CEO in Pennsylvania. "We don't get enough from commercial payers to bring us into profitability."

His hospital, he said, has been operating at a loss since 2013.

For many states, Medicaid expansion has meant that medical providers are compensated for treating patients who might otherwise be uninsured. A 2018 study in the journal Health Affairs linked Medicaid expansion to improved financial performances for rural hospitals and lower likelihood of closures.

Serious efforts are underway in Kansas, Missouri, North Carolina and Oklahoma to expand Medicaid. Proponents in all those states cite the jeopardy faced by their rural hospitals as one of the main justifications for expansion.

But, as Stone said, expansion itself is not the salvation for rural hospitals. Substantial reimbursement is better than none, but he said that the low reimbursement paid by Medicaid still leaves his hospital with debt.

Similarly, he said, the ACA has not entirely been a financial blessing for rural hospitals. In addition to Medicaid expansion, the ACA provides affordable commercial health insurance through its exchanges, but many of those with modest incomes buy high-deductible plans that carry lower premiums. When patients can't afford to pay those deductibles, rural hospitals end up with no payment for their services, he said.

Obstacles in Telemedicine

To reach rural residents, most states - especially those in the Northwest, Southwest and Northeast - have relaxed rules to give nurse practitioners, physician assistants and other medical professionals more authority to provide care that once was the purview of physicians. And most states allow Medicaid to reimburse services provided through telemedicine. But barriers remain.

For instance, Medicare limits reimbursement for telehealth in rural health clinics and federally qualified health centers, said Mei Wa Kwong, executive director of the Center for Connected Health Policy, a nonprofit in Sacramento, California, that promotes telemedicine. A measure to liberalize the law was introduced in the U.S. Senate last year, but it hasn't advanced.

"Policy tends to lag behind the technology," Kwong said.

The lack of broadband also hinders telemedicine in many areas of the country, she said. "The last thing you want is buffering or pixelating in the middle of a telehealth exam. That happens, and you're just not going to want to use it."

A number of states are aggressively seeking to expand their broadband, including in Minnesota, where last week Democratic Gov. Tim Walz announced $23 million in grants to expand high-speed broadband to unserved and underserved areas.

'Game Changer'

The federal Centers for Medicare and Medicaid Services supports the Pennsylvania experiment. It also has invested in another multiyear Medicare project geared toward rural areas.

It gave $96 million in loans to help establish rural health networks called accountable care organizations. Their purpose is to concentrate on the delivery of care in a way that also emphasizes preventive care and management of chronic diseases to avoid costly hospitalizations and ultimately reduce health costs.

Much of the invested dollars went toward creating data and analytics to help providers achieve better health outcomes at lower costs. The model involved 47 accountable care organizations in 37 states.

The results have been promising, saving Medicare million and cutting the numbers of hospitalizations, readmissions and emergency room visits.

"For us, it has been a game changer," said Patricia Schou, executive director of the Illinois Critical Access Hospital Network, an organization of 57 rural hospitals in the state. The analytics, she said, have greatly enhanced providers' ability to improve patient care and identify problem areas and correct them.

Seema Verma, the Centers for Medicare and Medicaid Services' administrator, has promised to introduce more payment changes to bolster rural health.

In Michigan, one Republican senator has a different idea for helping small rural hospitals: exempting them from some state regulation and oversight. State Sen. Curtis VanderWall's seven-bill package would relax state rules regarding psychiatric beds, helicopter ambulances and some heart procedures.

VanderWall also wants to allow rural hospitals with fewer than 25 beds to expand or provide new services without state approval.

VanderWall said the changes, which are backed by Americans for Prosperity, the conservative group founded by the Koch brothers, would reduce costs by eliminating red tape. But the Michigan Health and Hospital Association opposes some features in the package, arguing it could lead to redundant services among hospitals, higher overall health care costs and reduced quality of care.

Many states are trying to make targeted improvements. Colorado allows paramedics with special training to make calls in rural areas to monitor patients and make sure they are taking medications properly. Cox, Oklahoma's health commissioner, said his department identified $9 million in administrative savings, some of which he is using to raise the salaries of public health nurses working in rural areas.

In South Dakota, Republican Gov. Kristi Noem said in her State of the State address this month that she would soon announce a five-year plan to reduce suicides in the largely rural state.

In several states - including, Idaho, Oregon, Vermont, Washington and Texas - programs extend telemedicine to provide mental health services to young people, veterans and seniors. New mental health outreach programs also are underway in Michigan, Pennsylvania and North Dakota.

In Louisiana, Dr. Alexander Billioux, an assistant state health secretary, noted help the state provides rural health clinics to modernize information systems

Still, Billioux acknowledged, all the major health changes of the past few years, including passage of the Affordable Care Act and Medicaid expansion, have not done nearly enough to improve the crisis in health afflicting rural America.

"In terms of trying to improve the delivery of care while reducing costs, it seems to me that we have the greatest opportunity in rural areas," he said. "We've seen concerted interest, but we need to go beyond that now."

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Rural America's Health Crisis Seizes States' Attention * Stateline

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Read more State of the States 2020 coverage from Stateline. Dr. George Pink is a professor who studies rural health, not a doctor who tries to provide it. For the sake of his own blood pressure, he's grateful. "Not a day doesn't go by that I don't thank God I'm an academic and not the [...]

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MONTGOMERY, Ala. (WSFA) - A north Montgomery grocery store has closed its doors leaving local residents without a place to get fresh produce.

"I was really shocked and surprised to see that it had closed," said Chisholm community resident Rebecca Martin.

People in the Chisholm community are no longer in easy walking distance to a grocery store. The only source of fresh fruits and veggies, Piggly Wiggly, has closed its doors creating a fresh produce food desert.

"We're talking about an area of the city where not every single household has access to a vehicle of their own to drive themselves to the grocery store, so it's more important for groceries to be more readily accessible by foot or by public transit," said Building Our Neighborhoods for Development and Success Program Director Amanda Miller.

Piggly Wiggly was the only grocery store in the Chisholm community. Now, if someone without transportation wants access to fresh produce they'd half to walk just over 2 1/2 miles, or about 45 minutes, to the nearest grocery store.

In a statement sent to WSFA 12 News Thursday Tracy Larkin, the city council representative for the Chisholm community, expressed his disappointment in the store's closing.

"I am extremely disappointed to learn of the closing of the Piggly Wiggly Store on the Lower Wetumpka Road. It is especially depressing news considering the store opened a relatively short time ago. The number of so call 'food deserts' is increasing dramatically nationwide, making the access to affordable, healthy food options for certain communities very limited. Most of the communities that are experiencing this are black or brown and less affluent. Clearly, the store filled a critical void for the thousands of citizens who live in the Sheridan Heights, Brookview, Park Manor, and Chisholm neighborhoods, as well as surrounding areas. The answer to the problem is not easy, as it is really a function of private enterprise, but government must work collaboratively with private enterprise to find creative solutions. As the council member for this area, I pledge to offer my support to help attract and keep grocery stores within a convenient traveling distance from their homes."

Members of the community agree.

"I'm hoping and praying that we can lobby and find someone or some corporation that would be available to us to have a store that has produce in it," Martin said.

Health advocates say not only is there a want for fresh produce, there's a need.

"Having the availability of fresh fruits and vegetables allows you to offset the issues that you would have if you developed chronic disease and it also teaches you to manage your chronic diseases with those products," said The Wellness Coalition REACH Program Manager Latrice Lewis.

WSFA 12 News has reached out to officials with Piggly Wiggly about the reasoning behind the closing but have been unsuccessful.

Residents in the Chisholm community say multiple business have been closing their doors in that area over the past few years, and they are advocating for more business to set up shop near their neighborhood.
Copyright 2019 WSFA 12 News. All rights reserved.

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Piggly Wiggly closure leaves residents with few options

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A north Montgomery grocery store has closed its doors leaving local residents without a place to get fresh produce.

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Want to know where you can't buy fresh, healthful food? The USDA has the map for you.

The feds' new Food Access Research Atlas lets you find out just where it's difficult to buy broccoli or bananas in counties across the U.S. Forget walking to the store in St. Louis, Minn., where most people live more than a mile from a grocery store. Ditto for Hyde, N.C., and Pushmataha, Okla.

The atlas, which is a big upgrade from the USDA's 2-year-old Food Desert Locator, is intended as a tool for state policymakers, local planners and nonprofit groups concerned about food access.

"People can get a more detailed picture of exactly what challenges they encounter in getting to the grocery store," says Paula Dutko, an economist for the USDA Economic Research Service who helped craft the atlas.

Detailed, indeed. A few clicks and you're deep into individual neighborhoods, showing what percentage of people aren't within walking distance of a supermarket.

Thus I learned that an area just north of NPR's new headquarters on North Capitol Street Northeast "has a relatively high number of households (656 of 1,802 total households (36%)) without vehicles that are more than one-half mile from a supermarket."

Dutko and her crew added data on whether households have vehicles, because that can make a huge difference in grocery shopping. And they added more choices for distance from a store, including 20 miles for rural areas, instead of just 10.

Access by bus or train isn't on the map, Dutko says, because there are no national data. "It would be so great if we could look at public transportation availability throughout the United States," she told The Salt.

Food deserts have been a hot target of healthy-eating efforts, including Michelle Obama's Let's Move campaign.

But as programs zero in on improving access, they're finding that bringing in farmers markets and grocery stores doesn't necessarily mean that people start eating better.

So as our colleague Dan Charles has reported, efforts are now also working on lowering costs, consumer education and marketing.

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A new clickable atlas shows just how far it is to the grocery store, everywhere in the United States. "Food deserts" are the focus of state, local and federal anti-obesity efforts.

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Majority in some Alabama counties don’t have internet

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Alabama is near the bottom of national rankings for households without internet access.

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e-learning education concept, learning online with webinar, video tutorial, internet lessons
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Internet access has become a critical aspect of modern life. No longer just a realm of entertainment, the internet is a gateway for accessing basic public services, educational and economic opportunities. But in the US alone, more than 40 million people lack adequate access to broadband internet. Even in the EU, regarded globally as an advanced region in terms of digital access, around 11m citizens (2.4% of the EU population, rising to 7.6% among those considered at risk of poverty) suffer from the same problem.

This digital inequity is a cause for concern. In the US, the National Education Association highlighted that one-quarter of US students lacked access to remote education at the beginning of the Covid-19 pandemic. In the UK, the Royal Geographic Society warned of the growing necessity for computer skills, noting that households without internet access miss out on significant savings and opportunities. These examples underscore the multifaceted impact of the digital divide, affecting education, employment, and economic well-being.

In a panel that I moderated last year, Beth Fujimoto of AT&T highlighted three distinct but related challenges to achieving digital equity.

Availability: Internet providers and telecoms companies are failing to offer the infrastructure required for high-quality broadband access. Many rural areas, in particular, are inadequately served by the network, but there are problems in cities too, for example in provision to apartment blocks in some areas.

Affordability: Even where the infrastructure is available, it may be too expensive for some households, particularly as the cost-of-living crisis puts people's finances under pressure in both the US and Europe. Lack of competition in some areas has also led to higher prices.

Adoption: Many people feel intimidated by technology or may simply be unaware of how much easier it could make their lives to have internet access. In some communities, language barriers add to the difficulty of overcoming adoption issues. Moving past these challenges requires specific intervention ranging from improving infrastructure, making internet services more affordable, enhancing digital literacy and breaking down barriers to technology adoption.

In the U.S., work by the Federal Communications Commission to publish detailed maps of broadband access across the US, and the Biden's Administration's Affordable Connectivity Program are examples of targeted initiatives aimed at expanding internet access and making it more affordable. In Europe, similar strategies are being employed, with the European Commission's Gigabit Infrastructure Act and various national subsidies supporting internet access for low-income citizens.

Moreover, tackling the adoption barrier often requires localized, community-driven programs, such as digital literacy initiatives tailored to specific groups' needs. In the UK, for example, the charity Age UK has helped thousands of older people get online. The charity also employs specialist advisers in 120 outlets around the country. In France, the National Family Allowances Fund has launched a digital skills program to support vulnerable people in accessing online services.

However, the quest for digital equity is not just a regional challenge but a global imperative. Research suggests that lack of access to the internet is a much more acute issue in many developing economies. In countries such as South Africa and India, for example, as many as 70% of people struggle to get online.

The bottom line is that, in our schools, hospitals, homes, and workplaces - indeed, throughout society - internet connectivity is now a necessity. Without such access, the digital age will leave the less fortunate behind. Everyone, regardless of their economic status, must have access to the basic tools that allow them to participate in this new world.

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Why Internet Access Should Be A Right, Not A Privilege

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Internet access has to overcome three hurdles of availability, affordability and adoption to bridge the digital divide.