Nearly a quarter of U.S. rural hospitals are on the brink of closure – report
modernhealthcare.com
modernhealthcare.com
The rural hospitals typically serve a population that otherwise would be several hours travel from the nearest "real" hospital, and typically have a catchment area of 1-2 hours travel. Many of these hospitals are located in towns with populations of a few thousand people. Even when heavily subsidized, the economics of maintaining these hospitals is very poor, especially as populations decline. Maintaining a fleet of doctors and facilities that are increasingly rarely used is expensive. And even with the current distribution of rural hospitals, it is not uncommon for people to live several hours from the nearest hospital.
It is essentially a math problem. To ensure that virtually everyone lives within N hours of a hospital, you would need to build an enormous number of hospitals that each service a population of a few thousand people unless N is quite large. This has an extremely high cost per capita, most of which is wasted because they are often very underutilized, which does nothing to help reduce healthcare costs. And you can't force these people to move to more urbanized areas of the country either. The other challenge is finding enough doctors willing to work in a tiny remote town. Few people want to live in these areas and so many doctors that do work in these hospitals are effectively required to commute from a city that is hours away -- it is not a desirable assignment for most.
This is just a really hard problem. The best likely solution is to build more housing in the urbanized areas. But, yeah, how do you get that done profitably? It’s tough.
Additionally, there are several approaches that can be taken to lower housing costs other than price control. Housing policies are a huge mess throughout the country as its regulated locally, and exclusionary housing policies limit high density developments necessary to keep construction and infrastructure costs down.
https://www.healthsystemtracker.org/chart-collection/health-...
No one is talking about the elderly moving to places that are too expensive. We’re putting forth the idea that maybe they should move away from areas that are too expensive.
Just as a matter of full disclosure, I should let you know that I live in rural Wisconsin. I'm just trying to be as intellectually honest as possible about the subsidies that go into allowing me to be here.
More than anything, though, it really boils down to lifestyle. Often times, suburban senior living communities are reasonably affordable as well, avoid the major pain points of city life, and work out things like deliveries of everything from food to pharmacy goods.
(Driving is also easy in rural areas. There is nothing to run into. Young adolescents routinely drive in rural areas. I'd imagine it's a lot easier for older people to do than to deal with being exposed to the elements/dealing with broken elevators and escalators to use public transit.)
It might improve emergency response, local commerce, far-away commute, tourism, and availability of all services, including healthcare.
Short of that, maybe next-gen VTOL aircraft (robotic octocopters) for transporting the ill at a fraction of the cost of a helicopter.
Here’s one for $200k with a 70 mile radius. https://www.entrepreneur.com/article/307065
The highways will need to be built on the state/federal level, most transportation is that way.
And did it seem absurd 100 years ago to expect a nation-wide system of 55mph highways?
I'm pretty sure that it did seem absurd, and yet we're all better off for it in the end. Transportation infrastructure has a huge long tail of benefits.
You've just described a railroad.
Or not.
Some things can be boot-strapped, others cannot.
And it should just...happen, because you said so.
A sibling commenter had it: you're badly reinventing trains. What is with the obsession amongst the tech set to reinvent mass transit poorly? (See also "Loop," by one Musk, Elon.)
Hardly a re-invention.
[1] The lowest speed I observed was 100mph, and that was me in a clunky economy Opel wagon. Everyone else was going 120mph+, and a few cars flew by me faster than I could see them, I think at least 160mph.
Helicopters and similar have problems of limited range and operating ceiling, which are particularly relevant in the western US, in addition to requiring safe landing areas that may not be readily available. It is a challenging problem to solve, the US is quite large and many areas where people live are rugged and remote.
Edit: Which is to say that I agree with you more than the grandparent.
The major highways in the rural west, on the other hand, are very fast (90 MPH is normal) once you get to them, but the geographic distances between places that resemble civilization on those highways are often quite large even at that speed.
Do you think it will work in other parts of the country, and with a more capable copter?
I'm a physician working in NYC. I could make a full 75% more salary if I went to work in a rural area. Very inverse from most professions (I think) where people working in the city make the most. But I think it's that challenging to get physicians to work in rural areas.
That’s the short answer.
For instance, what about your husband/wife? They just put their career on hold to go live in the boonies for 5 or 10 years? That sort of thing will put an enormous strain on your relationship.
the sacrifice to their personal and social life is too high.
https://news.ycombinator.com/item?id=20853670
It's big fish in a small pond syndrome. If you have multiple years of college and your interests are fairly intellectual, you are going to be hard pressed to find like-minded friends, etc, in a rural area treating farm hands and the like. It's also tough being, for example, the only doctor in an area because then everyone is your patient and you have an inherent conflict of interest when trying to make friends.
A good number of the docs I work with here are actually from around these parts. They setup shop with their families, buy and build large homes on large swathes of land, and buy a propeller plane or two. Others are foreign medical graduates. These areas are almost always designated as medically underserved and that has all sorts of Visa and ultimately green card/citizenship implications. Effectively Trump's "shithole" immigrants are caring for his base.
We're unlikely to ever reach 100% urbanisation. In fact, the trend is likely to reverse to some extent at some point. Long term solutions lie in remote, largely automated care, remote triaging, widely distributed micro and mobile clinics, and efficient transportation infrastructure for when the care can't come to you.
Often you're better of driving a bit longer to a larger hospital.
This seems like an absolutely elementary analysis to do -- places with the Medicaid expansion are more likely to have people with health insurance; places without are less likely.
Ironically, the worst predicament for any form of infrastructure is under-use. In today's world where no town can be self-sufficient, low density can be the bane of its existence.
It is sometimes irritating how heavily favored rural communities are (per capita) in the way Govt.is structured.
https://www.usnews.com/news/healthiest-communities/articles/...
The main problem is that as a whole, we tend to romanticize and privilege rural living. It's generally bad for the environment and economy, and really the latter is why people have already been urbanizing for, well, centuries now.
That as many people are able to live in rural areas now with a modern-ish standard of living is largely because of subsidies from more productive urban areas: just look at state government tax revenues vs spending by county and this is obvious.
I don't hate rural areas, but there's really no reason we should be subsidizing a lifestyle choice that's bad for the environment. At the very least, zoning rules at city and county levels that prevent densification even from landowners who want it on their property should be illegal, there's no good reason for those to exist. Some regional housing and transportation authorities with teeth would also go a long way.
There are all sorts of ramifications to the inefficiency of rural living that developed societies struggle to cope with. That providing, say, high speed internet out there may be too expensive for its own residents to afford may seem like an ignorable problem, until you remember there are kids out there too, and what if the local school wants the students to do things at home that depend on that internet access, which is a reasonable expectation in most of the country these days?
This isn't some wild suggestion, living in Munich now I've gone through plenty of little Bavarian towns that are more walkable than US cities 100x as big. I think the US is a bit unusual in how once you get out of bigger cities, it's just assumed that yeah of course any kind of multi-family housing is going to be almost completely absent now, as if the economics of scale there suddenly stop existing.
The market might even achieve this by itself to a large extent, but usually zoning rules make it illegal. Plus, there are non-market effects like property taxes not taking into account how expensive it is for the government to provide services, resulting in subsidies from denser neighborhoods to sprawly ones.
Yes, you could have those things if you had... a thousand years of history with vastly different agricultural economics, socioeconomic pressures, political pressures, and climate pressures that led to the development of those "medium density small towns" in Europe. Oh, and of course on top of those things (and largely as a result of those things) you also now had a culture that predisposed people to remaining in the communities of their birth and childhood, a much more consistent (and much higher) population density (with large cities being uniformly extremely nearby by American standards), and rural communities that benefit from exporting large amounts of high-end agriculture products.
It's absurd to imply that the only difference between a place like rural Oklahoma and rural Bavaria is "zoning rules" and "property taxes"...
What changed was the car and development policies.
Anecdote: My father grew up in the 1950s in a very rural area outside Chicago, the type of area where you gave a 10-year-old a rifle and let him wander around rabbit hunting. He once visited my house in San Francisco, from rural Georgia, for my son's first birthday. He remarked how the shops near my house, in the Outer Richmond neighborhood, reminded him of the downtown area he worked as a teenager. The downtown he grew up near is now nothing like when he was a kid. Now it's hollowed out and less dense and lively.
Yes, living in rural areas outside major (literally the second largest city in the country in 1950) metropolitan areas (especially in the Union heartland), which have population densities more similar to Europe, is somewhat more similar to Europe; but the vast majority of rural America cannot be described as being "outside" a city like Chicago.
A rural Oklahoma, New Mexico, or even California town in 1900 was honestly not similar to contemporary Bavarian towns at all. To say so is just naive and simplifies "similarity" to simple walkability (in an arbitrary, hypothetical town center). The car (and several other appliances of modernity) literally built much of the rural (and urban) American south and American west.
I've traveled across the U.S. Not on the Interstate systems, but on the old U.S. highways. I've driven U.S. 50 from San Francisco (Sacramento) to D.C. U.S. 20 from Newport, OR to Boston. U.S. 90 from Florida to Van Horn, TX, and then old U.S. 80 from Van Horn to California (with some diversions). And I took my time, driving through and often visiting every little town. It took me weeks to make each cross-country trip. And I've taken other, more circuitous routes on other trips, like a cross country where we just zig-zagged north and south visiting towns and friends while taking a mostly southernly route from the east coast to the west coast.
I also grew up in various rural towns in the Panhandle of Florida, Alabama, and (very briefly) Louisiana, in addition to [once] small towns outside Chicago. In the South, the really poor, like my family, often either lived on trailers set up on the corner of someone's farm, or in some old house near the hollowed out local downtown core. I was always acutely aware of this dichotomy, as the middle-class families lived in nether regions unlike either.
I've seen plenty of the U.S. I know exactly what it looks like today, and I have a darned good sense of what it looked like before my time. And I know that small, dense downtown areas were once extremely common. Yes, people living out on small farms was also very common, but the patterns are totally different from today. Outside the downtowns was much less dense than today (because people lived on real farms growing food, not grass on a couple of acres), while the small downtowns were much more dense than today. We're simply more evenly spread out today.
Those downtowns were never as extensive as the small towns of Europe, as in most cases they only ever had several decades to grow before people either moved on or before cars became ubiquitous. But they were there. And they were walkable; infinitely more walkable than what came afterward. The pharmacy, the mill, the doctor, the insurer, the bank, the bars, the restaurant(s), many with apartments above them, and blocks upon blocks of tightly packed single-family homes. And you can walk the husks of many of them today, especially if you stay far way from the freeways, in places where areas were never redeveloped but just slowly abandoned. I've seen the same towns over and over again all across the U.S.--Nevada, Utah, Colorado, Kansas, West Virginia, Virginia, Georgia, Florida, Oklahoma, Arkansas, Louisiana, Texas, New Mexico, Arizona, Oregon, Idaho, Montana, Wyoming, South Dakota, Nebraska, Iowa. They're the same everywhere.[1] Before the car became ubiquitous it couldn't have been any other way. And even after the car downtowns still thrived, extending the reach of the downtown (e.g. at the time of my father, who lived in a rural area with a multi-acre subsidence "garden" but who could catch a ride into town to work at the pizza parlor). The single-family home plots grew only modestly. It wasn't really until the freeways that the pattern of American development was truly revolutionized, draining downtowns of their vitality across the country from the 1960s onward, following the migration away from the major cities from the 1940s and 1950s. And that's a relatively recent thing in American culture and politics.
[1] I think I saw the fewest downtowns in places like Louisiana, Mississippi, and Arkansas, extremely poor states where people and services have been spread out, and even where people lived in close proximity (i.e. relatively densely packed single-family homes) you still didn't see any commercial conglomerations.
This is silly. That you needed a car to reach small towns from elsewhere doesn't mean you had to design the town itself to require a car for intra-city transportation.
> "medium density small towns" in Europe
Don't make excuses here. We chose poorly, and we're suffering for it, and so is the environment. Yes, there are historical reasons for why we have sprawliness and car dominance, but nobody made us do it. Don't deny people's agency.
> It's absurd to imply that the only difference between a place like rural Oklahoma and rural Bavaria is "zoning rules" and "property taxes"...
It's a pretty good thing I didn't do that, then. Perhaps you should try replying to the comment I made, rather than the one you invented.
The town I live in now has messed with zoning so much over the last 30 years that any extant property is a minefield of exceptions and variances, so any time you want to even repair what's there, you need a $500 zoning variance application. Anytime you want to expand in place, you violate the setback rules. Anytime you want to do anything other than stay exactly as is, doing only the mowing the lawn and walking to the restaurants in town that the "City Master Plan" expects, you are begging for permission from the high and mighty civil masters ahem servants. All of my friends that enjoy the same things as I do, do what I'm working towards doing -- move out of the city and away from the upper class zoning that intends to keep the working class out.
I think the point the parent is making is that the people in urban areas are the ones subsidising your extra-urban lifestyle, which would be unaffordable if you had to pay the real cost of all your services
- cheap loans to terrible creditors that nobody else in the world would loan to
- not allowing governments to negotiate prices, even when they’re the buyer (drug prices)
- extra taxes, errr, tariffs, on their competitors
- exemptions from those same tariffs when its their input
- access to cheaper labour pools that no small business could possibly do the paper work for (various visas)
It could have been the plan all along to engineer a "market failure" so these people have no choice but to accept socialized healthcare even if they're vehemently opposed to it.
Many democrats thought (and said so) that there was a huge problem of all this money moving around without government control. The first attempt, which failed badly under Hillary Clinton's leadership during her time as First Lady, failed because it tried to do everything at once. It could therefore be seen as a massive power-grab.
The ACA on the other hand, delivered an incremental approach that included lots of things people wanted: ignoring pre-existing conditions, broadening coverage. But it also did things like say there could be no new doctor-run hospitals, and existing ones could not add beds. Doctor-run hospitals, at the time, were actually a success of the free market in health care. Their outcomes in terms of patient recovery and survival rates were higher than state run hospitals. They were a direct threat to the idea that the government should run health care.
The ACA also set the stage for the failure of private medical insurance. We're in limbo on that score, but the needle has moved toward that failure.
I swear modern Republicanism is just agreeing with Donald Trump and blaming anything that goes wrong on Hillary or Obama.
I don't think Donald Trump is truly fit to be president, and I don't think the modern Republican party represents my views. Nor do I think Hillary Clinton was a suitable choice either. But disagreeing with the modern Democrat party is often met with derision, even if it is reasoned objection.
I actually remember the political discourse during President Clinton's first term, having been part of it back then. I remember the speeches Hillary Clinton gave as chair of the task force, including the notion that it was tragedy to allow so much of the economy to flow outside the purview of government. The notion of regulatory capture is not new [2].
It is my opinion that the purpose of the ACA was to lead to single-payer. It was the kind of boiled-frog strategy that Democrat party leaders had been using successfully for decades at the point ACA came a along.
The restrictions on doctor-owned hospitals are part of the law [3].
That the law would cause increased costs and dramatic deficits was predicted by the Congressional Budget Office (CBO) [4, 5].
The way I formed my opinion was taking all of this into account, including the model Hillary's task force put forth in the 90s as being what Democrats actually wanted. It is a reasonable opinion that if the ACA didn't deliver all of the things from the original plan, yet it opened up many unsolved problems, that the intent was to "continue reform" and make the "natural solution" a single-payer system.
I do wish we could have discussion without every comment on politics becoming a college paper.
[1] https://en.wikipedia.org/wiki/Clinton_health_care_plan_of_19...
[2] https://en.wikipedia.org/wiki/Regulatory_capture
[3] https://www.cms.gov/medicare/fraud-and-abuse/physicianselfre...
[4] https://www.cbo.gov/topics/health-care/affordable-care-act
[5] https://www.factcheck.org/2017/03/cbos-obamacare-predictions...
https://dash.harvard.edu/bitstream/handle/1/22856850/4558297...
TLDR; Previous research found that speciality physician owned hospitals (POHs) are treating less Medicare patients that are also healthier and focusing on more profitable patients while still receiving whatever benefits being a Medicare provider gets them. This lead to a blanket restrictions on all POHs in ACA. The above paper compared both specialty and non specialty POHs, which is what ACA actually targets, and found no significant differences between them and non POHs in terms of types of patients, cost of care and outcomes. This suggests that the policy has been too broad and is in need of a revision.
FYI RomneyCare was passed by a supermajority of Democrats in the MA state legislature. They negotiated some parts with Governor Romney but the reform was not a “republican idea”. ObamaCare in general was not a republican plan - it was a moderate Democrat plan.
People at conservative think tanks coming up with an idea doesn’t make it “republican”. In reality the party ignores many things that the heritage foundation or various other foundations or think tanks say, they’re much more focused on politics than on ideas.
https://en.m.wikipedia.org/wiki/Massachusetts_health_care_re...
And if we skip ahead 4 years to 1993, a Republican Senator introduced, a bill with 20 Republican co-sponsors including Bob Dole, Orrin Hatch, and Charles Grassley called the HEART bill.
That bill included an individual mandate, vouchers for low income individuals, and protection for prexisting conditions.
Not all Republicans supported this plan, but almost half of the Republican Senators including most of the leadership supported it. I'd call that a Republican plan--a plan based squarely on the proposal from the heritage foundation.
Costs should be cut, regardless of urban/rural, if we're being overcharged. Not sure what this has to do with killing off rural hospitals though.
> generally pretty hostile to the idea of subsidising rural folks
I have seen no evidence of this...do you care to elaborate or provide some links or something?
It will be too difficult to square their political convictions with economic realities. Providing healthcare in rural areas will always be economically difficult. There aren't enough consumers in rural areas to support modern hospital facilities. Admitting this isn't a problem markets will solve, and that government taxes and spending might be the answer, is something that will prove very difficult indeed.
The tribal politics in the comments here are obnoxious and myopic.
Rural hospitals are receiving the majority of their money from Medicare and Medicaid. They don't pay enough. There was a great NPR show on this a few weeks ago.
Hospitals in the US overcharge (cost shifting is the technical term) patients with private insurance to offset losses from offering services at below cost to Medicare/Medicaid patients.
Too few private insurance patients means they close their doors.
Long live nuance.
[1] https://www.kff.org/wp-content/uploads/2018/11/status-of-sta...
I am still in favor of doing that though. And ignoring that part, there are huge cost reductions to be had elsewhere, say, for example, an entire industry of medical billing and debt collection - though it'd sure be a shame to see all those nice folks out of work.
At some point you conclude that the USA wants these problems. China could not ask for a better boogeyman.
What utter nonsense. The doctor shortage in the US has nothing on that in Canada. Not just the rural areas, either; in the biggest cities in the four Atlantic provinces, it is impossible to get a family doctor unless you are already a patient.[1]
[1] https://www.thetelegram.com/in-depth/doctor-shortage/atlanti...
I have trouble understanding why social issues make nerds stop thinking systemically, but there you have it.
Make it cheaper to fly people to hospitals, in slightly less safe craft.
A classic example of this small towns implementing city like water/sewer systems without the tax base to do the maintenance; the federal government provides a grant for the initial installation and the town slowly goes bankrupt trying to pay for it.
The easiest answer for many states is to expand Medicaid to cover a larger share of the low income population which can bring revenue to the hospitals with visits etc, but that seems to be very difficult politics for some individuals.
Moving people to areas that have higher economic advantages and jobs is a long term fix. On other solutions are just bandaids and doesn't solve the underlying economic issues.
Well, the frustrating thing is that those who are suffering essentially advocated for these policies that make them suffer and then just blame Obama and praise lord Trump for "getting things back on track" while their hospitals close.
These communities need smaller facilities with fewer beds, not mid 20th century style hospitals.
That being said, your comment also strikes me the wrong way, and I have received similar comments in real life where I had the same reaction, so I thought a bit about why I really feel that way.
More precisely:
1. the patronizing "you should know", as if your goal was to educate the person, as if not offending others would be a matter to be solved by education, etc.
2. pointing out in a lukewarm and passive-aggressive way that something is offensive. What should the other person do? He clearly knows already, and his goal is to offend. There is no right "not to be offended".
3. that it is not directed at you, but you are offended on other people's behalf.
All in all, while I am on your side, I would find it more heartfelt, if you said "you call me a hick? I'll kick your ass!" then this type of reaction.
Also, why are you so sure that the responder is not offended on his or her own behalf? Hopefully you don't think that just because someone is commenting on HN that they would never be associated with "hicks". I find HN has people of more backgrounds than most folks realize, and as a person with a family who would certainly be categorized that way by many (southern, rural, working-class), I find your insinuation that it would be somehow more "authentic" to threaten violence as far more patronizing and stereotyping than the original comment even.
I also find the insinuation that I should have threatened violence patronizing and prejudiced. The parent comment also included an example of how I "should" talk to sound more "authentic". Textbook prejudice.
Most rural people aren’t so easily triggered.