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It’s not just urban/rural divide, it’s young and old as well. The areas where hospitals are closing are disproportionately filled with retired folks who are on Medicare and will need more and more healthcare (Medicare pays out less than private insurance so these hospitals have less money coming in from patient care and need direct subsidy. I think the answer here is pretty clearly to close down the hospitals and highly encourage/enable older folks to move to urban areas where we can provide their care more cost effectively and they will be able to age safer (no driving, stronger social services etc). In the US, you have a right to live where you want but you don’t have an unlimited subsidy to age in place.

I'm speaking as someone who has never lived in a rural area, but the thought of living in a rural area as a retiree seems very exhausting. Between the upkeep, driving everywhere to get anything, and the healthcare accessibility issue it doesn't seem practical for someone in their old age. Am I missing something here?

On the flip side, retired people don't need to live near jobs in the city, and their living in rural areas reduces the demand for housing in urban areas. Rural people are typically on fixed incomes, and cannot afford the skyrocketing rents or property taxes of urban areas. Now, of course, you can do things like rent controls, but those are also subsidies. So you're just trading one subsidy for another. At least subsidies to keep rural hospitals open doesn't distort the housing market for younger people looking for housing near where they work in the city.

(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.)

I'm not following your logic at all. I don't think it's a common phenomenon for retirees who once lived in urban or suburban areas to move to rural ones. I'm guessing the majority of these people have always lived in rural areas and just stayed put through retirement.

That doesn't matter--the point is that because retired people don't need to be near urban jobs, we can reduce pressure for housing in urban areas by leaving retired rural people where they are. (Or, conversely, we can avoid increasing pressure for housing in urban areas by moving retired rural people into urban areas.)

That would cause an even greater housing price crunch in the cities than we currently have. Much of the retirement advice out there is that once you're on a fixed income, you need to move out of a high cost area into a lower cost, typically at a minimum less dense one. Also, in practice, quite a few older folks move to be close to family members who can support them, which requires living wherever your children and grandchildren live... Even strongly encouraging the urbanization of the elderly strikes me as the wrong answer here for so many reasons, even beyond the ones I've listed above.

But as the previous poster said, you don’t have a right to infinite subsidy for the purposes of moving to your “low cost” area. We’re entering an era where these places are low cost for elderly people precisely because everyone else is subsidizing a lot of that infrastructure for you. From the hospitals and clinics, to the roads.

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.

Even if you build more housing, having older people live in urban areas still increases the price of housing. Crucially, older people don't need to be near urban jobs, so it's much more socially practical for them to live in rural areas. At the end of the day, the question is which subsidy is harder to deal with? Cash payments to keep rural hospitals open seems a lot easier than wading into enormously expensive and distortionary urban housing policies like rent control.

San Fran is not the only urban area in the US. Of course elderly people can’t move to Manhattan or San Fran. But there is lots of affordable housing in Omaha, Cleveland, Houston, Milwaukee, etc etc etc. Additionally, there is no reason we can’t build more housing in mid sized metros of that nature. (I guess Houston is not “mid sized”, but you get the idea.)

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.

I think you don’t understand how cheap rural areas are. My Oregon family blanches at the prices even in Eugene, forget Portland or Seattle. It’s not at all clear to me that whatever subsidies (rent control, etc.) would be required to allow the elderly to live in Omaha would be less than the subsidies for keeping rural hospitals open.

>I think you don’t understand how cheap rural areas are...

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.

There’s a bit of circular arguments going on here. Sure moving more people into an urbanized area may mean higher housing costs, but housing is not the only expense. Healthcare is a huge expense with over half of all healthcare expenses consumed by those 55 and older [1]

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-...

If you can't drive anymore and you don't have to go up steps, transit is amazing for your mobility at that age. I know old people who got a house in SF, citing that as one of their reasons. I know it's not the best transit, but it's definitely better than the american no transit, drive everywhere default that they were living at.

So we need to combine that with a plan of action that ameliorate urban problems we already have, such as building more medium and high density housing and creating more public transits instead of sprawling out.

The rural area is only low cost in certain aspects. Other aspects, such as medical care, is far more costly due to having to pay substantially more to incentivize doctors to want to work in rural areas.

The certain aspects are important, though. Rental and ownership costs for housing are typically 2-4x or higher in an urban area versus a rural setting. When you're already on medicare and have a fixed income, that can make all the difference.

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.

> Maintaining a fleet of doctors and facilities that are increasingly rarely used is expensive.

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.

This. Staffing these hospitals requires paying very large cash compensation premiums compared to cities. I have a couple acquaintances that worked at these hospitals, and they all did it for the money. Even then, most of them wouldn't do it for any length of time because the sacrifice to their personal and social life is too high.

I was a physician working in NYC. I now make a full 100% more working in the rural Midwest. You can think of it like Uber's surge pricing - pull drivers in when there's a demand-supply mismatch. Except in rural America the mismatch is constant and so is the surge pricing.

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.

Huh, if the pay is better, why is it challenging to get physicians to work in rural areas? If you don't mind sharing, why wouldn't you do it?

This is the answer you are looking for:

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.

“Money isn’t everything.”

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 pay is better, but not sufficiently better to offset benefits of urban life. Offer $5M per year, and it won't be challenging to get physicians to work in rural areas. So the problem is merely that there isn't enough funding to incentivize doctors to work in rural areas.

Not the person you wanted a response from, but money isn't everything.

Another serious problem is that the care you get at rural hospitals is often much worse than at bigger hospitals. Doctors perform procedures less often and make more mistakes. A smaller variety of equipment is available.

Often you're better of driving a bit longer to a larger hospital.

We can also improve coverage by building faster roads. How about a dedicated fast lane with a minimum speed of 120 mph and modern-car requirement? Add toll to reduce congestion.

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

Building new, faster roads in rural areas would be outrageously expensive per capita and would rarely be used, there is no economy to justify the expenditure. There are 2.2 million kilometers of unpaved road in the US. Even for the paved rural roads, many of them are relatively low-speed or circuitous because it is cheaper to go around myriad engineering obstacles than through them. It is difficult to justify tunneling 20 kilometers through a mountain range with a high-speed road so that 100 people can shave an hour off getting to the other side of that mountain range where there might be a fast highway.

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.

I would beg to differ -- the vast majority of rural roads in this country west of Pennsylvania are mile by mile grid, wide, and 55 MPH fast moving. They don't get you anywhere nearly as fast as freeways, they often slow down through tiny hamlets and they have lots of stop signs, but they're already very fast compared to a lot of places.

Edit: Which is to say that I agree with you more than the grandparent.

Those grids are not a problem, they drive relatively fast for unpaved roads, but the grids completely disappear once you reach the mountains in the western third of the US, even in large unbroken crop areas like The Palouse with proper rural roads. Many parts of the South are similar, though in those parts the meandering rural roads are defined more by water obstacles.

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.

So you are saying that my copter solution will not work in parts of the country and given a low-capability copter. Ok, I concede on this point.

Do you think it will work in other parts of the country, and with a more capable copter?

> a dedicated fast lane with a minimum speed of 120 mph and modern-car requirement? Add toll to reduce congestion.

You've just described a railroad.

Railroads are spaced much further apart than highways, and the train schedule may not be that great when you're in a hurry to get to the hospital.

The idea is interesting but your "minimum speed of 120mph and modern car requirement" is not. Remember, this is rural America we're talking about, that is having trouble keeping hospitals running.

If it costs $100m/year to run a single hospital, it will probably cost, what, 1/10th of that to maintain a fleet of self-driving high-speed ambulances?

The highways will need to be built on the state/federal level, most transportation is that way.

The amount of construction needed for that kind of project that would only benefit a small number of people... It's just absurd. Rural people would rather that money go into more important projects.

Did it seem equally absurd to build the East Coast - West Coast railroads in the 18xx? Only a small group of the Wild-West settler would benefit from it.

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.

A 120mph minimum in rural areas is probably a way to get more people into rural hospitals in those areas...

More like graveyards. There is a reason that most crash tests don't exceed 40 MPH.

The two of you have missed the part of my post about "modernized car requirement" (that would be something like autopilot), and "dedicated lane" that prevents other cars from getting in. I'm pretty sure this road, if built, will have fewer deaths on it than a regular highway.

So a thing that doesn't exist should be anticipated by cash-strapped governing bodies and should have massive capital expenditures poured into it, to solve a problem that does exist in the here-and-now.

Or not.

Yes? That's pretty much the story of every single capital-intensive project in history: first there is a present need, then goes the massive expenditure, then comes the completed project, then appear various positive and negative unintended consequences.

Some things can be boot-strapped, others cannot.

Let me be more specific. You are saying that they government should anticipate a thing that doesn't work and has no realistic timetable to be adopted at any scale. Further, you don't take into account such little things as car tires rapidly deteriorating at your proposed speed (and for just that one little thing you must ignore that that any changes to composition just for your wonder-roads will increase cost and decrease other valuable aspects of tires, like road grip, which matter more in inclement weather in more rural areas).

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.)

High-speed roads are the most proven thing in the history of proven things - if you make them people drive on them with high speeds. For example, Germany is doing just fine with high speed roads [1]. In particular the car tires are not coming apart at all, nor does any other part of the car.

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.