US Rural Hospital Closures Since 2005
shepscenter.unc.edu
shepscenter.unc.edu
People have voted with their feet and the feet have voted for cities.
Politicians are not selected today like they were when the founders lived. In rural districts, when given the choice between
A. A carpetbagger endorsed by the most recent Republican president who talks about wedge issues whose outcome has almost no impact on daily life
B. A local star who promises to make his votes cost his party a lot of pork (money for projects in his district, like keeping hospitals open), and represent his district's very specific economic interests
most districts are voting for candidate A in the primary.
The rural county I live in saw an influx of people moving very far from the city, only to be forced to leave again because of RTO. We had a huge population boom, only for it to be ripped away by shortsighted managers who don’t care about what their workers want.
That reality is that it's dramatically cheaper to provide services to people that are living close to eachother.
Unless we get to a post-scarcity utopia, or someone repeals the law of economics, city services will continue to be, as a rule, better and, in relative terms, cheaper than rural ones.
Living inner city kind of makes you a social hub where everyone wants to come to your place because it's super accessible by public transport so everyone can drink and hang out in the spa/steamroom/sauna and then walk out to the local pubs and restaurants.
Meanwhile I see all my rural family stagnating, getting addicted to drugs, stuck on welfare, and living subjectively depressing lifestyles.
Honestly? I did too and I'm am absolutely not sold on this lifestyle at all. I told myself I wanted to try it and see what it was like for a year and I have never been more lonely before in my entire life. Unless something changes I will move back after my lease is up, because a boring life is better than a lonely life.
There are more social events, but IMO they're very surface level, people don't want any deeper connection.
> Meanwhile I see all my rural family stagnating, getting addicted to drugs, stuck on welfare, and living subjectively depressing lifestyles.
I mean you're making pretty harsh judgments about their lives. If someone lives rural and is happy, that should be good enough even if you don't want the same lifestyle.
Getting addicted to drugs? I walk past junkies literally all the time now in the city, rural areas don't have a monopoly on drug issues.
Shouldnt be that surprising.
I think everyone should move away at some point of their life, but permanent city-life isn't for everyone. I simply enjoy gardening, small-scale farming, tinkering and trekking in forests way more than any services cities offer.
dating apps? or how?
I think this is the key, people should experience different cultures, lifestyles, and social opportunities. I'm an introvert myself, but I'm passionate about certain topics and enjoy discussing them with people who are also passionate about them.
Finding these niche communities or people who shared my ideas was impossible for me where I grew up, which was much less densely populated than where I live now. Now I have access to additional sharing of ideas, gatherings, and social bonds that I couldn't have imagined before I came to an urban area.
I never thought of myself as a city person, but after living in a rural area, a midsize city, a huge city, and a small town, I've found that my current large to midsize city is where I thrive.
This. I would ditch living in a city in a heartbeat if I could.
Healthcare, decent schools, used to be a problem to get fast internet, restaurants, bookstores, extracurriculars for your kids, etc.
We’re over 2 hours from the nearest airport (on a highway), so pretty “out there.”
Source: https://www.census.gov/newsroom/press-releases/2022/urban-ru...
https://carsey.unh.edu/publication-rural-america-lost-popula....
For example, not as many people are needed to farm, but many rural areas are attractive to new remote workers. The areas don’t necessarily overlap.
My hometown farm community has shrank dramatically, but my new rural community has been extremely successful at attracting white collar workers.
Macro-trends always contain variance which can infer an opposite micro-trend.
The housing supply is infamously constrained right now. Many counties have a cap on density which simply don't allow people to pick up and move on a whim to rural areas.
Big migrations take a long time.
Living on twenty acres sounds great until you realize you'd like TVs, internet, toilet paper, a car, and education for your kids. Turns out those things cost money because there's only so much of them - how are you gonna make an income living in the middle of nowhere to pay people to send it all your way?
What can you do for them? Who do you know?
If you're lucky you can provide agricultural products, but likely not at a competitive scale - so you'll hemorrhage money season after season. All of those people you see on instagram selling cabbages? They're not selling the cabbages, they're selling the instagram. Your network will be reduced to a bunch of other people in the same boat. Your life will likely enter a downward spiral into irrelevance.
You either bring all of the money you'll ever need, or find a way to decouple from society as much as possible because you'll likely have little to offer it. Remote work affects all of this but even then it's a dangerous proposition - if the winds change you're done for, and your network is still going to be shot.
Piling into cities (and suburbs) is just common sense. It's where the jobs are.
EDIT: some wording, two -> twenty (oops lol)
With a remote tech job, like I've been doing for over a decade while living on a rural four acre lot. I started with crappy satellite internet and now have decent satellite internet. And also toilet paper, etc.
I love it out here and can hardly imagine wanting to live in a city anymore.
I also moved out of the major metros - some things are worth the risk :)
Rural is when you have to drive to get to your nearest neighbor. I think the vast majority of people who live in rural areas only do so out of generational inertia. The entire rural population can very easily be fit into the exurbs around metros if that's what they wanted
We have pretty much every profession in the area. Teachers, lawyers, doctors, software engineers, etc. You’re probably out of luck if you’re, say, an actuary.
The real difference is you’re not going to reacher the professional peaks that you can in a city. You can be a lawyer, but you’re not going to be able to become some hotshot partner at a big, well known firm. You also might not be able to specialize in what you want. You can be a software engineer, but maybe not one that specializes in machine learning.
Of course, nowadays we have WFH and you very well might be able to have your cake and eat it too. That’s part of the reason I’m quitting my job as a wedding photographer and moving back into the SWE space this winter.
Also, there's something beetween between big city suburbs and middle of nowhere. Smaller towns can offer a healthy amount of jobs and services, especially ones that are within commute distance from larger ones. Moving from a village/town of 4000 people to one of 140 000 didn't really change my daily life much, apart from having more variety of food in supermarket, and much more expensive and worse housing.
It is indeed peaceful. It is just a lot of physical work and being in the sun. At least half the year or so.
Lots of people are leaving the cities. Many of the major cities in the US fit the definition of a failed state. Including SF.
"A failed state is a state that has lost its effective ability to govern its populace. A failed state maintains legal sovereignty but experiences a breakdown in political power, law enforcement, and civil society, leading to a state of near-anarchy." [1]
And most of them aren't moving to Flyover, Nowhere. They are moving 8 miles down Main Street, to another part of their metro area.
> definition of a failed state
You have a very strange definition of a failed state. Are there rival warlords conscripting people into their liberation armies at gunpoint? Is drinking the tap water going to kill you? Does SF have to make do with 8 to 18 hours of electricity a day? Is there no food at the grocery? Are the schools and universities open? Are there multiple acts of terrorism a week, caused by plain-clothes insurgents? Has unemployment hit 30%? Have employers stopped paying people? Are pensioners lining up on Market Street every day, to try to sell strangers their fur coats and toasters and jewelry, so they can afford to feed themselves next week? Has life expectancy dropped by a decade or so?
Gang shootings every day?
>Are pensioners lining up on Market Street every day, to try to sell strangers their fur coats and toasters and jewelry
No the pensioners couldn't afford to live there and moved out. You have immigrant people selling [stolen] toasters and shampoo on the street.
>Has life expectancy dropped by a decade or so?
Life expectancy is significantly shorter for a large segment of the population via overdose, because lawlessness pervades.
> Are the schools and universities open?
Yes I believe SF has reopened schools again, finally.
You have masses of people living on the street in tents. And rampant open air drug use and sale. Lawlessness. I suggest you re-evaluate what you are willing to tolerate.
Usually when people talk about leaving cities, it's because of the cost of living in many cities.
Plus, are people leaving cities? Click on Population Change at https://mtgis-portal.geo.census.gov/arcgis/apps/MapSeries/in... and zoom a bit. Rural America is emptying out. It's one of the reasons that services like hospitals are becoming harder to support. The counties containing Raleigh and Charlotte in North Carolina have grown by 25% and 21% while rural northeastern North Carolina is seeing double-digit declines. In Georgia, the Atlanta and Savannah metro areas are growing and there's a lot of decline in rural areas.
You might not like cities, but it's rural areas that people are leaving and it's rural areas that are failing.
This is a massive mischaracterization. Do you have first-hand experience with these people? I specifically have an issue with your phrasing: "taking over". It may be more common, relatively, to find this sort of thing in rural areas, but that does not mean it's taking over.
Rural America, in the sense that the OP meant it - "It is just a lot of physical work and being in the sun" - effectively no longer exists. "Rural America" is largely a term used by people who live in cities for people who don't live in cities, but the latter are by and large not "rural" by historical standards.
If you fly over the midwest, what you will see in terms of land use is a large amount of farmland broken up by enormous neighborhood networks and mid-size cities. People who live here are largely not working on farms. They are commuting to office jobs, service work, or gig economy positions. They don't walk anywhere, so they're not "in the sun"; even getting to the grocery store or a friend who lives nearby is practically untenable without a car. They certainly aren't living off the land. "Rural" America is basically the leftovers of farmland, and in many locations it's actively being partitioned into subdivisions.
I lived more than half my life to this point in a "rural" area, but for me this meant ~5 unfarmable acres. Virtually everyone else I knew lived in a neighborhood (isolated from other neighborhoods by miles of driving). This lifestyle isn't the idyllic thing it's made out to be.
> Religious fundamentalism, racism, homophobia, and outright Nazism
I don't think I'd point to rural areas specifically as the source of this problem. Instead, I'd point to the "Orange-County-ification" of the US. The heat centers for the problems you're talking about are relatively wealthy subdivisions full of people who can afford F150s that they don't need and keep small arsenals in their basements. Think people like the McCloskeys in suburban St. Louis: https://www.bbc.com/news/world-us-canada-53481537
As for racism - part of the truth of the "crime problem" in cities is the fact that huge segments of their populations are effectively a permanent underclass living in poverty or near-poverty.
Why is your land unfarmable? Is it dry land?
Even many third world locales don't have those issues.
So yes it is a reasonable definition.
Surely such an unstable and violent state must make it hard to run any kind of business. There's definitely no way any giant tech organizations would ever put offices there, much less headquarters.
Your argument is a non-sequitur.
And many large retail firms have closed down and left. I can produce citations if needed.
It's not just possible, that's exactly why. The vast majority of people live in cities because of economics, not because they inherently prefer cities.
One big reason is that remote work was never guaranteed to last. It's starting to crumble now with big tech requiring RTO x days a week or factoring in physical presence into performance reviews. People that aren't already independently wealthy couldn't risk buying a house in the country. In my rural home town your options for work if you lost your tech job(easier because crappy internet options) would be hard labor on a farm or dairy or maybe work at the grocery or fast food joint - nothing else.
A catw majority of people stayed in cities, or are moving back, but some did vote with their feet and left for the country.
It's important to not that it might be easy to#if hear from those that started in cities, anyone that moved more rural may be out of your field of view and seemingly not exist.
Let's just say any town <20k people is considered rural. From what I've seen, it is almost unheard of for someone who was not raised in a rural area to successfully live long term in an area like this.
I have plenty of anecdotal evidence of seeing retirees leave the city and try to live full time in a remote cabin on a recreational lake. None of them lasted more than a couple years. A surprising number of divorces. Growing up in a small town I have plenty of similar stories of families moving in from a larger city and leaving shortly after.
I'm not exactly sure how to explain this but generally I think the challenges of rural living (weather, social, economic, isolation, etc.) are very difficult if someone isn't familiar. As you mention, people see the benefits (incredibly serene, peaceful place, etc) but I think many aren't expecting or prepared for the challenges.
One of the big issues (at least AFAICT) is the lack of good paying jobs in reasonable proximity to rural areas.
Why is that? Among other things, one issue seems to be a lack of specific kinds of infrastructure in rural areas: High-speed rail and high-speed internet connectivity.
High-speed rail with hubs in urban (or urban-adjacent) areas can provide reasonable access for folks to commute to where the jobs are.
High-speed internet connectivity would allow for (some) businesses to start and thrive in rural areas.
Improving such infrastructure in rural areas would encourage (at least for a while), urban/suburban dwellers to move to more rural areas without compromising their earnings ability.
And if such a migration is made possible/desirable, other businesses supporting those new residents (apartment buildings, bars/restaurants, cultural activities and a raft of other opportunities will present themselves for other, local, businesses.
Would moving stuff like this be easy? No. There are a whole bunch of issues that block creating such infrastructure and the business environment that would depend upon such infrastructure.
That said, urban/suburban folks moving to a functional (in terms of access and services) rural areas will increase the incentives for other businesses (hospitals, anyone?) to come to, remain and/or expand in rural areas.
This would reduce some of the pressure on housing prices in urban/suburban areas and revitalize the economies of rural areas.
I don't expect to see such movement in the near to medium term, and more's the pity. But that doesn't mean we shouldn't advocate for such things.
Edit: Fixed typo.
You don't need HSR for this. Actually, high-speed rail and commuting are mutually exclusive, because commuter rail lines stop way too often to reach even rural two-lane highway speeds.
The TGV is very nice and will get you from Reims to La Defense, about a hundred miles of commute, in an hour and a half (via Paris l'Est), but only because Reims happens to be on the TGV trunk line and has a stop. If you're coming in from Vaires-sur-Marne, which that same TGV line goes through but doesn't stop at? About an hour to La Defense on the commuter RER despite covering less than a third of the distance.
A fair point, high speed rail is really only good for point-to-point travel. That said, using the hub and spoke model could alleviate that issue significantly.
Have high-speed rail spokes in a ring, with spoke ends at 75-100 mile intervals around the ring, with the urban area at the center of the ring, along with good roads and feeder rail to the spoke ends could work. Trains from the spoke ends wouldn't make any stops (or perhaps one or two, if you wanted to create concentric rings), and so wouldn't need to continually stop.
That assumes (unlike Amtrak's Acela) railroad track on the spokes which allow for 200-300mph (~340-510kph) speeds. And without stops, you can get from say, Fort Sumner, NM (in the 48th most rural county in the US[0]) to Albequerque, NM in less than an hour. While folks would still need to travel to such spoke hubs, such hubs, along with more hybrid/WFH jobs, that could absolutely work.
It would be a huge undertaking, but construction of such rail lines while laying fiber along the track rights-of-way could kill two birds with one stone.
Is it a perfect (or even a good one) solution? Maybe not. But anything that can both revitalize rural areas and mitigate the housing shortages in urban/suburban areas is a good idea. Perhaps you have a better, more workable solution?
[0] https://www.newsweek.com/these-are-50-most-rural-counties-am...
Yeah, it's simple: fix the glaring problems in urban areas, and have people move there. If there's a housing shortage, build more housing. Fix the stupid zoning laws that prevents that. That's a lot easier than this ridiculous HSR ring idea.
And leave folks who live in rural areas to rot, without even a hope of revitalizing their communities? That seems both reductive and likely harmful.
Because the issue isn't just housing shortages in urban areas, it's also the decline of much of the US by flight from rural areas. Which has been the source of a great deal of the economic dissatisfaction in the US for many folks for a long time.
I'd point out that people who live in rural areas are humans too and, at least in the US, for the most part Americans, with just as much right to exist and thrive as anyone else.[0]
I'm not saying that you feel this way, but the sense I get from your response is: "I don't like rural areas or the people who live in them. In fact, I hope they all leave or die." If that's not what you're trying to say, my apologies -- although you might want to try to be more clear about what you're saying if you don't want to be perceived that way.
[0] I'd note that I was born, raised and have lived almost all of my life (and still do) in the most urban city in the US.
>"I don't like rural areas or the people who live in them. In fact, I hope they all leave or die."
No, my attitude is that rural people live an unsustainable lifestyle that demands subsidization by city dwellers. Why should rural dwellers get this if they're not able to afford the extravagance of rural living on their own? If they want money and jobs, they need to move to where the jobs are. Human societies have been working this way for thousands of years now. This isn't something brand-new.
If rural dwellers like it so much in rural areas, they need to learn to accept and live with the downsides that go with that, such as lack of medical services, instead of complaining.
I see this idea in a lot of places but don't understand it. You could equally fairly say that city dwellers live an unsustainable lifestyle that demands subsidization by farmers in Kansas or oil drillers in North Dakota.
But doing so does absolutely nothing to revitalize lower population density areas, where 20% of the population[0] lives. I'd expect that better communication/transportation infrastructure would increase that somewhat as well, since if you don't need to live in an urban metro area to have a good job, a whole bunch of people would move to those areas. Potentially making them not rural any more, but why does that even matter?
Or should we just tell folks in rural areas to fuck off and die? I don't support that, although I'm sure there are some (you, perhaps?) who do.
[0] https://www.census.gov/library/stories/2017/08/rural-america...
Fort Sumner has less than 1000 people, the whole county is at 1,680. That sounds like about the least productive use of funds. Japan has high speed rail trains that could transport the entire town, with room to spare, in one go. It's a huge gamble to build it in the hopes people move to Fort Sumner and use it.
It's very simple: if you want the benefits of living in civilization, like medical care, bullet trains, and other infrastructure, you need to move to cities because those are the only places where economies of scale exist to make that stuff work.
>And if such a migration is made possible/desirable, other businesses supporting those new residents (apartment buildings, bars/restaurants, cultural activities and a raft of other opportunities will present themselves for other, local, businesses.
If you have a place with a bunch of apartment buildings, bars/restaurants, and all this other stuff, what you have is not a "rural area".
>There's no HSR to rural communities because there aren't enough people riding it frequently enough to make it work, and the people who'd like to use it are too spread out over too large an area for the logistics to work. You can't have a bullet train that stops every 10 miles at some small town to pick people up; you'll end up with an average speed that's too low to even be called "HSR". Your whole post really makes no sense in the real world.
Which is why I suggested a hub and spoke system, where the ends of a spoke services several thousand square miles.
Nor am I talking about "making stops every ten miles," either. It seems you didn't read my comment very closely and applied my thoughts to systems that exist today.
I don't disagree about economies of scale, but there's certainly room for better communication and transportation infrastructure outside urban/suburban metro areas.
In fact, over the long term (after both of us are dead, I'm sure) such initiatives could increase economic activity in the US enormously.
>If you have a place with a bunch of apartment buildings, bars/restaurants, and all this other stuff, what you have is not a "rural area".
Yep. That's true. I never said "rural areas need to stay rural forever." In fact, reviving the economically struggling rural areas necessitates increasing population density and economic activity. And that's a good thing.
Do you really think people are going to pay ~$200 each way to commute to the city every day? Because that's the kind of ticket price you can expect with HSR. Train systems like that are not cheap to run. They work great here in Japan for traveling between cities, where they're competing with airplanes, but the tickets are not as cheap as you seem to think. Your idea means far more miles of track to build and maintain.
>In fact, reviving the economically struggling rural areas necessitates increasing population density and economic activity. And that's a good thing.
Why? Just because you like those places? If they were economically viable, they wouldn't need all this help. And if you increase the population density, suddenly it's no longer "rural" but is now a "city", which is exactly what most of the people there don't want, or else they would have moved to a city.
It is urban vs rural because rural folks are less educated and therefore more susceptible to forces that are predatory to those who do not make a practice of critical thinking, such as fox news (or worse).
I don't think it's controversial to say that education liberalizes.
Here's Nate Silver talking about education as a predictor of the 2016 election:
https://fivethirtyeight.com/features/education-not-income-pr...
> In short, it appears as though educational levels are the critical factor in predicting shifts in the vote between 2012 and 2016.
Here is Pew weighing in:
https://www.pewresearch.org/politics/2016/04/26/a-wider-ideo...
Why would any individual fisherman be happy with quotas?
So I won't deny that they don't want (some of) those values, but that is why education is important, to see that if you aren't willing to make sacrifices (to say fight global warming) then you will be forced into even worse situations.
> I don't think it's controversial to say that education liberalizes
Highly-educated city folks make totally preposterous claims with zero critical thinking all the time. So you're right that education tends to liberalize, but wrong that education somehow makes people engage in more critical thinking.
I posit that for every piece of garbage that comes out of Fox News, there's an equal and opposite piece of garbage coming out of MSNBC.
- Mom-and-pop restaurants that are just Sysco retail outlets.
- Three screen movie theaters that only play the absolute most popular films.
- Underfunded schools.
- After-school activities that amounted to drinking, driving, drugs, or all three.
- Empty main streets.
- No local theater, bands, or culture in general.
- Absolutely no transit options beyond driving yourself or walking, and walking on rural roads is dangerous.
A casual search for that quote shows no results, is it a paraphrasing of something?
Either way, some skepticism is needed when one considers the source: Wealthy landowners that didn't need a city near them in order to command conveniences and comforts in their mansions, estates, and/or plantations.
Maybe Franklin: https://www.city-journal.org/article/benjamin-franklin-city-...
Redundancy and resilience have n associated cost. Not everybody is keen to pay this cost, especially when the benefits do not seem large. As every complex thing, it's a matter of balance.
As usual, it depends.
For example, out west the tension is with water rights. All other political issues are like molehills to the mountain that is water.
To be clear, the western US states aren't running out of water, they are running out of cheap water.
Usually, this pit the mountains against the farmers/ranchers, but it affects the whole population of a state in changing and varied ways. Divides are formed and forgotten every 20 years or so.
So, no, the real tensions aren't in the US's population centering methods, it's in dozens of different ways at dozens of different times and places. Thinking that ~350M people can be divided in any black-white manner for any length of time is a failure of imagination.
It could be similarly portrayed as rural agriculture water rights vs. city dwellers water rights. Both want cheap water. Both point to the unsustainable practices of the other regarding water usage.
In CA, there is a huge North-South divide when it comes to water. Northern CA constantly complains about LA 'stealing' all the water. In this case, it's urban vs urban.
In CO, it's rural mountain areas where the water comes from versus the rural plains ranchers where the water is needed. Frontrange cities mostly have their own water rights figured out, mostly.
In UT, it's just a hell of a mess and everyone is angry at everyone else and the Great Salt Lake becomes ever more that little brine pond over there.
Then you add in all the compacts along the Colorado and everyone just has more to fight about.
I guess you can sorta squint and say it's urban v. rural in some cases. And that would only be due to the square mileage per capita in the definitions. But, it's so much more than that and so much more complicated and legalistic and messy. The only common thread in the western US is water and how there just isn't enough of it for cheap.
>The only common thread in the western US is water and how there just isn't enough of it for cheap.
Isn't this specifically because agricultural water is disproportionately (severely) discounted? I.e., it is extremely cheap for agriculture, which drives them to use more water, especially on crops that wouldn't otherwise be well-suited to that climate. Which leads to non-agricultural water to disproportionately more costly. I've read on HN that 80% of water in the west is used for agriculture, which would seem to confirm this dynamic.
Honestly, each waterway can have it's own rules and it's own rights. In CO, until recently, you weren't able to collect rainwater from your own roof, as that water was already earmarked for the right's holder of the water the second it touched the ground. They've changed that and are more in line with other states, but such strange little provisions and regulations exist in other manners all over the US West. I wouldn't doubt your stats on water usage though, 80% is the right ballpark. But again, that system is the result of a bazillion little laws and regulations that would each have their day in court.
Industrial agriculture and mining, I cannot.
Don't romanticize dangerous jobs working for some corporation.
Scarce talent is being recruited away by higher paying providers in urban centers, which is why you see occasional headlines about the skyrocketing pay of travel nurses. COVID made this more acute, and while that crisis has faded, the secular trends have not gone away, notably America's demographic aging.
A sub-issue is that even when the hospital stays open, you often get poor care. My family has been on the receiving end of that, with my aunt dying prematurely because her cancer was missed by a subpar rural GP.
See a vox piece from 2022 on this topic: https://www.vox.com/22989930/residency-match-day-physician-d...
*Also note this has been slightly fixed with an increase of residency spots, but still puts the US in position to have fewer doctors per person than almost all other developed countries.
** Also see this piece published in medical economics for further reading on the subject of physician shortage: https://www.medicaleconomics.com/view/match-day-2023-a-remin...
* Systems not hospitals. These groups are gobbling up the entire industry. Hospitals are only a part of their diversified portfolio of businesses.
—-
What about the universities with the medical schools? How many of them are sitting on giant endowments?
The federal government has a lot of money. So does the California government. So does the San Francisco government. So does the Bill and Melinda Gates Foundation. So does Harvard University. So does Amazon. So does UnitedHealth Group. So does NY Presbyterian.
I reiterate: Why does the federal government need to pay for every single residency?
Or rather, misaligned incentives. If they aren't paying for residencies today, there's no reason to believe they'll magically do so tomorrow. Also, if a state decides to do so, that still leaves every other state with insufficient funding for residencies.
They don’t seem to be getting anywhere. Looking at the current state of Congress and the trend line I’m not super optimistic they will pass any sort of “common sense” laws in any area anytime soon.
What I’m suggesting then, is perhaps all these advocates should find some other trees to bark up. Maybe they’ll get no where, maybe they’ll be pleasantly surprised.
Or they can just keep doing what they are doing. I don’t especially care.
All you have to do is look at other countries and see the same issue playing out. Germany, Vietnam, and Australia are all very different from the US, and from one another, and all have issues with rural health care.
The reality is that low populations make it hard to provide any service and most of the "first world infrastructure" they do have is provided by federal or state/provincial government (i.e. not their own tax base). They aren't attractive places to live for many professionals, who usually trained in bigger cities and are used to small comforts like being able to eat a variety of cuisines or seeing live events (sports, music, drama) or having good schools for their children. The cost structure and (relatively) low demand affect the financial side of the equation. Etc etc.
Many countries allow "foreign doctors" provided they do some kind of provincial work (think of the old comedy series Northern Exposure) but that hasn't exactly proven to be a panacea.
Also some people have a plan to leave their country either way, so giving them opportunities in fields that might be useful for everyone should be a net positive.
On the former, Phillipines are sailant example of sending people abroad to get goods and money back, but this happens at some scale for all other countries with a significant emigration. The money fed back in the original country is usually not something to sneeze at.
The other part is, education benefits everyone beyond the single individuals. Having a strong enough education programs that opens the door to move to other countries with strong requirements is an asset that also benefits the origin country. In most countries only a small portion will go abroad, so improving the overall level of students stays important, and the bigger the pool the more you have inter-student emulation + economy of scale effect.
Also the monney spent by the country into education is not just for single children and has a global societal effect.
All in all, IMHO it's not a black and white as "that kid wasted our tax dollars by going abroad"
(light edits made to capture nuance vs absolutes, previous comment version started with "there is no healthcare labor shortage", which is not accurate)
Why would I, a qualified and respected doctor in my country want to move to the US (or Canada) if it involves going through 4 more years of bullshit just to get re-qualified for a system that adds even more red-tape, expenses, and middle-men between me and the patient?
I know, you're probably saying, "oh, but so many people have" - but hey, that was in the past. Unless my country is getting bombed to hell, I'm probably making a damn good living where I am, because, guess what? There's a shortage of doctors everywhere outside of Cuba!
I used to be a big libertarian proponent for immigration and now I've become the complete opposite after seeing how much money wall street (and almost exclusively corporate special interests) puts into increasing immigration.
also, the wage argument doesn't make sense because rural doctors earn more than urban doctors due to the low desirability of the location, and despite med schools specifically selecting for students who are willing to become rural doctors, they still cannot find enough doctors to fill those spots. (https://medrecruit.medworld.com/articles/how-much-do-rural-d...)
its also concerning that the reason you decided to oppose immigration was not for a tangible reason, but because wall street supports it. seems like contrarianism run amok. did you become a communist because wall street supports capitalism?
If rural hospitals need to pay doctors even more than so be it. I want that job going to an American.
Is it concerning because I don't care about what society thinks? Is it concerning that I don't care about getting an attaboy (e.g. karma) for towing society's latest groupthink?
"If rural hospitals need to pay doctors even more than so be it. I want that job going to an American."
the crux of the issue is that there literally aren't enough american doctors. med schools giving recruitment preferences to doctors willing to work in rural areas + a much higher salary + a much lower COL still aren't enough to attract american doctors there. I don't know what magical solution you have to make thesecommunities desirable destinations but I am all ears.
"Is it concerning because I don't care about what society thinks? Is it concerning that I don't care about getting an attaboy (e.g. karma) for towing society's latest groupthink?"
no? There are many valid arguments to heavily restrict immigration, largely based on middle class incomes and cultural attrition, i just don't see how any of those apply to doctors in rural areas. and i was responding to how you openly admitted that you dislike it because wall street likes it. seems like a bad way to approach policy!
Once they're here they can follow the nurse practitioner process which allows them to do many of the same things as doctors.
edit: and if they aren't BS (which they are) my previous assertion applies: increase pay to make the job more attractive.
The baby boomer generation has more chronic health problems than the generation before them. And, there are more of them. This leads to more health care services needed.
Yet, where I live the nursing schools have not expanded the number of graduates per year.
Supply and demand. Demand is going up. Supply is staying constant.
Also, this has nothing to do with politics. It has everything to do with private payers not paying out rural hospitals enough: https://ruralhospitals.chqpr.org/downloads/Rural_Hospitals_a... (another source)
Rural hospitals were always on a time limit, there isn't enough people sticking around for rural or small town to keep the business running. The same goes for any business there. Death of the town is exacerbated by the cities who offer greater salaries and sometimes better activities at the cost of some living space, which can be offset by enough salary.
We will see whether or not the lure of cities stay true over the next decade or two, but nothing is here to save anything small from their death.
That seems overly focused on the economics. Which are important, but when someone in one area needs to travel 100 miles to the nearest hospital, while another has a dozen hospitals within a 35sq mile area, there's a problem.
Considering only the operating costs ignores the people rural hospitals serve.
Which is why a single-payer system of some sort in the US is how we get out of this, reducing overhead/profit/middlemen and (potentially) redirecting those resources to providing decent care to everyone in the US.
If we don't move that forward, healthcare company execs will continue to channel Maxey Eckstein[0]:
On his first day as a bus driver, Maxey Eckstein handed in receipts of $65.
The next day his take was $67. The third day's income was $62. But on the
fourth day, Eckstein emptied no less than $283 on the desk before the
cashier.
"Eckstein!" exclaimed the cashier. "This is fantastic. That route never
brought in money like this! What happened?"
"Well, after three days on that cockamamie route, I figured business would
never improve, so I drove over to Fourteenth Street and worked there. I tell
you, that street is a gold mine!"
put another way, when someone who needs hospital access chooses to live 100 miles away from one while other living options offer a dozen hospitals within a 35sq mile area, that person has caused a problem for themselves
Probably because economics is the determining factor to everything. Notice how you went directly into the same issue, and then kept the same focus for the remainder of your comment.
> Which is why a single-payer system of some sort in the US is how we get out of this
This is a massive jump of logic with no attempt, let alone meaningful, in connecting ideas together.
My point was to compare the utility of hospitals to the utility of city buses.
Yeah, if you go where all the people are, you'll have more customers. But that leaves the folks who depend on a hospital (or a bus route) without any service.
>This is a massive jump of logic with no attempt, let alone meaningful, in connecting ideas together.
There's no "jump of logic" here. At all. Removing the profit motive provides more resources to, you know, provide health care.
Reallocating resources to more broadly provide services, in this case, to the "rural" (which is, as broadly defined by the US Census, anything that's not an urban area or adjacent suburban area -- as defined by population density, includes most small towns) population.
I didn't specifically spell that out, as it seemed intuitively obvious. But I guess not, at least not for you.
The US doubles down on this problem, due to not having a single-payer system.
Traveling nurses like myself can fill the holes, but we don't come cheaply as we give up a lot to work away from friends and family in undesirable locations. Traveling docs (locums) feel the same, and are even more expensive- 20k to work a weekend in an ER isn't unheard of.
My personal opinion having driven all across America over the last few years and working in a bunch of these small to mid size cities is that they really have no reason to exist and would fade away without government welfare prolonging the misery. Most were founded near a mine or factory that has long since left and is extremely unlikely to ever return. In the past you'd quickly get a ghost town, today you get an economically depressed meth town that stumbles along for decades consuming lives.
For the last 10 years, they've struggled to keep it staffed and pay the bills because the rural community and economy continues to shrink. It should have never been built but it's difficult to say 'no' when all those 'free' federal dollars are waved in front of the local powers that be.
No it wouldn't IMHO. It cannot have the expertise, the equipment, the clubs, the social opportunities, the field trips, the sports or 101 other things that a facility with even just 10 classes can offer.
Those are very different institutions and pretending they are the same is likely deceptive when they will produce vastly different outcomes for their users.
Mount Graham Regional Medical Center in Safford, AZ, is a Level IV trauma center. It has 25 staffed beds. Safford has a population of just over 10,000, and is approximately two hours to Tuscon by car. A Level IV trauma center provides initial evaluation, stabilization, diagnosis, and, perhaps, surgery and critical care, but what it mostly provides for serious cases is transportation to a bigger hospital, especially in the case of Mount Graham, which is listed as a short term acute care facility.
This comes directly from combat medicine: Small facilities save lives, especially if they're geared up to send serious cases to bigger units. Level IV trauma centers are at the bottom of what the American College of Surgeons recognizes as a trauma center, but they're still a vital part of the infrastructure.
Rural as used by studies is “extremely rural” whereas most people would classify small town America as rural when speaking colloquially.
To fix this problem you would either need to accept that rural areas will need to be subsidized by urban tax payers or you would need to build a proper transportation system that allows for easy and quick movement between urban and rural areas.
You get low productivity, high costs, very limited access to services, very poor outcomes for health, education, happiness, etc.
Instead of eeking along and pretending we can make these places work, we should spend those resources enabling people to move to urban areas.