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May 2010 ORH Newsletter Share This OHSU Content

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National EMS Week

Oregon EMS

May 16 – 22, 2010

Have you thanked your EMS provider today?

There is one thing most of us feel we can count on—when we call 911 for a medical emergency, someone will respond. EMS services in Oregon come in many shapes and sizes. Some are private operations, others are operated by public health districts, hospitals, volunteers or fire departments. It is critical that we do whatever we can to continue these essential operations in rural Oregon.

The recruitment and retention of rural volunteer EMS providers is an ongoing challenge – even more so in the current economic climate. These dedicated rural volunteers take time off work and away from their families to become Emergency Medical Technicians and First Responders. They pay out of their own pockets to get the training and continuing education needed to respond to emergencies 24 hours a day, 7 days a week, 365 days a year.

In 2009, the Office of Rural Health (ORH) founded the Apple A Day Campaign to help address the issues of volunteer EMS recruitment and retention. This campaign raises funds to help offset the cost of continuing education for the volunteers. The ORH recently announced the first 13 volunteer EMS providers to receive funds from the campaign.. “This is great,” says Briston Gilman, EMT-B. “I have been doing this work since last June. It is a great feeling to be able to give back to the community. I really enjoy this type of work, which is why I volunteer. We are all volunteers in my service and I think we have the best crew in all of Klamath County.”

The 2nd Annual Apple A Day fundraising dinner and Auction will be held on Friday, September 24, 2010 at the Salem Conference Center in conjunction with the 27th Annual Oregon Rural Health Conference. Tickets will be available for purchase on the ORH website in mid-July. Donations, however, are accepted any time of the year by going to www.ohsu.edu/oregonruralhealth and clicking on the Apple A Day Campaign.

The ORH wants to thank all of Oregon’s EMTs
for the dedication to their communities.
Oregon’s EMTs—Anytime. Anywhere. They will be there.


Health Care GPS—Helping you track health reform implementation

The George Washington University School of Public Health and Health Services and the Robert Wood Johnson Foundation have launched Health Reform GPS, a comprehensive Web portal that offers users the information and insights needed to cover, analyze and implement recently passed health reform legislation.

The purpose of this web site is to track health reform from enactment through implementation, through notes, expert and public commentary and key documents. This site will grow and expand as the legislation and its implementation unfolds.

Visit the site by going to: http://www.healthreformgps.org/

Gathering Insurance Information

Under the Affordable Care Act, a website is being established on July 1, 2010 to assist people and small businesses in identifying affordable health insurance coverage options in each State. The consumer information will be clear, salient, and easy to navigate, and include:

  • Individual health coverage offered by health insurance issuers,
  • Medicaid coverage,
  • Children's Health Insurance Program (CHIP) coverage,
  • State health benefits high risk pool coverage,
  • Coverage within the small group market for small businesses and their employees.

The website will evolve over time and begin to include pricing information in October 2010 on insurance available to individuals and small businesses. For additional information you can go to:

Health Care Reform—what’s in it for your mouth?

The American Dental Education Association (ADEA) has compiled a summary of oral health components in the federal health care reform legislation. The ORH will work with the Oregon Dental Association to keep you updated on changes to dental coverage. Dental coverage includes:
  • Require insurance plans to include pediatric oral health services for children up to 21 years of age
  • Require essential health benefits package to include: ambulatory patient services; emergency services; hospitalization; maternity and newborn care; mental health and substance use disorders; prescription drugs; rehabilitative and habilitative services and devices; laboratory services; prevention and wellness services and chronic disease management; pediatric services, including oral and vision care
  • Expand Medicaid eligibility for adults and children
  • Increase federal support to states to pay for expanded Medicaid coverage
  • Extend the Children Health Insurance Program for five years
  • Establish an oral health prevention program and fund states to develop oral health leadership
  • Enhance oral health data systems
  • Improve the delivery of oral health
  • Implement dental sealants, water fluoridation and preventive programs
  • Establish a five-year national, public education campaign focused on oral health care prevention and education and targeted to certain populations, including children, the elderly, and pregnant women
  • Award demonstration grants in consultation with professional oral health organizations to eligible entities to demonstrate the effectiveness of research-based dental caries disease management activities
  • Authorize the Medicaid and CHIP Payment and Access Commission (MACPAC) to review payments for dental services in Medicaid and CHIP
  • Establish a process for updating payments to dental health professionals
  • Reaffirm that dentists will be members of the Commission
  • Establish a separate dental section and funding line of $30 million for training in general, pediatric, and public health dentistry
  • Increase eligibility for new grant programs in the Title VII Health Professions Programs to train dental and allied dental health professionals
  • Make dental schools eligible for federal grants for pre-doctoral training, faculty development, dental faculty loan repayment, and academic administrative units, grants currently available only to medical schools
  • Modify current law to allow hospitals to count dental and medical resident time spent in didactic (scholarly) activities toward Indirect Medical Education (IME) costs in hospital settings and toward Direct Graduate Medical Education (D-GME) in non-hospital settings (dental school clinics)
  • Extend the National Health Service Corps (NHSC) and increase funding for its scholarship and loan repayment program by $2.7 billion over five years
  • Reauthorize the Indian Health Service (HIS) and allow for the election by Indian tribes and tribal organizations in a State to employ dental health aide therapists when authorized under State law
  • Authorize grants to establish training programs for alternative dental health care providers to increase access to dental health care services in rural, tribal, and underserved communities
  • Reauthorize the Centers of Excellence (COE) program which develops a minority applicant pool to enhance recruitment, training, academic performance and other support for minorities interested in careers in health and fund it at $50 million
  • Increase funding from $37 million to $51 million over five years for Health Professions Training for Diversity which provides scholarships for disadvantaged students who commit to work in medically underserved areas as primary care providers, and expands loan repayments for individuals who will serve as faculty in eligible institutions
  • Exempt dental coverage from the premium amounts subject to excise tax on high cost insurance plans

CAHs and FQHCs—Working Together to Meet Rural Health Care Needs

In the past few years, the number of health center sites has increased dramatically. Today, there are more than 1,500 community-based health center grantees in some 7,500 service delivery sites across the Nation with a third located in rural communities. As the health centers have grown, so have the numbers of Critical Access Hospitals, which are a lifeline to rural residents in need of health care.

With health centers and Critical Access Hospitals both facing increasing demand for services, the need for collaboration has never been greater. HRSA, is encouraging strong partnerships between community health centers and Critical Access Hospitals. Collaboration is not always easy, but HRSA has compiled a new manual to help—Effective Collaboration Between Critical Access Hospitals and Federally Qualified Health Centers. This manual will help to promote the many benefits of working together.

The manual looks at collaboration from a variety of angles. It covers all the basics and highlights three success stories. In addition to this manual, HRSA is also taking other steps to promote collaboration among rural safety net providers. They are working to allow State grantees in the Medicare Rural Hospital Flexibility grant program to use that funding to promote collaboration between community health centers and Critical Access Hospitals, and looking to revise the new access points guidance for community health centers to promote collaboration among all existing safety net providers.

Please visit www.hrsa.gov where you can get a copy of this manual or call 301-443-0835.

The Cost of Turnover—How is it Impacting Your Agency?

The EMS Agency Research Network for Quality & Safety Improvement (EMSARN) has released a toolkit for EMS agencies designed to help EMS managers track the turnover and the cost of turnover on their agencies.

Created in January 2010, EMSARN is a network of Emergency Medical Services (EMS) agencies assembled by academic and industry leaders to research issues affecting EMS. The goal of EMSARN is to improve the quality, safety and performance in EMS nationwide. You can find additional information by going to their website.

You can also get a copy of their new toolkit and a podcast on Turnover and Cost in EMS.

Consumer Health Information Services from the OHSU Library

Did you know that the OHSU Library provides help for the general Oregon public? The public can peruse their web site for consumer health information, or even ask them for help. To ask an OHSU librarian for health information the public may send postal mail, e-mail, or call via phone. For more information please visit the OHSU Library's Health Information by Mail page.

Health Reform Legislation Benefits Loan Recipients—The Bad News & Good News!

The Bad news first: you have already filed your 2009 Oregon State tax return.

The Good News: You may be eligible for money back from the State if you file an amended return. Public Law 111-148, Patient Protection and Affordable Care Act, became law on March 23, 2010. Section 10908 of this law states, “Payments under…certain state loan repayment programs—in the case of an individual, gross income shall not include any amount received….under any other State loan repayment or loan forgiveness program that is intended to provide for the increase availability of health care services in underserved or health professional shortage areas (as determined by such State).” The effective date of this amendment applies to payments received by an individual in taxable years beginning after December 31, 2008.

So what does that mean for someone in Oregon receiving loan repayment through the Oregon Student Assistance Commission? Well, that’s the good news! According to the Oregon Department of Revenue: Under ORS 316.048, income that is exempt from taxation for federal purposes, will also not be subject to Oregon tax.”

You likely received a 1099 from the Oregon Student Assistance Commission (OSAC) indicating the amount of award you received in 2009. If you have not received one, you can contact OSAC and see if you qualify.

You may wish to consult with your tax preparer about filing amended State and Federal tax returns. This is GOOD NEWS, indeed!

Senate Rural Health Caucus Asks for Continued Support for Rural Health Care Programs in FY 2011 Appropriations

On April 15, a bipartisan group of 28 Members of the Senate Rural Health Caucus sent a letter to Senator Tom Harkin (D-IA), Chair, and Senator Thad Cochran (R-MS), Ranking Member, of the Subcommittee on Labor, Health and Human Services and Education of the Senate Committee on Appropriations, asking for continued support for rural health care programs in the FY 2011 appropriations bill, while thanking them for their “historic leadership and support for rural health care programs.”

The letter states:

While current spending for all rural health discretionary programs is relatively small, it plays a critical role in solidifying the fragile health care infrastructure common in rural communities. We understand the current constraints on the federal budget and recognize the need to eliminate wasteful and inefficient programs. However, we also believe that we must continue to support government policies that work and urge you to take into consideration of the effectiveness of the rural health programs listed below.

The letter asks for continued support of the National Health Service Corps; Rural Health Outreach, Network Development and Telemedicine Grant Program; Rural Health Research Grant Program; Medicare Rural Hospital Flexibility Program; Small Rural Hospital Performance Improvement Act; Rural Access to Emergency Devices; Office for the Advancement of Telehealth; State Offices of Rural Health; Consolidated Health Centers Program; Rural EMS Grant Program; and Health Professions, such as the Quentin Burdick Rural Training Program.

No requested funding amounts were included in the letter. Hearings and mark-ups for FY 2011 Appropriations bills have not begun yet. Both the Senate and House Budget Committees are currently holding hearings on the FY 2011 Budget and its spending parameters. Oregon Senator Ron Wyden and Sen Jeff Merkley are both members of the Rural Health Care Caucus.

Learn more about appropriations at the National Rural Health Association's site, which contains links to the appropriations letters.

Education Partnerships Enhance Nurses’ Skills, Encourage Retention

Oregon and Wisconsin Programs Show Promise
by Candi Helseth

After her grandmother became sick, Shelly Deyo decided she wanted to be a nurse working with the elderly. Deyo also wanted to teach and work in management. She has found the perfect job in her current position as director of assisted living at St. Clare Meadows Care Center, a nursing facility licensed for 25 beds in Baraboo, Wis. In addition, Deyo works as a coach and preceptor with the Wisconsin Nurse Residency Program (WNRP), helping new nurses develop the critical thinking skills and knowledge base they need to successfully handle the unique demands of rural nursing.

Dawson & Draper

Above: Nurses Carolyn Dawson (left) and Jessica Draper, who graduated from Oregon's N2K nursing program in mid-March, prep for surgery at Harney District Hospital in Burns, Ore.

Deyo

Above: Shelly Deyo, director of an assisted living facility in Baraboo, Wis., credits the Wisconsin Nurse Residency Program for giving her the skills and knowledge necessary for the unique demands of rural nursing.

Deyo credits WNRP for providing the support she needed to succeed when she was a new nurse graduate. “Being in the nurse residency program gave me a better foundation, more confidence and more knowledge in core nursing areas,” Deyo said.

Wisconsin’s program grew out of the need to improve nurse retention rates; many nurses change jobs or leave the profession within two years of graduating, according to Cella Janisch-Hartline, a nurse consultant with Rural Wisconsin Health Cooperatives (RWHC), which worked in conjunction with Marquette University to develop the federally funded WNRP. Janisch-Hartline pointed out that Deyo’s first job, in a hospital where she often worked alone and was responsible for as many as six patients at a time, wasn’t unique. Janisch-Hartline noted that studies show rural nurses often work alone on a shift and care for a wide variety of patient needs.

“Typically, these nurses were just out of school and had just passed their boards,” Janisch-Hartline said. “This setting places many demands and a lot of stress on new graduates to develop competency in a relatively short period of time. Since we implemented WNRP, retention rates have soared.”

In Oregon, the N2K Nursing Education Program, housed in the Oregon Health Career Center, is a response to critical nursing shortages, particularly in rural areas. The N2K program brings together health care providers and Oregon colleges in a partnership that recruits and trains employees from participating hospitals’ existing work forces. Since it began in 2001, approximately 120 nurses have graduated and returned to their home communities to practice.

At Mountain View Hospital, a 25-bed critical access hospital in Madras, Ore., Will Bean, nursing education and emergency department manager, welcomed four new nurses to the staff in March, all of whom had come through the N2K program. Three formerly worked as Certified Nursing Assistants at the hospital and one was a phlebotomist there.

“I’m confident we’ll still have at least three of the four here 10 years from now because they have deep ties to this community,” Bean said. “We’ve gotten four great nurses that we had a hand in selecting because of their strengths, and we trained them within our own system. If they’d left to go to another nursing school, we’d have had to fill their current position and there’s no guarantee they’d return here. This program is definitely a better alternative for us.”

Nursing shortages and retention problems in rural areas will likely be even greater issues nationwide as the baby boom generation retires and more RNs continue to work outside the rural areas where they live, according to an April 2009 Policy Brief released by the WWAMI Rural Health Research Center (WWAMI). The proposed solutions WWAMI lists in the Policy Brief mirror much of what Wisconsin and Oregon are already doing: support and expand nursing and distance education, encourage students from rural locations to pursue nursing because they are more likely to return to rural areas, and better prepare rural RNs through the use of rural-relevant curricula and opportunities.

N2K: a different type of education

The Oregon Office of Rural Health has been a partner in bringing N2K to the state’s small, rural hospitals. Calling it “our most ambitious project to date,” Oregon Health Career Center CEO Gary Wappes said the Oregon Consortium for Nursing Education partnered with Mount Hood Community College at Gresham to develop a rural cohort separate from already existing nursing programs that were offered through Oregon colleges. Nursing students selected for N2K complete didactic education requirements from home via an on-line educational system and do their clinical training in their home communities and hospitals.

The advantage, Wappes said, is that students continue their jobs in the facility where they are employed, do coursework without having to leave their community, and then do most of their clinical instruction within the facility where they already work. Upon entering N2K, they agree to return to work for their employer for a specified period of time.

Bean said N2K’s OCNE (Oregon Consortium for Nursing Education) component is particularly advantageous for rural nursing because, unlike traditional nursing programs, OCNE starts nurses at a base level working in several different departments.

“That’s similar to what is happening in real working experiences in rural facilities,” he explained. “And as they gain experience, their level of educational challenges gets more intense. But they continue to work in all areas such as pediatrics, orthopedics, acute care, etc. So they get very well-rounded.”

The Office of Rural Health also pursued development funding through Medicare and Medicaid that allows rural hospitals to be reimbursed for a major portion of their costs for N2K. Robert Duehmig, Office of Rural Health communications director, said the funding mechanism reduces strain on rural hospitals’ budgets.

WNRP: sustaining new nurse graduates

Marquette University and RWHC developed WNRP six years ago, with funding from the Health Resources and Services Administration (HRSA), to continue education for new nurse graduates and to retain them long-term. Curriculum includes monthly educational sessions and mentoring by preceptors and clinical coaches that spans at least 15 months of a new nurse graduate’s employment. To date, nearly 400 rural nurses have completed the WNRP or are currently enrolled in the year-long program, and WNRP has trained more than 700 preceptors.

The nurse retention rate in RWHC rural-supported hospitals from 2005-2008 was 88 percent, Janisch-Hartline said. Prior to WNRP’s implementation, some participating hospitals had new graduate turnover rates that exceeded 50 percent.

Nurse replacement costs are reported to be equal to a nurse’s average annual salary, which is $62,140 for Wisconsin nurses according to the Bureau of Labor Statistics (2008). Therefore, if the residency program prevents at least one new graduate nurse from leaving the organization, the program becomes cost neutral, Janisch-Hartline said. The RWHC organizations typically pay the fee for participating nurses in their employment.

WNRP’s success has attracted attention from health care organizations facilities across the country. Marilyn Meyer Bratt, Assistant Professor at Marquette University and Project Director/Primary Investigator of the WNRP, has applied for an additional HRSA grant that will address the unique needs of newly licensed nurses practicing in rural hospitals. Building cultures to retain and advance role competency in rural nurses and coordinate dialogue on a national level to support rural nursing practice are the primary purposes of this proposal. To accomplish this, Bratt intends to develop partnerships with rural-based community and Critical Access Hospitals and health networks in Idaho, Illinois, Pennsylvania and Wisconsin. The grant will enable the delivery of a nurse residency program and other supportive services that are tailored to rural nursing practice.

For Deyo, WNRP has made all the difference. “I encourage everyone I know to go through this program,” Deyo said. “Something like this should be available for nurse graduates in all rural facilities. Being a rural nurse is a specialty in itself.”

Look What’s Coming

By Wayne Myers, MD

The monumental health insurance reform bill that passed last month is only the beginning. Within the evolving regulations and, perhaps, legislation, I think we’ll see several of the following trends.

One important idea is “bundled payments.” The policy objective is to reduce incentives for doctors and hospitals to do so many tests and procedures. Bundling of payments, paying a single, predetermined lump sum to care for an entire episode of illness from diagnosis through hospitalization to recovery regardless of how often tests are repeated, will save startling amounts of money. It will be widely adopted in spite of frantic lobbying by imaging and related interests.

For rural communities, bundled payments will accelerate movement toward the development of community health systems in which the docs, the hospital, the rehabilitation facility and home care join in a single organization. This will also increase pressure for rural hospitals and community health centers to develop an organizational framework under which they can join and prosper.

Such community-wide organizations can almost certainly do a better job of taking care of patients than our current fragmented arrangements. This deserves repeating. Coordinated care is not only cheaper. It’s better.

Kaiser Health News on January 26th, 2010 ran a compelling article on the good work being done by the Southcentral Foundation in Anchorage, Alaska. The Foundation, a consumer-controlled quasi-tribal organization, is doing a remarkable job taking care of complicated patients with multi-system problems by coordinating their care and doing what the customers need to have done instead of what clinics are accustomed to doing.

A few rural communities already own and operate their health care systems. The most completely evolved that I know of are the tribal Alaska Regional Health Corporations. They typically operate a hospital, several rural community clinics, and mental health, dental and EMS facilities. They draw contract funds from the Alaska Area Native Health Service, an element of the Indian Health Service, but they also collect from private insurers, Medicare, Medicaid, and state and federal grant and contract funds. The coverage area for such an organization in rural America would correspond to a trade area for other purposes.

Where will the docs come from to staff such organizations? The United States has more physicians than England and Canada, but significantly fewer than most countries of Western Europe. Our problem is that over 70 percent of our physicians are in referral specialties instead of primary care. The shortage of primary care physicians has gotten appropriate attention. If we start paying physicians for the care we need through mechanisms such as bundled payments I believe we’ll have a surplus of referral docs. What should happen to them? During the Clinton efforts at reform there was a cartoon of a physician with white coat, stethoscope and sign that said “will practice cardiology for lots and lots of money.”

Can a $390,000 per year radiologist be retrained to earn $170,000 per year as a family doc? I know of no data on that question. There are issues of adjustment, cognition and temperament. I’m being a bit facetious but there are very real competency issues involved when referral docs try to do primary care. Internal medicine sub-specialists can probably relearn a lot of their general internal medicine. Family practice is the only primary care specialty taught as a primary care specialty. The coordination of the care of multiple disorders is difficult and has infinite numbers of permutations. Picking referral docs for retraining would be tough.

Nurse practitioners and physician assistants can handle much of primary care, and many other specialties for that matter, but it is a serious mistake to think that ends the story. People who write on the subject seem to have no idea of the complex outpatient and inpatient work rural general internists, family docs and pediatricians do. Maggie Mahar’s recent blog on the subject (“Hey Nursie!” The Battle over Letting Nurse Practitioners Provide Primary Care) is excellent but misses the rural angle.

Other predictions: Incomes of primary care docs will increase a bit over the next 15 years, but not as much as referral physician incomes will fall relative to the overall economy. Institutional support patterns (big town/ middle town/ little town) will become more fixed as referral relationships become formalized and ready to work on a moment’s notice. Telemedicine, a solution in search of a problem for 40 years, will become more useful, as health care develops regional systems. Smaller hospitals with lower intensity capability will decrease in relative importance as inpatient facilities.

The local hospital, though, with the right leadership, may take on a new role as the health hub of the community, fostering health promotion from before conception through grief, mourning and resolution. Expect change. Create it.

Wayne Myers, a pediatrician, founded the University of Kentucky Center for Rural Health and served as its director. He also served as director of the Office of Rural Health Policy in the Department of Health and Human Services’ Health Resources and Services Administration. He is a past president of the National Rural Health Association.

Opinions expressed in this column are those of the author and do not necessarily reflect the views of the Rural Assistance Center.

Dr. Myers welcomes your feedback. Comments and questions can be sent to him at .

Challenges for Human Services

The Promise of Spring or Winter Continued?
By Tom Corbett, Ph.D.

Spring is the season of rebirth and this year there is some reason for cautious optimism. Jobs are finally being added to the economy—162,000 in March, though surely not in the numbers required for a full recovery. Unemployment has begun to decline, falling from over 10 percent to 9.7 percent. And the Dow has broken through the 11,000-point barrier again, up 68 percent over the past year.

Has the tide turned? Will this apparent rebound reflect many prior recoveries where job growth takes off six or seven months after the recession technically ends? If so, visible substantive employment gains are at our doorstep. Or, will we see the kind of jobless recovery that some fear or, worse, a double-dip recession in which the ravages of a full recession will return?

According to a recent report,A Year or More: The High Cost of Long-Term Unemployment, from the Pew Economic Policy Group, over 44 percent of those out of the labor market met the definition of being “long-term unemployed,” or unemployed for at least six months. That is the highest rate since the Second World War. This far exceeds the 26 percent calculated for 1983. Even worse, some 23 percent of the nearly 15 million unemployed have been out of work for over one year. That also is a record rate.

Unfortunately, the Pew report does not separate out rural versus urban data. However, we can draw some inferences when rates are broken down by occupation. The unemployment rate for those in farming, fishing and forestry positions, essentially rural-type activities, was 21.8 percent in December 2009. This is more than double the national rate.

Earlier this year, in a speech at the USDA’s annual Outlook Forum, Secretary of Agriculture Tom Vilsack expressed concern about the 50 million people who live in rural America. He noted that rural communities have fewer college graduates, enjoy an average annual income that is $11,000 less than the national average, and are the home to 84 percent of the least healthy (the bottom 50) counties in the United States. “These statistics on rural America are a wake-up call, ” Vilsack said.

Rural communities also are aging. The average age of the principal operators of farms has risen to about 57 years, up over six years during the past quarter-century. Adding to the stresses of rural communities is the precarious economic position of so many farms. The last Census of Agriculture showed that, of the 2.2 million farms nationwide, only one million showed net cash income from their farm operations. The remaining 1.2 million depend on non-farm income to get by and many of those jobs have disappeared.

Economic vulnerability does not exist in a vacuum. For one thing, there are spillover effects. One adverse effect is on the quality of family life. In its Winter 2010 Issue Brief, the Carsey Institute reports that child maltreatment in rural families tends to mirror their urban counterparts. Some differences exist, however. Rural families reported to the Child Protective Services (CPS) because of suspected child maltreatment are more likely to be experiencing high family stress and financial difficulties. More than 60 percent of rural caregivers being reported to CPS evidence high family stress as opposed to half of urban families. Nearly one in three have trouble meeting basic needs as opposed to just over one-in-five of their urban counterparts.

In another report (Fact Sheet No. 10, Spring 2010), the Carsey Institute suggests that at-risk children living in remote rural areas are more likely to be removed from their homes (13.7 percent to 10.3 percent). Moreover, about half of all states evidence the highest placement rates in remote rural areas.

Generally speaking, out-of-home placements are not viewed as a positive outcome. Professionals would prefer to work with children in their homes and to strengthen families through improved parenting. The authors conclude that higher poverty rates and a “scarcity of supportive services or gaps in mental health services to address issues contributing to higher placement rates in resource-poor areas” might explain the findings.

Two things would help these rural communities: money and a more coherent system for delivering human services. Let us take money first. One immediate step would be to ensure that rural communities are fully accounted for in the ongoing 2010 Census. Why? Population estimates are used to distribute critical federal dollars.

The top ten federal programs that distribute resources, at least in part, on Census data are: Medical Assistance Program, Unemployment Insurance, Highway planning and construction, Supplemental nutrition assistance program (formerly Food Stamp program), Temporary Assistance to Needy Families (formerly welfare), Federal Pell Grant funds, Title I education grants, Special Ed grants, School Lunch grants and Head Start. We are talking real money here, over $370 billion in 2007.

Unfortunately, some rural areas are likely to be undercounted in the Census count, according to a third Carsey Institute report, Rural Areas Risk Being Overlooked in 2010 Census. The usual suspects that might account for this failure are higher vacancy rates, relatively poor communications (lack of telephones), lower educational levels and higher poverty rates.

The second factor would be better organized interventions and human services. In its 2009 Report, the National Advisory Committee on Rural Health and Human Services argued that stronger and more preventative interventions are needed to address the needs or rural children at risk. According to the Committee, “This is a particular concern in rural areas because programs and resources are more limited than in urban areas and coordination of services for these children and their families can be made more difficult, given their geographic isolation.” [p.3]

So, what do we have? The specter of another Great Depression has passed. Still, there are deep economic scars that may stay with us for some time. These scars, including related social problems, are particularly acute in remote rural areas. Money to address these issues will be tight. As a consequence, we need to use every resource available to us and to think creatively about how we organize and deliver human services in rural communities.

Tom Corbett has emeritus status at the University of Wisconsin-Madison and is an active affiliate with the Institute for Research on Poverty where he served as Associate Director. He has worked on welfare reform issues at all levels of government and continues to work with a number of states on issues of program and systems integration.

Opinions expressed in this column are those of the author and do not necessarily reflect the views of the Rural Assistance Center.

Professor Corbett welcomes your feedback. Comments and reactions can be sent to: .

E-Pharmacy Catches Drug Mistakes for Rural Hospitals in Five States

Cheryl Clark, for HealthLeaders Media, May 5, 2010

It's always refreshing to hear about a big, geographically diverse hospital system that tries to find solutions for its smallest facilities, and succeeds. Especially when doing so saves tons of money and prevents medication errors that endanger patients.

Welcome to the world of e-pharmacy, and Bravo Banner Health.

The non-profit, Phoenix-based 22-hospital system that stretches across seven states, from Alaska to Nebraska, is doing just that for eight of its small, rural facilities that don't have pharmacy staff to review prescriptions around-the-clock.

"Previously when the hospital's pharmacist went off duty, the drugs would be reviewed the next day," possibly after critical mistakes could have been made, says Richard Einhellig, director of pharmacy at Northern Colorado Medical Center in Greeley, 60 miles northeast of Denver.

With its remote medication order processing service, now in place for about two years, a crew of pharmacists review 9,000 prescription orders a month for those eight small—25-bed to 40-bed—hospitals in five states: Colorado, Wyoming, Nebraska and Nevada and even one hospital sitting amid northern California's mountains, 1,102 miles away.

Einhellig or one of his staff can pull up a digital image of each physician's order that was handwritten for a patient far away. Those orders are checked for "right dose, right patient, right drug, and appropriate indication for use," by comparing these prescriptions against the patient's electronic medical record, all visible on the Greeley computer monitor, he says.

After review, the electronic system sends a message to automated dispensing prescription drug cabinets at each hospital that allows those medications to be released to the patients.

Einhellig says the system helps Banner's smaller hospitals meet a new Joint Commission patient safety goal, which says that a pharmacist should read all prescriptions before they reach the patient.

"What you could say is that for those hospitals that are limited to one pharmacist who works 40-hours a week, we're providing an additional 128-hours per week of pharmacy review that formerly would have happened retrospectively," Einhellig says.

Recently, he recalls, "We intervened in a situation where an insulin dose ordered turned out to be two times too high—a result of a miscommunication with the family member." Einhellig's team questioned the dose, the nurse clarified the order and a potentially dangerous situation was averted.

"And there have been drug-allergy interactions that I have caught as well," he says. "I saw an order for a medication that was a penicillin derivative, piperacillin, but the patient's chart showed a penicillin allergy." Einhellig called the nurse at the hospital and stopped the medication, and another adverse event was averted.

Along with the patient safety benefits, the financial savings have been huge.

Einhellig says that Banner estimates it saves $960,000 annually compared with using an outsourced company, and $2.7 million annually if Banner had to staff each facility with an on-site pharmacist 24 hours a day, seven days a week and 365 days a year.

Einhellig says he can't quantify how much the program has saved in avoidance of prescription mistakes. However, in 2006 an Institute of Medicine report estimated the cost of treating drug-related injuries occurring in hospitals at a "conservative" $3.5 billion a year.

"Medication errors are among the most common medical errors, harming at least 1.5 million people every year," the IOM report said.

Banner Health has so far spent $180 million to install its remote medication order processing system throughout its hospitals, but Einhellig says it's been well-worth it.

Now in place almost two years, the new system "catches errors almost every day," says Ed Maurino, director of pharmacy at Banner Lassen Medical Center, a 25-bed critical access facility in Susanville, 1,100 miles away from Greeley.

"There's just so many things that they can catch that we weren't able to before," Maurino says. Errors that could cause major adverse drug-drug or drug-patient reactions might include a drug that might be bad for a patient with a low creatinine clearance rate, he says.

Einhellig's team reviews prescriptions for East Morgan County Hospital in Brush and Sterling Regional Medical Center, both in Colorado; Ogallala Community Hospital in Nebraska; Banner Churchill Community Hospital in Fallon, NV; and three hospitals in Wyoming: Torrington Community, Platte County Memorial in Wheatland and Washakie Medical Center in Worland.

All are 25-bed hospitals except for Churchill, which has 40 beds, and Sterling, which has 36.

Kerri Kilgore, director of pharmacy at Banner's Torrington Community Hospital, 151 miles to the east of Greeley, says the system is very helpful to her and her nurses. "They scan in the electronic order [to Greeley]," a process that seems to run smoothly. And it's given her some valued peace of mind.

"It used to be that it was just me, with phone calls at all hours of the night," Kilgore says. Now the off-hour interruptions are greatly minimized, except for emergencies when Kilgore is called in to administer a sensitive intravenous drug.

"It's nice to have a backup, and not have it be always be just me, 24-hours a day," she says.

Though the results have so far been promising, the process has had some challenges. One problem that they needed to overcome was dealing with different formularies available for different groups of patients in different states, and the varying ways hospitals stocked their automated dispensing machines. Once they addressed that, the program has been moving along smoothly.

The Rural Economy—The President's View

What are President Obama's plans for the rural economy? In April, he released a 47-page report on strengthening rural America.

US Rural Seal

The President's Council of Economic Advisers released this week its plan for the economy of rural America.

Editor’s Note: The President’s Council of Economic Advisers has released a 47-page report entitled “Strengthening The Rural Economy.” This is the first Presidential document aimed at the rural economy in our memory, so below are extensive excerpts. (You can get your own copy here.) The rollout of this document coincides with the President’s tour of the rural Midwest. We have tried to stay away from the parts of the report that list the Administration’s accomplishments and have concentrated on both the President’s analysis of rural issues and his plans for rural America. We have added paragraphs to ease reading.

Rural areas are home to about 50 million Americans and are an essential part of the overall economy. This report surveys the current state of rural America and describes the Obama Administration’s policies for strengthening the rural economy. Many of these policies are already being implemented through the American Recovery and Reinvestment Act of 2009. But further work remains to ensure the prosperity and vitality of rural America.

Our survey of the current state of rural America identifies both important strengths and significant challenges facing the rural economy.

  • The rural economy is more economically diverse than it once was. Agriculture directly employs only a small fraction of rural workers, though ancillary businesses are included in other sectors. Manufacturing, services, government, and wholesale and retail trade are important additional sources of rural employment.
  • The U.S. agricultural sector remains more productive than those of other high-income countries and is highly competitive in international markets.
  • The labor force of rural America is aging and its educational attainment lags behind that of urban areas for the working-age population.
  • Improvements in health status in rural areas have not kept pace with those in urban areas, and access to doctors and health services has been an important challenge in rural areas.
Scope of Report

We organize the discussion of the Administration’s policies for strengthening the rural economy into four main categories. The first category includes policies to support the growth of new businesses in rural areas. These policies include programs to help strengthen small businesses in a wide range of rural industries. They also involve incentives to greatly expand clean energy opportunities, which are often centered in rural areas. There are also important new opportunities for rural tourism and recreation.

A second category of policies is aimed at strengthening rural infrastructure. Infrastructure investment is central to rural prosperity. Without road, bridges, water projects, and telecommunications, rural America cannot get its products to market efficiently or be fully integrated with the rest of the economy. For this reason, the Federal government has traditionally supported rural infrastructure projects. The Obama Administration has continued that support in important and innovative ways, such as by supporting the expansion of broadband Internet access to rural areas.

farm/nonfarm productivity

Productivity in agriculture has increased dramatically over the years while employment has dropped.

A third category of policies focuses on strengthening the agricultural sector. American agriculture is among the most productive in the world. The Administration has proposed measures to further open international markets to U.S. agricultural products, proposed reforms to better target farm support programs, and urged a greater focus on local and regional food systems.

The fourth category of policies is aimed at strengthening the labor force and improving the quality of life in rural America by investing in education and health care. A new set of policies aims to close the gap in educational outcomes between rural and urban areas. The Administration is also investing in the health of rural America by taking actions to increase the affordability and quality of health care, while bolstering the medical workforce and infrastructure to address the specific challenges facing rural areas.

Agriculture

The agricultural sector is also an important but declining source of employment and earnings for rural America. In 2007, the agriculture, forestry, and fishing sector constituted about 6 percent of employment in high-density rural areas and about 12 percent of employment in low-density rural areas, down from 13 percent and 23 percent in 1970, respectively. Note that these shares somewhat understate the importance of agriculture in rural America, since ancillary businesses are counted in other sector categories. For example, workers who truck or wholesale crops or livestock are generally not included in the agriculture sector classification, though livestock breeders and cotton ginners are.

farm average income

Farm income has been a declining source of income for people who identify themselves as farmers.

Among individuals who identify themselves as farmers, agriculture has become a less important source of income.2 Figure 2 shows that about half of farm household income came from the farm in 1960. Today, the vast majority (89 percent in 2008) comes from off the farm.

Perhaps the defining feature in the history of U.S. agriculture is its persistent gains in efficiency. Even relative to America’s surge in productivity over the past half century, American agricultural productivity has grown rapidly. Figure 3 shows that farm productivity nearly tripled in the second half of the twentieth century, while non-farm productivity increased by about 75 percent. Almost all of this divergence in productivity growth occurred after 1980. A consequence of this tremendous increase in productivity is that, despite increases in total agricultural output, employment has declined. In 1900, about 41 percent of the total U.S. workforce farmed. This share dropped to 16 percent in 1945, 4 percent in 1970, and only 2 percent in 2000.

It should not be surprising that the U.S. agricultural sector is very competitive in the international market. Indeed, in 2008, U.S. agricultural exports were worth $70 billion according to Census definitions, and $115 billion using the Department of Agriculture’s broader definition. The share of American agricultural output exported in 2007 (using the Census definitions) was 15 percent, having increased from 11 percent in 1999. Thus, access to foreign markets is very important for American agriculture. Likewise, although gross agricultural output only constituted about 2.5 percent of total GDP over this period, agriculture made up 2.8 percent of total exports in 1999, rising to 3.4 percent in 2007, according to Census definitions. Notably, this competitiveness is not primarily driven by farm support programs. Since 1991, high-value commodities (for instance, fruit and meat) have made up a larger fraction of exports than bulk commodities (for instance, wheat and rice), though they receive far less Federal support.

Labor Force

While the rural economy has become increasingly diverse, it faces a number of unique challenges regarding its labor force. First, incomes are lower and poverty rates are higher in rural areas than they are in urban areas. Second, a lower proportion of the rural population is of working age (20-64), which presents challenges for future job creation, and the share of the U.S. population living in rural counties has steadily declined over time. Third, a higher portion of rural residents are on disability and therefore unable to participate in the rural workforce. Fourth, educational attainment lags behind that of urban areas for the working-age population. Recognizing these challenges, the Administration has made education a major pillar in its policies for rural America. Its focus on expanding opportunities for small businesses, tourism and recreation, and clean energy will also help to make rural households better off while attracting a new generation of young workers.

The overall share of the U.S. population living in rural counties also has been steadily declining over time, with high-density rural counties experiencing particularly sharp declines (see Figure 5).8 From 1900 to 1970, rural counties lost nearly 0.3 percentage point of the U.S. population per year. From 1970 to 2008, this trend has continued, albeit at a slower rate, costing rural counties almost 0.1 percent of the U.S. population annually. The net effect of these declines is a broad-scale population shift from rural to urban America. In 1900, about 40 percent of the population lived in a county that ultimately would be classified as rural in present-day America, whereas today that share has dwindled to half this amount.

An additional measure of labor force depth is the share of the working-age population (25-64 years old) healthy enough to be counted as an active member of the labor force.9 The Federal Social Security Disability Insurance (SSDI) program provides monthly cash benefits to people who are unable to work due to a disability. In 2008, disability insurance enrollment as a share of the working-age population was 6.5 percent in high-density rural areas and 5.7 percent in low-density rural areas, compared with 3.9 percent in urban areas.10 Thus, the average rural resident was much more likely to be enrolled in SSDI than his or her urban counterpart. Because individuals enrolled in SSDI are unlikely to exit from the program, these disparities are also likely to impact future labor force capacity.

Educational Attainment

Over time, the share of the population of ages 25–64 with more than a high school education in an average urban county has been persistently above the share in an average rural county (see Table 5). While rural counties have made great strides in ensuring that larger proportions of their populations pursue schooling beyond high school, they have been unable to close this gap. Additionally, the rate of progress in educational attainment has been slightly slower in rural areas, causing education levels in rural areas to slip further behind those in urban areas. In 2000, an urban resident was between 10 and 15 percentage points more likely to have attended college than a rural resident. Two decades earlier, this difference was between 9 and 13 percentage points.

This growth differential is driven by the share of the working-age population that has completed only high school. In the average urban county, this share fell 11 percentage points over the two decades, compared with just 3 to 6 percentage points in the average rural county. Put another way, in 1980 rural residents were 1.1 times more likely to stop attending school after high school than urban residents. By 2000, this ratio was up to 1.3-1.4.

Health

While residents of non-metropolitan areas have comparable rates of health insurance coverage to metropolitan areas and the nation overall, they are more likely to be enrolled in public programs such as Medicaid for low-income families, the Children’s Health Insurance Program, and especially Medicare for the elderly (due to the relatively older rural population) rather than holding private insurance, as shown in the Table 6.12 Residents of rural areas have less access to doctors and other health care providers than their counterparts in urban areas. As a result, they are more likely to forego needed care. Finally, improvements in health status in rural areas have not kept pace with those in urban areas.

Families in non-metropolitan areas are more likely than families in metropolitan areas to have a high burden in affording health insurance coverage, defined as health expenses exceeding 10 percent of after-tax family income. While total out-of-pocket health expenses are comparable in metropolitan and non-metropolitan areas ($3,265 versus $3,216 in 2005, the year with the most recent available data, in 2007 dollars), incomes in non-metropolitan areas tend to be lower. As a result, 24.2 percent of families in non-metropolitan areas spend more than 10 percent of their income on health insurance coverage, compared with 18.1 percent of families in metropolitan areas.

Non-metropolitan counties had on average 1.2 active doctors for every 1,000 residents in 2007, compared with 3.0 active doctors for the same number of residents in metropolitan areas. Metropolitan counties also had more than 3 times as many specialists, 1.1 for every 1,000 residents compared with only 0.3 for every 1,000 residents in non-metropolitan counties.14 Finally, in addition to disparities in health care infrastructure and workforce capacity, rural residents face specific geographic challenges in accessing medical care. One report found longer travel times for emergency services in small and geographically isolated rural communities.

Diverging Mortality Rates

metro/nonmetro mortality

Recently, mortality rates in rural and urban America have begun to diverge. While mortality rates in the United States overall have declined over the past few decades, mortality rates in metropolitan and non-metropolitan areas have diverged since the early 1990s. Figure 6 shows that, since 1990, non-metropolitan mortality has declined at an average annual rate of only 0.73 percent, significantly slower than the metropolitan rate of 1.27 percent. While the source of this divergence is unclear, it is likely that improvements in access to health care and in the affordability of that care in rural areas could help to narrow this gap in mortality rates.

Federal Support

Long before the Administration’s recent efforts to strengthen rural America, Federal support for rural areas through these many agencies was extensive. To illustrate this traditional support, consider expenditures in 2007.

About $390 billion in Federal funding was directed to rural areas through non-loan, non-insurance programs in that year. (See chart below.) The left-hand pie chart in Figure 7 shows that approximately 84 percent of this funding went to health care, Social Security, military wages and procurement, and non-military wages and procurement (including the Postal Service). The remaining 16 percent – denoted as “other spending” – is further broken out in the right-hand pie chart. This “other” component of rural spending constituted about $62 billion in 2007. About one-quarter of this spending was directed toward transportation infrastructure. Spending on social services and food assistance (17 percent), income security (16 percent), the agricultural sector (15 percent), and education (13 percent) represent the next largest areas of spending. Spending on housing and other infrastructure, while smaller, was still a substantial portion of Federal funding.

Federal/Rural Spending, 2007

Federal spending in rural America.

Small Business

Long-term investment in innovation and entrepreneurship is critical for the economic health of rural communities. In addition to continuing strong support of existing programs, the Administration has introduced new policies that will foster rural revitalization. In particular, the Department of Agriculture will lead a strategy to promote economic opportunities through regional planning among Federal agencies and state and local governments through its Rural Innovation Initiative (see Box 5, in Section VI). Recognizing that rural areas often suffer from higher poverty and unemployment rates, the Department of Agriculture and the Small Business Administration recently announced their intent to work together to better coordinate development programs and increase the number of guaranteed small business loans.

The fiscal year 2011 budget also includes almost $100 million for the promotion of regional innovation clusters through the Small Business Administration and the Economic Development Administration. The Economic Development Administration will use its budget allocation to distribute regional planning and matching grants to support the creation of regional innovation hubs. The Small Business Administration will promote small business participation in regional economic clusters by awarding grants on a competitive basis to facilitate the coordination of resources through business counseling, training, and mentorships. The proposed fiscal year 2011 budget also expands the Emerging Leaders Initiative and the Minority Business Development Agency, both of which will play critical roles in supporting American Indian and Alaska Native businesses by providing technical assistance and connecting business leaders to regional networks.

President Obama

Lawrence Jackson/White House President Barack Obama tours the Siemens Wind Turbine Blade Manufacturing Plant in Fort Madison, Iowa, April 27, 2010.

Clean Energy

The rural economy will also benefit from policies aimed at moving the American economy toward cleaner domestic sources of energy. Existing Administration policies – the Renewable Fuel Standard recently enacted under the Energy Independence and Security Act of 2007 (EISA) and Recovery Act incentives for the development of bio-energy – will increase the amount of bio-based transportation fuels and renewable energy produced in rural areas. Further energy and climate legislation could greatly expand the use of energy sources located in rural areas such as bio-energy, solar, wind, biomass, and geothermal to produce electricity and transportation fuels.

Recreation and Tourism

America’s Federal lands are precious national assets that are an important source of employment in rural areas through their support of the tourism industry. These lands – wildlife refuges, national parks, national forests, and Bureau of Land Management lands – are located disproportionately in rural areas.

Recently, there have been more than 620 million annual visits to these lands, including over 310 million to national parks and wildlife refuges. The Department of the Interior estimates that its lands support over 320,000 jobs in tourism and recreation. Recent studies estimate that the National Park Service alone annually contributes $6.3 billion in labor income and $9 billion in value added, the wildlife refuges provide an estimated $1.7 billion in sales and $542.8 million in employment income, and recreational visits to the National Forests contribute $11.2 billion to GDP.

America’s Federal lands support a wide variety of activities. Every year, about 7 million anglers visit national wildlife refuges, as do 2 million hunters and many millions of birders. Of those surveyed on their national forest recreation visits, the primary activities were hiking or walking, downhill skiing, viewing natural features, hunting, and fishing. Additionally, about 40 percent listed viewing wildlife as an activity in which they participated.

Recreation and tourism on Federal lands is a growth industry, with the potential to increasingly benefit rural America. For example, the Department of Agriculture estimates that the number of visitors has increased at national forests from 134 million in 1964 to 206 million in 2007. Likewise, the number of recreation visits to the national parks has increased from 205 million in 1979 to 275 million in 2008.

Unfortunately, two problems – deferred maintenance and damaged ecosystems – prevent America’s Federal lands from reaching their full economic potential. In 2009, the Fish and Wildlife Service, Bureau of Land Management, National Parks Service, and Forest Service had a combined deferred maintenance project backlog of between $16 and $22 billion. The Forest Service estimates that 37 percent of its administrative facilities need major repairs or renovations.

The failure to do needed maintenance leads to eroded roads, closed-off trails, and hazardous dilapidated buildings, and reduces the safety and accessibility of America’s Federal lands. In turn, this makes them less attractive tourist destinations.

Similarly, a legacy of damaged ecosystems has decreased the attractiveness of many Federal lands. Aside from the reduction in ecosystem services that these lands provide to the whole country, the harms to recreation and tourism take many forms.

Whether through decreasing bird biodiversity that attracts birders, fish abundance that attracts recreational fishermen, the population of native species prized by amateur naturalists, or the quality and quantity of water available for water recreation, ecosystem degradation is harmful to tourism on Federal lands.

For example, the Forest Service estimates that 25 million acres of its lands are at future risk from insects and diseases. Furthermore, a legacy of counterproductive fire suppression has led to an excessive build-up of combustible material on Federal lands, leading to more extreme wildfires which – aside from endangering surrounding communities – harm ecosystems and site facilities, keeping away visitors.

New Tourism Policies

Through the Recovery Act, the Administration has increased investment on Federal lands, reducing the problems of deferred maintenance and ecosystem degradation and creating a stronger foundation for the future of rural tourism.

The Recovery Act invests over $2.3 billion to preserve and improve the accessibility and experience of America’s extraordinary Federal lands. Much of this spending goes disproportionately to rural areas; for example, the CEA estimates that 65 percent of Forest Service spending has been allocated to rural counties. The funding is roughly evenly split between the Department of the Interior (National Park Service, Fish and Wildlife Service, and the Bureau of Land Management) and the Department of Agriculture’s Forest Service. To make parks and forests safer and more accessible, these funds will repair eroded trails and roads, close hazardous abandoned mines near tourist sites, build visitor facilities, and invest in many other assets.

Rural Infrastructure

The Federal government’s traditional support of rural infrastructure has focused on transportation, telecommunications, and energy and water infrastructure. This support has played a crucial role in linking rural residents economically and socially with the rest of the country and the world and in providing them with important basic services.

Transportation

Of all the Federal efforts to tie Americans together, none is more tangible than the Federalaid highway system. The Department of Transportation supports the construction and maintenance of important highway projects in all 50 states and has invested billions of dollars in highway construction and maintenance since the 1950s. About 65 percent of all interstate highway miles – and 70 percent of all Federal-aid highway miles – run through rural areas.

These highways allow rural Americans to sell their products in key markets throughout the country and the world. Beyond highways, Federal programs also support the rail, barge, and ocean-going transportation infrastructures.

Telecommunications

While the Postal Service has long been the primary vehicle for sending goods and written communications in the United States, the Federal government has also played a crucial role in ensuring access to telecommunications in rural areas, with the same goal of connecting Americans to one another.

Today, all telecommunications carriers that provide interstate or international service contribute to the Universal Service Fund (USF), often through a service fee on their bills. Contributors paid about $7.3 billion into the Fund in 2009, and this revenue was used to support a range of programs designed to promote universal access to essential communications services at reasonable rates. For example, the USF’s Rural Health Care program subsidizes telecom and Internet services for rural health care providers. Additionally, the Department of Agriculture’s Rural Utilities Service (RUS) provides loans to fund traditional telecommunications infrastructure and voice telephone service.

Rural Broadband

Only about 70 percent of rural households with Internet access had a high speed broadband connection in 2007, compared with 84 percent of urban households. This difference in broadband adoption is not just a consequence of income differences. Even when rural and urban households are matched by income, broadband connections are less prevalent among rural households.

Much of the difference between rural and urban broadband subscribership reflects availability: residents of some rural areas have no terrestrial broadband Internet service providers, and other areas are served by only a single provider and therefore have no competition. The Administration has made a priority of accelerating the rollout of broadband Internet service to rural America.

The most important vehicles for accomplishing this goal are monies authorized in the Recovery Act for providing loans, grants, and loan-grant combinations to expand access to broadband in rural and underserved areas of America. For instance, the Department of Agriculture’s Rural Utilities Service will use billions to support loans and grants that facilitate broadband deployment in rural areas, with the objective of funding projects that will support rural economic development and job creation beyond the immediate construction and operations of the broadband facilities.

The Department of Commerce’s National Telecommunications and Information Administration was given $4.7 billion for its Broadband Technology Opportunities Program to deploy broadband infrastructure in unserved and underserved areas (many of which are rural), expand public computer center capacity, and encourage sustainable adoption of broadband service. And the Administration intends to support broadband expansion in rural America beyond the Recovery Act. For instance, the Administration has included $690 million for direct loans in telecommunications and $418 million for loans and grants to help transition rural economies into the modern information economy in its proposed fiscal year 2011 budget.

There are several reasons that expanded broadband service is important for employment and income growth in rural areas. Most employment growth in the United States over the last several decades has been in the service sector, where jobs are particularly likely to benefit from broadband access.

Broadband service may allow rural areas to compete for a range of service jobs, from call centers to software development. And even in non-service industries, Internet tools can help businesses connect more efficiently with customers and suppliers. For instance, American farmers can use the Internet to track product prices, obtain weather forecasts, buy and sell commodity futures, track the progress of supplies ordered or products shipped, and find markets for specialty farm products. Broadband Internet connections also are increasingly useful as a substitute for business travel.

Broadband-enabled employment is valuable in rural areas not only for the income opportunities it provides, but also because it helps further diversify local economies. Broadband Internet access enables employment that is both flexible and untethered to local economic conditions. One example of how broadband access can diversify income sources is through home businesses, which are substantially more common in rural areas than urban ones.

Broadband service helps rural businesses find markets that otherwise might be unavailable to them, facilitates online ordering and billing, and integrates the rural economy with the rest of the country (and the world) more effectively than is possible over slow-speed Internet connections. It also allows continued access to online training and education.

Finally, broadband service expands opportunities for improving the provision of medical and health services for rural populations. More accessible health information, products, and services confer real economic benefits to rural communities and their residents. One study of hospitals in 24 rural communities found that the benefits of telemedicine include savings from outsourcing of procedures, transportation savings for patients who were able to obtain services electronically from their local hospital rather than traveling to a distant specialist, and income savings to patients from reductions in missed work.

Agricultural Exports

As part of the Administration’s National Export Initiative, the President has called for further measures to open foreign markets to American products. A key beneficiary of such expanded opportunities will be American agriculture, which is extremely competitive in international markets.

The President recently called for concluding the Doha round of trade negotiations, a large component of which is related to opening up agricultural markets around the world. This would require countries to reduce protective tariffs and distortive subsidies in their agricultural sectors.

More open trade allows the highly productive U.S. agricultural sector to export its products more easily. Further, the United States tends to have lower barriers to trade than many other countries. As discussed previously, the change in access that has resulted from previous free trade agreements has often been bigger for U.S. exporters than importers into the United States. An agreement such as this would allow the United States to reform policies that have been in some cases ruled noncompliant with the World Trade Organization (such as the subsidies for cotton). Having subsidies that are ruled illegal can cause damage to the industry and other sectors as other countries are allowed to impose retaliatory tariffs on U.S. goods.

Ensuring Competition

Finally, the Administration is working to promote fair competition in agriculture not only internationally, but also at home.

The Administration is committed to protecting fair and open competition and enforcing antitrust laws in the agricultural sector. The Department of Justice and the Department of Agriculture are holding five public outreach workshops in 2010 to solicit public input on the state of competition, regulation, and consolidation in the agricultural industry.

One aim of these workshops is to foster dialogue and ensure that a wide variety of viewpoints are heard on issues such as the impact of agriculture concentration on food costs, how patents and intellectual property affect agricultural marketing and production, and increasing retailer concentration.

The first such event, held in Iowa in March, drew hundreds of farmers, ranchers, and industry leaders, who participated in a vigorous discussion about competition in markets ranging from seeds to livestock. Four more workshops have already been scheduled in 2010 to focus specifically on the poultry, livestock, and dairy markets.

Farm Support

The Administration’s proposed fiscal year 2011 budget includes a number of reforms to existing Federal support for the agricultural sector.

First, to better target payments, it proposes more stringent income eligibility requirements to preclude the wealthiest farmers from receiving payments. Currently, farms with $500,000 or more in sales receive 38 percent of subsidies, although they account for only 4 percent of farms.

In the Administration’s budget, after being phased in over three years, farmers with a farm-adjusted gross income (AGI) over $500,000 or non-farm AGI over $250,000 would no longer be eligible for direct payments.

Second, it proposes reforming the crop insurance program to reduce windfall profits enjoyed by private companies that supply reinsurance. The crop insurance program has grown dramatically since it began in 1981, from $18 million to $7 billion in 2009 (all in 2008 dollars). This change to the crop insurance program is projected to save $8 billion over 10 years. Together, these reforms ensure that the Federal government will continue to provide a safety net to farmers while freeing up resources that can then be directed toward other priorities.

Health and Education

There are significant gaps in educational attainment and in the quality and availability of health care between rural and urban communities.

These gaps arise in part because rural areas face several unique challenges in achieving high-quality education and health care. First, the recruitment of high-quality teachers and health care professionals may be more challenging; for example, rural professionals often face lower pay and difficult working conditions.

Second, because of lower population densities, it is harder for rural areas to support specialized classes in their schools, such as vocational and advanced classes, and specialized health care providers, such as experts in the treatment of relatively unusual conditions.

And third, the fact that rural students are often far from institutions of higher education makes it more costly for them to attend school beyond high school, and the fact that rural residents are often far from hospitals makes it more difficult for them to obtain timely, high-quality medical care.

The Administration is working to help rural communities overcome these challenges, and in doing so, to close the gaps with urban areas. These efforts are being conducted through the Recovery Act, which is funding a range of programs strengthening rural education and health care; through health care reform, which may prove particularly beneficial to rural America.

Conclusion

The history of rural America is one of proud accomplishment.

American agricultural productivity is among the very highest in the world and agricultural products are important exports. Rural America also contributes to the production of U.S. goods and services in many other sectors including manufacturing, services, government, and wholesale and retail trade. The President is committed to ensuring that the future of rural America is as distinguished as its past.

The Administration is actively taking steps to put rural Americans on a path toward greater prosperity through a wide range of policies. One set of policies seeks to promote rural businesses and further the diversification of the rural economy by helping rural small business, fostering rural areas’ role in leading the clean energy transformation, and encouraging rural recreation and tourism. Other policies are providing crucial investments in rural infrastructure in telecommunications, water distribution, and other areas.

To promote the continued vitality of American agriculture, the Administration is working to open foreign markets, improve farm income support programs, and promote local and regional food systems. The Administration is also working to strengthen the rural labor force through initiatives in education and healthcare.

Crucial steps to strengthening the rural economy are already being taken through the Recovery Act and other policies. These steps include investments in areas ranging from health information technology and education to infrastructure and small business loans; comprehensive health insurance reform that will have large benefits for rural communities; and much more. The Administration is committed to building on these unprecedented measures in the months and years to come.

Funding Opportunities

Go to RAC Funding Database

Active Living Research: Building Evidence to Prevent Childhood Obesity
Letter of Intent (Required): Jul 1, 2010
Application deadline: Applications accepted on an ongoing basis.
Funding to support opportunistic, time-sensitive studies on emerging or anticipated changes in physical activity-related policies or environments.  

ARRA - Equipment to Enhance Training for Health Professionals Programs
Application deadline: May 17, 2010
Several funding opportunities for the Equipment to Enhance Training for Health Professionals (EETHP) program, hereby known as EETHP Equipment Initiative. 

Getting Americans Covered: Ideas From the Field
Application deadline: May 27, 2010
Funding for projects that promote the Foundation’s goal of ensuring that all Americans have stable, affordable health care coverage. 

Bound Tree Medical Legacy Scholarship
Application deadline: May 28, 2010
Scholarships for students to pursue an EMT career or to further their training. 

Injury Prevention Program
Application deadline: May 28, 2010
Funding to promote the capacity of Tribes to build sustainable evidence-based Injury Prevention Programs. 

Flex Rural Veterans Health Access Program
Application deadline: Jun 4, 2010
Grants to provide mental health services and other services to veterans and other residents of rural areas. 

Rehabilitation Training: Rehabilitation Long-Term Training
Application deadline: Jun 7, 2010
Financial assistance to provide training in areas of personnel shortages in rehabilitation. 

Training and Information for Parents of Children with Disabilities—Community Parent Resource Centers
Application deadline: Jun 17, 2010
Grants to local community parent resource centers for parents of children with disabilities. 

AcademyHealth Health Services Research Impact Award
Application deadline: Jul 30, 2010
Awards for health services research that has made a positive impact on health policy and/or practice. 

Community Access to Child Health (CATCH) Implementation Funds Program
Application deadline: Jul 30, 2010
Funding supports pediatricians in the initial and/or pilot stage of developing and implementing a community-based child health initiative. 

Community Access to Child Health (CATCH) Resident Funds Program
Application deadline: Jul 30, 2010
Grants to support pediatric residents in the planning of community-based child health initiatives. 

Amy’s Courage Fund
Application deadline: Applications accepted on an ongoing basis.
Provides emergency financial assistance to victims of domestic violence and their children to meet their immediate needs after escaping an abusive home. 

Healthcare X Prize
Application deadline: Applications accepted on an ongoing basis.
The Grand Challenge for this Healthcare X PRIZE will be to create an optimal health paradigm that empowers and engages individuals and communities in a way that dramatically improves health value.

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