This is a longstanding problem of geography and demographics. It is not unexpected that many of the States with the worst problem are also the ones that are least urbanized i.e. much of the population is diffused across a vast region. The aging and decline of these populations makes the situation worse.
The rural hospitals typically serve a population that otherwise would be several hours travel from the nearest "real" hospital, and typically have a catchment area of 1-2 hours travel. Many of these hospitals are located in towns with populations of a few thousand people. Even when heavily subsidized, the economics of maintaining these hospitals is very poor, especially as populations decline. Maintaining a fleet of doctors and facilities that are increasingly rarely used is expensive. And even with the current distribution of rural hospitals, it is not uncommon for people to live several hours from the nearest hospital.
It is essentially a math problem. To ensure that virtually everyone lives within N hours of a hospital, you would need to build an enormous number of hospitals that each service a population of a few thousand people unless N is quite large. This has an extremely high cost per capita, most of which is wasted because they are often very underutilized, which does nothing to help reduce healthcare costs. And you can't force these people to move to more urbanized areas of the country either. The other challenge is finding enough doctors willing to work in a tiny remote town. Few people want to live in these areas and so many doctors that do work in these hospitals are effectively required to commute from a city that is hours away -- it is not a desirable assignment for most.
It’s not just urban/rural divide, it’s young and old as well. The areas where hospitals are closing are disproportionately filled with retired folks who are on Medicare and will need more and more healthcare (Medicare pays out less than private insurance so these hospitals have less money coming in from patient care and need direct subsidy. I think the answer here is pretty clearly to close down the hospitals and highly encourage/enable older folks to move to urban areas where we can provide their care more cost effectively and they will be able to age safer (no driving, stronger social services etc). In the US, you have a right to live where you want but you don’t have an unlimited subsidy to age in place.
I'm speaking as someone who has never lived in a rural area, but the thought of living in a rural area as a retiree seems very exhausting. Between the upkeep, driving everywhere to get anything, and the healthcare accessibility issue it doesn't seem practical for someone in their old age. Am I missing something here?
On the flip side, retired people don't need to live near jobs in the city, and their living in rural areas reduces the demand for housing in urban areas. Rural people are typically on fixed incomes, and cannot afford the skyrocketing rents or property taxes of urban areas. Now, of course, you can do things like rent controls, but those are also subsidies. So you're just trading one subsidy for another. At least subsidies to keep rural hospitals open doesn't distort the housing market for younger people looking for housing near where they work in the city.
(Driving is also easy in rural areas. There is nothing to run into. Young adolescents routinely drive in rural areas. I'd imagine it's a lot easier for older people to do than to deal with being exposed to the elements/dealing with broken elevators and escalators to use public transit.)
I'm not following your logic at all. I don't think it's a common phenomenon for retirees who once lived in urban or suburban areas to move to rural ones. I'm guessing the majority of these people have always lived in rural areas and just stayed put through retirement.
That doesn't matter--the point is that because retired people don't need to be near urban jobs, we can reduce pressure for housing in urban areas by leaving retired rural people where they are. (Or, conversely, we can avoid increasing pressure for housing in urban areas by moving retired rural people into urban areas.)
That would cause an even greater housing price crunch in the cities than we currently have. Much of the retirement advice out there is that once you're on a fixed income, you need to move out of a high cost area into a lower cost, typically at a minimum less dense one. Also, in practice, quite a few older folks move to be close to family members who can support them, which requires living wherever your children and grandchildren live... Even strongly encouraging the urbanization of the elderly strikes me as the wrong answer here for so many reasons, even beyond the ones I've listed above.
But as the previous poster said, you don’t have a right to infinite subsidy for the purposes of moving to your “low cost” area. We’re entering an era where these places are low cost for elderly people precisely because everyone else is subsidizing a lot of that infrastructure for you. From the hospitals and clinics, to the roads.
This is just a really hard problem. The best likely solution is to build more housing in the urbanized areas. But, yeah, how do you get that done profitably? It’s tough.
Even if you build more housing, having older people live in urban areas still increases the price of housing. Crucially, older people don't need to be near urban jobs, so it's much more socially practical for them to live in rural areas. At the end of the day, the question is which subsidy is harder to deal with? Cash payments to keep rural hospitals open seems a lot easier than wading into enormously expensive and distortionary urban housing policies like rent control.
San Fran is not the only urban area in the US. Of course elderly people can’t move to Manhattan or San Fran. But there is lots of affordable housing in Omaha, Cleveland, Houston, Milwaukee, etc etc etc. Additionally, there is no reason we can’t build more housing in mid sized metros of that nature. (I guess Houston is not “mid sized”, but you get the idea.)
No one is talking about the elderly moving to places that are too expensive. We’re putting forth the idea that maybe they should move away from areas that are too expensive.
I think you don’t understand how cheap rural areas are. My Oregon family blanches at the prices even in Eugene, forget Portland or Seattle. It’s not at all clear to me that whatever subsidies (rent control, etc.) would be required to allow the elderly to live in Omaha would be less than the subsidies for keeping rural hospitals open.
>I think you don’t understand how cheap rural areas are...
Just as a matter of full disclosure, I should let you know that I live in rural Wisconsin. I'm just trying to be as intellectually honest as possible about the subsidies that go into allowing me to be here.
There’s a bit of circular arguments going on here. Sure moving more people into an urbanized area may mean higher housing costs, but housing is not the only expense. Healthcare is a huge expense with over half of all healthcare expenses consumed by those 55 and older [1]
Additionally, there are several approaches that can be taken to lower housing costs other than price control. Housing policies are a huge mess throughout the country as its regulated locally, and exclusionary housing policies limit high density developments necessary to keep construction and infrastructure costs down.
If you can't drive anymore and you don't have to go up steps, transit is amazing for your mobility at that age. I know old people who got a house in SF, citing that as one of their reasons. I know it's not the best transit, but it's definitely better than the american no transit, drive everywhere default that they were living at.
So we need to combine that with a plan of action that ameliorate urban problems we already have, such as building more medium and high density housing and creating more public transits instead of sprawling out.
The rural area is only low cost in certain aspects. Other aspects, such as medical care, is far more costly due to having to pay substantially more to incentivize doctors to want to work in rural areas.
The certain aspects are important, though. Rental and ownership costs for housing are typically 2-4x or higher in an urban area versus a rural setting. When you're already on medicare and have a fixed income, that can make all the difference.
More than anything, though, it really boils down to lifestyle. Often times, suburban senior living communities are reasonably affordable as well, avoid the major pain points of city life, and work out things like deliveries of everything from food to pharmacy goods.
> Maintaining a fleet of doctors and facilities that are increasingly rarely used is expensive.
I'm a physician working in NYC. I could make a full 75% more salary if I went to work in a rural area. Very inverse from most professions (I think) where people working in the city make the most. But I think it's that challenging to get physicians to work in rural areas.
This. Staffing these hospitals requires paying very large cash compensation premiums compared to cities. I have a couple acquaintances that worked at these hospitals, and they all did it for the money. Even then, most of them wouldn't do it for any length of time because the sacrifice to their personal and social life is too high.
I was a physician working in NYC. I now make a full 100% more working in the rural Midwest. You can think of it like Uber's surge pricing - pull drivers in when there's a demand-supply mismatch. Except in rural America the mismatch is constant and so is the surge pricing.
A good number of the docs I work with here are actually from around these parts. They setup shop with their families, buy and build large homes on large swathes of land, and buy a propeller plane or two. Others are foreign medical graduates. These areas are almost always designated as medically underserved and that has all sorts of Visa and ultimately green card/citizenship implications. Effectively Trump's "shithole" immigrants are caring for his base.
We're unlikely to ever reach 100% urbanisation. In fact, the trend is likely to reverse to some extent at some point. Long term solutions lie in remote, largely automated care, remote triaging, widely distributed micro and mobile clinics, and efficient transportation infrastructure for when the care can't come to you.
It's big fish in a small pond syndrome. If you have multiple years of college and your interests are fairly intellectual, you are going to be hard pressed to find like-minded friends, etc, in a rural area treating farm hands and the like. It's also tough being, for example, the only doctor in an area because then everyone is your patient and you have an inherent conflict of interest when trying to make friends.
For instance, what about your husband/wife? They just put their career on hold to go live in the boonies for 5 or 10 years? That sort of thing will put an enormous strain on your relationship.
The pay is better, but not sufficiently better to offset benefits of urban life. Offer $5M per year, and it won't be challenging to get physicians to work in rural areas. So the problem is merely that there isn't enough funding to incentivize doctors to work in rural areas.
Another serious problem is that the care you get at rural hospitals is often much worse than at bigger hospitals. Doctors perform procedures less often and make more mistakes. A smaller variety of equipment is available.
Often you're better of driving a bit longer to a larger hospital.
We can also improve coverage by building faster roads. How about a dedicated fast lane with a minimum speed of 120 mph and modern-car requirement? Add toll to reduce congestion.
It might improve emergency response, local commerce, far-away commute, tourism, and availability of all services, including healthcare.
Short of that, maybe next-gen VTOL aircraft (robotic octocopters) for transporting the ill at a fraction of the cost of a helicopter.
Building new, faster roads in rural areas would be outrageously expensive per capita and would rarely be used, there is no economy to justify the expenditure. There are 2.2 million kilometers of unpaved road in the US. Even for the paved rural roads, many of them are relatively low-speed or circuitous because it is cheaper to go around myriad engineering obstacles than through them. It is difficult to justify tunneling 20 kilometers through a mountain range with a high-speed road so that 100 people can shave an hour off getting to the other side of that mountain range where there might be a fast highway.
Helicopters and similar have problems of limited range and operating ceiling, which are particularly relevant in the western US, in addition to requiring safe landing areas that may not be readily available. It is a challenging problem to solve, the US is quite large and many areas where people live are rugged and remote.
I would beg to differ -- the vast majority of rural roads in this country west of Pennsylvania are mile by mile grid, wide, and 55 MPH fast moving. They don't get you anywhere nearly as fast as freeways, they often slow down through tiny hamlets and they have lots of stop signs, but they're already very fast compared to a lot of places.
Edit: Which is to say that I agree with you more than the grandparent.
Those grids are not a problem, they drive relatively fast for unpaved roads, but the grids completely disappear once you reach the mountains in the western third of the US, even in large unbroken crop areas like The Palouse with proper rural roads. Many parts of the South are similar, though in those parts the meandering rural roads are defined more by water obstacles.
The major highways in the rural west, on the other hand, are very fast (90 MPH is normal) once you get to them, but the geographic distances between places that resemble civilization on those highways are often quite large even at that speed.
The idea is interesting but your "minimum speed of 120mph and modern car requirement" is not. Remember, this is rural America we're talking about, that is having trouble keeping hospitals running.
If it costs $100m/year to run a single hospital, it will probably cost, what, 1/10th of that to maintain a fleet of self-driving high-speed ambulances?
The highways will need to be built on the state/federal level, most transportation is that way.
The amount of construction needed for that kind of project that would only benefit a small number of people... It's just absurd. Rural people would rather that money go into more important projects.
Did it seem equally absurd to build the East Coast - West Coast railroads in the 18xx? Only a small group of the Wild-West settler would benefit from it.
And did it seem absurd 100 years ago to expect a nation-wide system of 55mph highways?
I'm pretty sure that it did seem absurd, and yet we're all better off for it in the end. Transportation infrastructure has a huge long tail of benefits.
The two of you have missed the part of my post about "modernized car requirement" (that would be something like autopilot), and "dedicated lane" that prevents other cars from getting in. I'm pretty sure this road, if built, will have fewer deaths on it than a regular highway.
So a thing that doesn't exist should be anticipated by cash-strapped governing bodies and should have massive capital expenditures poured into it, to solve a problem that does exist in the here-and-now.
Yes? That's pretty much the story of every single capital-intensive project in history: first there is a present need, then goes the massive expenditure, then comes the completed project, then appear various positive and negative unintended consequences.
Let me be more specific. You are saying that they government should anticipate a thing that doesn't work and has no realistic timetable to be adopted at any scale. Further, you don't take into account such little things as car tires rapidly deteriorating at your proposed speed (and for just that one little thing you must ignore that that any changes to composition just for your wonder-roads will increase cost and decrease other valuable aspects of tires, like road grip, which matter more in inclement weather in more rural areas).
And it should just...happen, because you said so.
A sibling commenter had it: you're badly reinventing trains. What is with the obsession amongst the tech set to reinvent mass transit poorly? (See also "Loop," by one Musk, Elon.)
High-speed roads are the most proven thing in the history of proven things - if you make them people drive on them with high speeds. For example, Germany is doing just fine with high speed roads [1]. In particular the car tires are not coming apart at all, nor does any other part of the car.
Hardly a re-invention.
[1] The lowest speed I observed was 100mph, and that was me in a clunky economy Opel wagon. Everyone else was going 120mph+, and a few cars flew by me faster than I could see them, I think at least 160mph.
Weirdly, the article didn't notice the very strong correlation between "states that didn't accept the Medicaid expansion" and "places with under-payed rural hospitals".
This seems like an absolutely elementary analysis to do -- places with the Medicaid expansion are more likely to have people with health insurance; places without are less likely.
I honestly wonder if any form of sparsely populated settlement would be sustainable if it was not heavily subsidized by taxes from the urban regions.
Ironically, the worst predicament for any form of infrastructure is under-use. In today's world where no town can be self-sufficient, low density can be the bane of its existence.
It is sometimes irritating how heavily favored rural communities are (per capita) in the way Govt.is structured.
Wouldn't be better for pretty much everyone to just help the people in areas where services are unsustainably expensive to move to denser areas where they can be properly attended? At this point the less dense areas are a waste of energy and resources that are worsening our climate outlook, we should be starting to think about real solutions instead of some cockamamie telemedicine patch - seeing a doctor over the phone is only a solution for trivial problem, as soon as there's something serious the only option is a very long car ride or a very expensive helicopter ride.
The main problem is that as a whole, we tend to romanticize and privilege rural living. It's generally bad for the environment and economy, and really the latter is why people have already been urbanizing for, well, centuries now.
That as many people are able to live in rural areas now with a modern-ish standard of living is largely because of subsidies from more productive urban areas: just look at state government tax revenues vs spending by county and this is obvious.
I don't hate rural areas, but there's really no reason we should be subsidizing a lifestyle choice that's bad for the environment. At the very least, zoning rules at city and county levels that prevent densification even from landowners who want it on their property should be illegal, there's no good reason for those to exist. Some regional housing and transportation authorities with teeth would also go a long way.
There are all sorts of ramifications to the inefficiency of rural living that developed societies struggle to cope with. That providing, say, high speed internet out there may be too expensive for its own residents to afford may seem like an ignorable problem, until you remember there are kids out there too, and what if the local school wants the students to do things at home that depend on that internet access, which is a reasonable expectation in most of the country these days?
Well, that depends. Will the urban area allow me to have a workshop? Will it do like San Diego did and disallow any personal car repair even in my own damn garage? Will I be able to even modify the way in which I enjoy my hobbies without incurring literally 100x the cost in an urban area vs. a rural one?
The town I live in now has messed with zoning so much over the last 30 years that any extant property is a minefield of exceptions and variances, so any time you want to even repair what's there, you need a $500 zoning variance application. Anytime you want to expand in place, you violate the setback rules. Anytime you want to do anything other than stay exactly as is, doing only the mowing the lawn and walking to the restaurants in town that the "City Master Plan" expects, you are begging for permission from the high and mighty civil masters ahem servants. All of my friends that enjoy the same things as I do, do what I'm working towards doing -- move out of the city and away from the upper class zoning that intends to keep the working class out.
> Will I be able to even modify the way in which I enjoy my hobbies without incurring literally 100x the cost in an urban area vs. a rural one?
I think the point the parent is making is that the people in urban areas are the ones subsidising your extra-urban lifestyle, which would be unaffordable if you had to pay the real cost of all your services
Rural areas also have non agricultural industry. Heck, it doesn’t make sense to do manufacturing in dense urban areas these days, which are restricted to mostly services. That means a lot of light manufacturing falls into semi rural areas.
Yes, but there you could easily have people living in medium density small towns. You don't need everyone sprawled out on huge lots as is common in the states.
This isn't some wild suggestion, living in Munich now I've gone through plenty of little Bavarian towns that are more walkable than US cities 100x as big. I think the US is a bit unusual in how once you get out of bigger cities, it's just assumed that yeah of course any kind of multi-family housing is going to be almost completely absent now, as if the economics of scale there suddenly stop existing.
The market might even achieve this by itself to a large extent, but usually zoning rules make it illegal. Plus, there are non-market effects like property taxes not taking into account how expensive it is for the government to provide services, resulting in subsidies from denser neighborhoods to sprawly ones.
> you could easily have people living in medium density small towns.
Yes, you could have those things if you had... a thousand years of history with vastly different agricultural economics, socioeconomic pressures, political pressures, and climate pressures that led to the development of those "medium density small towns" in Europe. Oh, and of course on top of those things (and largely as a result of those things) you also now had a culture that predisposed people to remaining in the communities of their birth and childhood, a much more consistent (and much higher) population density (with large cities being uniformly extremely nearby by American standards), and rural communities that benefit from exporting large amounts of high-end agriculture products.
It's absurd to imply that the only difference between a place like rural Oklahoma and rural Bavaria is "zoning rules" and "property taxes"...
100 years ago rural American living was much more like those Bavarian towns. Where do you think all of those relatively densely packed small downtowns dotted across the country came from?
What changed was the car and development policies.
Anecdote: My father grew up in the 1950s in a very rural area outside Chicago, the type of area where you gave a 10-year-old a rifle and let him wander around rabbit hunting. He once visited my house in San Francisco, from rural Georgia, for my son's first birthday. He remarked how the shops near my house, in the Outer Richmond neighborhood, reminded him of the downtown area he worked as a teenager. The downtown he grew up near is now nothing like when he was a kid. Now it's hollowed out and less dense and lively.
Yes, living in rural areas outside major (literally the second largest city in the country in 1950) metropolitan areas (especially in the Union heartland), which have population densities more similar to Europe, is somewhat more similar to Europe; but the vast majority of rural America cannot be described as being "outside" a city like Chicago.
A rural Oklahoma, New Mexico, or even California town in 1900 was honestly not similar to contemporary Bavarian towns at all. To say so is just naive and simplifies "similarity" to simple walkability (in an arbitrary, hypothetical town center). The car (and several other appliances of modernity) literally built much of the rural (and urban) American south and American west.
My dad once explained to me that in the 1950s "outside Chicago" didn't mean what it means today. It's just a geographical reference, for which I know no other better term. It was nothing but farm country where he grew up.
I've traveled across the U.S. Not on the Interstate systems, but on the old U.S. highways. I've driven U.S. 50 from San Francisco (Sacramento) to D.C. U.S. 20 from Newport, OR to Boston. U.S. 90 from Florida to Van Horn, TX, and then old U.S. 80 from Van Horn to California (with some diversions). And I took my time, driving through and often visiting every little town. It took me weeks to make each cross-country trip. And I've taken other, more circuitous routes on other trips, like a cross country where we just zig-zagged north and south visiting towns and friends while taking a mostly southernly route from the east coast to the west coast.
I also grew up in various rural towns in the Panhandle of Florida, Alabama, and (very briefly) Louisiana, in addition to [once] small towns outside Chicago. In the South, the really poor, like my family, often either lived on trailers set up on the corner of someone's farm, or in some old house near the hollowed out local downtown core. I was always acutely aware of this dichotomy, as the middle-class families lived in nether regions unlike either.
I've seen plenty of the U.S. I know exactly what it looks like today, and I have a darned good sense of what it looked like before my time. And I know that small, dense downtown areas were once extremely common. Yes, people living out on small farms was also very common, but the patterns are totally different from today. Outside the downtowns was much less dense than today (because people lived on real farms growing food, not grass on a couple of acres), while the small downtowns were much more dense than today. We're simply more evenly spread out today.
Those downtowns were never as extensive as the small towns of Europe, as in most cases they only ever had several decades to grow before people either moved on or before cars became ubiquitous. But they were there. And they were walkable; infinitely more walkable than what came afterward. The pharmacy, the mill, the doctor, the insurer, the bank, the bars, the restaurant(s), many with apartments above them, and blocks upon blocks of tightly packed single-family homes. And you can walk the husks of many of them today, especially if you stay far way from the freeways, in places where areas were never redeveloped but just slowly abandoned. I've seen the same towns over and over again all across the U.S.--Nevada, Utah, Colorado, Kansas, West Virginia, Virginia, Georgia, Florida, Oklahoma, Arkansas, Louisiana, Texas, New Mexico, Arizona, Oregon, Idaho, Montana, Wyoming, South Dakota, Nebraska, Iowa. They're the same everywhere.[1] Before the car became ubiquitous it couldn't have been any other way. And even after the car downtowns still thrived, extending the reach of the downtown (e.g. at the time of my father, who lived in a rural area with a multi-acre subsidence "garden" but who could catch a ride into town to work at the pizza parlor). The single-family home plots grew only modestly. It wasn't really until the freeways that the pattern of American development was truly revolutionized, draining downtowns of their vitality across the country from the 1960s onward, following the migration away from the major cities from the 1940s and 1950s. And that's a relatively recent thing in American culture and politics.
[1] I think I saw the fewest downtowns in places like Louisiana, Mississippi, and Arkansas, extremely poor states where people and services have been spread out, and even where people lived in close proximity (i.e. relatively densely packed single-family homes) you still didn't see any commercial conglomerations.
> The car (and several other appliances of modernity) literally built much of the rural (and urban) American south and American west.
This is silly. That you needed a car to reach small towns from elsewhere doesn't mean you had to design the town itself to require a car for intra-city transportation.
You don't see a thousand years of different history to change zoning rules and incentives now. Significant change will take many years, even decades, but that's all the more reason to start as soon as possible.
> "medium density small towns" in Europe
Don't make excuses here. We chose poorly, and we're suffering for it, and so is the environment. Yes, there are historical reasons for why we have sprawliness and car dominance, but nobody made us do it. Don't deny people's agency.
> It's absurd to imply that the only difference between a place like rural Oklahoma and rural Bavaria is "zoning rules" and "property taxes"...
It's a pretty good thing I didn't do that, then. Perhaps you should try replying to the comment I made, rather than the one you invented.
A lot of those small towns might as well be called exurb equivalents? When you have an s-bahn train running through your small town and commuting to work at BMW or whatever is 45 minutes anyway, why not stay there?
Interesting, you have to wonder if this will help accelerate a push from rural voters for government-run health care where gov run hospitals have a mandate to stay open and the cost is spared across the system.
The hospital in the rural area I grew up in closed it's doors two years ago.
The tribal politics in the comments here are obnoxious and myopic.
Rural hospitals are receiving the majority of their money from Medicare and Medicaid. They don't pay enough. There was a great NPR show on this a few weeks ago.
Hospitals in the US overcharge (cost shifting is the technical term) patients with private insurance to offset losses from offering services at below cost to Medicare/Medicaid patients.
Too few private insurance patients means they close their doors.
I doubt it. My grandparents and inlaws both live in rural towns, and I think they'd rather have the hospital close down than have to pay more taxes. I know the news likes to show people from rural towns that want the government to provide urban ammenities in areas that can't financially support it, but in my experience, those people are in the minority. Most rural people I've met know the risks of living far from government services, and they think the benefits outweigh the risks.
Still even people living 'far from government services' should be able to get emergency help when they need to and the closure of the hospitals might just drop the general level of life in the area
I've made a comment somewhere else in this thread, but I think it applies to your observation. We should have different laws for rural/urban about almost everything. Make flying cheaper in rural areas; less insurance, less safety standards. Rural people know what they are getting into and know the risk of living in rural areas. They are also more self-sufficient. The rural/urban divide is too great.
Unfortunately, I think it's more likely that no matter how bad private healthcare gets, people in the deep red states mentioned in the article will just assume that socialized healthcare would be even worse and dig in their heels all the more out of redoubled fear of losing what little they have left.
I'm not sure they'd be wrong. The politicians pushing to socalize US healthcare are doing so on a platform of cutting costs and are generally pretty hostile to the idea of subsidising rural folks. Both of those point in the direction of healthcare reforms that kill off rural hospitals.
It could have been the plan all along to engineer a "market failure" so these people have no choice but to accept socialized healthcare even if they're vehemently opposed to it.
The ACA was a repackaging of Massachusetts' "RomneyCare" that was passed by Republicans in that state. The reason this legislature was chosen was because it was thought to be a bipartisan solution to rising healthcare costs.
> Massachusetts' "RomneyCare" that was passed by Republicans in that state
FYI RomneyCare was passed by a supermajority of Democrats in the MA state legislature. They negotiated some parts with Governor Romney but the reform was not a “republican idea”. ObamaCare in general was not a republican plan - it was a moderate Democrat plan.
The central idea, the individual mandate, came from a 1989 lecture by Stuart Butler, an economist at the conservative Heritage foundation. It originated as a conservative alternative to socialized healthcare.
But in politics, the idea was pushed by democrats. The idea that Republicans came up with RomneyCare is simply false, it never would have happened if the Republican Party controlled Massachusetts. Look at actual republican controlled states and you can see what they did on health care pre-ACA and it was pretty much nothing.
People at conservative think tanks coming up with an idea doesn’t make it “republican”. In reality the party ignores many things that the heritage foundation or various other foundations or think tanks say, they’re much more focused on politics than on ideas.
The Heritage Foundation is the flagship conservative think tank, Republican and conservative are synonymous in popular usage, so yeah I think it's safe to call their proposals Republican proposals despite the fact the party can't actually enact all of them.
And if we skip ahead 4 years to 1993, a Republican Senator introduced, a bill with 20 Republican co-sponsors including Bob Dole, Orrin Hatch, and Charles Grassley called the HEART bill.
That bill included an individual mandate, vouchers for low income individuals, and protection for prexisting conditions.
Not all Republicans supported this plan, but almost half of the Republican Senators including most of the leadership supported it. I'd call that a Republican plan--a plan based squarely on the proposal from the heritage foundation.
You're just wrong. Just because no republicans voted for it doesn't mean that enormous compromise was necessary to get certain independents and conservative democrats to vote for it, which is exactly what happened. The entire legislative approach to the ACA was to get a 60 vote filibuster-proof majority in the Senate (and subsequently to prevent the bill from returning to the Senate because of changes made by the House), in a Senate that only had 58 democrats.
You don't believe Democrats because they compromised with Republicans to get a bill passed?
If you recall, Republicans used the filibuster in the Senate, which meant Democrats needed a 60 vote supermajority to get a healthcare bill passed. When they floated the idea of a Medicare-for-all bill, Republicans promised to filibuster in the Senate.
Democrats compromised with Republicans on policy that Republicans wrote themselves, and Republicans still filibustered and not a single one of them voted in favor of it.
If not a single Republican voted for it that means the bill is entirely the responsibility of the Democrats. It is a bill created and passed exclusively by Democrats. The Democrats passed a Republican plan without one Republican vote. The Democrats had a filibuster proof supermajority, and they decided to pass Mitt Romney's healthcare plan. But it's all the Republicans fault. Obama didn't even try for a public option like he had promised during the campaign.
This shouldn't be downvoted, because this was was what the ACA was meant to do. Exacerbate the cost problem (which it has done), restrict doctor-run hospitals (which it does), and lead to a problem where the "solution" is a single-payer system so that 11% of the economy (back then), could be "captured".
Many democrats thought (and said so) that there was a huge problem of all this money moving around without government control. The first attempt, which failed badly under Hillary Clinton's leadership during her time as First Lady, failed because it tried to do everything at once. It could therefore be seen as a massive power-grab.
The ACA on the other hand, delivered an incremental approach that included lots of things people wanted: ignoring pre-existing conditions, broadening coverage. But it also did things like say there could be no new doctor-run hospitals, and existing ones could not add beds. Doctor-run hospitals, at the time, were actually a success of the free market in health care. Their outcomes in terms of patient recovery and survival rates were higher than state run hospitals. They were a direct threat to the idea that the government should run health care.
The ACA also set the stage for the failure of private medical insurance. We're in limbo on that score, but the needle has moved toward that failure.
Hillary Clinton led the effort to reform health care during her husband's first term in office [1]. I am literally claiming that Hillary did things that she actually did. I'm sorry you weren't aware of history. That Hillary led this effort was actually noteworthy less for its failure and more for the fact that this was the first time a First Lady took a publicly visible hand in core policy-making.
I don't think Donald Trump is truly fit to be president, and I don't think the modern Republican party represents my views. Nor do I think Hillary Clinton was a suitable choice either. But disagreeing with the modern Democrat party is often met with derision, even if it is reasoned objection.
I actually remember the political discourse during President Clinton's first term, having been part of it back then. I remember the speeches Hillary Clinton gave as chair of the task force, including the notion that it was tragedy to allow so much of the economy to flow outside the purview of government. The notion of regulatory capture is not new [2].
It is my opinion that the purpose of the ACA was to lead to single-payer. It was the kind of boiled-frog strategy that Democrat party leaders had been using successfully for decades at the point ACA came a along.
The restrictions on doctor-owned hospitals are part of the law [3].
That the law would cause increased costs and dramatic deficits was predicted by the Congressional Budget Office (CBO) [4, 5].
The way I formed my opinion was taking all of this into account, including the model Hillary's task force put forth in the 90s as being what Democrats actually wanted. It is a reasonable opinion that if the ACA didn't deliver all of the things from the original plan, yet it opened up many unsolved problems, that the intent was to "continue reform" and make the "natural solution" a single-payer system.
I do wish we could have discussion without every comment on politics becoming a college paper.
TLDR; Previous research found that speciality physician owned hospitals (POHs) are treating less Medicare patients that are also healthier and focusing on more profitable patients while still receiving whatever benefits being a Medicare provider gets them. This lead to a blanket restrictions on all POHs in ACA. The above paper compared both specialty and non specialty POHs, which is what ACA actually targets, and found no significant differences between them and non POHs in terms of types of patients, cost of care and outcomes. This suggests that the policy has been too broad and is in need of a revision.
Nah, rural politicians will most-likely find it more politically advantageous to claim that the hospitals are closing because of 'illegals', welfare-bound decadent city folks, or some hare-brained conspiracy theory.
It will be too difficult to square their political convictions with economic realities. Providing healthcare in rural areas will always be economically difficult. There aren't enough consumers in rural areas to support modern hospital facilities. Admitting this isn't a problem markets will solve, and that government taxes and spending might be the answer, is something that will prove very difficult indeed.
That depends on the state they're in. If they're in a state that didn't expand Medicaid with the ACA, like the states in orange on this map[1], then no, they do not have access to government-run healthcare unless they are retired or disabled.
Rural areas supported Trump who promised not to reform Medicare/Medicaid and was perceived by voters as a more moderate alternative to the rest of the GOP primary field (who did have plans to cut entitlements).
I have been told that once you go after increasing health care costs (one goal of government run health care) hospitals will have to accept lower payments, which will not be good for rural hospitals specifically.
I am still in favor of doing that though. And ignoring that part, there are huge cost reductions to be had elsewhere, say, for example, an entire industry of medical billing and debt collection - though it'd sure be a shame to see all those nice folks out of work.
Not really, the same questions are common in many large European countries too. In France the “continuity of public service” is harder and harder to keep going, as taxpayers balk at the cost of subsidising telecoms, post, hospitals etc for sparsely populated areas
>Honestly I don't feel sorry for the USA any more. The rest of the world solved these problems 50 years ago.
What utter nonsense. The doctor shortage in the US has nothing on that in Canada. Not just the rural areas, either; in the biggest cities in the four Atlantic provinces, it is impossible to get a family doctor unless you are already a patient.[1]
Does everyone here grow everything they eat in a windowbox? Dig their own ore? Not everyone in a rural area is just sitting in their trailer living off Social Security, and many of those that are were productive citizens in their youth. All the stuff NIMBY urbanites care not to do gets done elsewhere, and those people have just as much right to healthcare as anyone.
No, they're not, because implicit in a right to healthcare is access to subsidy. There's literally no other way for it to be systemically provided. Literally every other option results in provisioning failure. The former requires and cannot not require the latter.
I have trouble understanding why social issues make nerds stop thinking systemically, but there you have it.
I'm not arguing against subsidy, everyone else is- most of the comments here are that rural citizens are 'getting what they deserve' because they don't vote correctly in national elections and burn too much carbon on the farm or whatever. I don't believe someone in SF has to subsidize a hospital in Alabama, but I do believe they have to subsidize a hospital in the Central Valley, either through taxation or through higher food prices.
The urban/rural divide is so great we really need to sets of laws. Aviation laws should be different in rural areas; reducing cost by sacrificing safety.
Make it cheaper to fly people to hospitals, in slightly less safe craft.
It seems to make sense, as populations fall -- there would be less need for healthcare. The more we subsidize rural living the more we distort their long term viability. Towns and cities shouldn't be deploying infrastructure that they can't support, it adds up over time and makes their situation even more untenable in the future.
A classic example of this small towns implementing city like water/sewer systems without the tax base to do the maintenance; the federal government provides a grant for the initial installation and the town slowly goes bankrupt trying to pay for it.
Why shouldn't they close? If it is not cost effective to support rural communities why do we prop them up? Lot of these places have 20% unemployment rates(areas listed in the article) yet there is a severe job shortage in urban areas. How about we fund moving them to areas that have better economic conditions/jobs?
The question is how to provide healthcare for rural communities, these hospitals are it. The citizens often can't afford the healthcare, can't afford to go to a doctor until it's an emergency, and now with many of these closures they can't even get that.
The easiest answer for many states is to expand Medicaid to cover a larger share of the low income population which can bring revenue to the hospitals with visits etc, but that seems to be very difficult politics for some individuals.
The example given in the article was in New Mexico which is a state that expanded medicaid. The labor participation in that county is 30% with 14% of working age people on disability. There aren't jobs in the county. Sante Fe on the other hand has 70% labor participation.
Moving people to areas that have higher economic advantages and jobs is a long term fix. On other solutions are just bandaids and doesn't solve the underlying economic issues.
>that seems to be very difficult politics for some individuals.
Well, the frustrating thing is that those who are suffering essentially advocated for these policies that make them suffer and then just blame Obama and praise lord Trump for "getting things back on track" while their hospitals close.
A disproportionate number of people living in rural communities are retired and would not benefit from moving to a place with more jobs. I do 100% relocating old people from the country to the city though, more for reasons of reducing their subsidy, saving the planet, and reducing the number of people over 80 driving cars.
I agree with what you say, and I think it is wrong for the parent comment to use such derogatory terms.
That being said, your comment also strikes me the wrong way, and I have received similar comments in real life where I had the same reaction, so I thought a bit about why I really feel that way.
More precisely:
1. the patronizing "you should know", as if your goal was to educate the person, as if not offending others would be a matter to be solved by education, etc.
2. pointing out in a lukewarm and passive-aggressive way that something is offensive. What should the other person do? He clearly knows already, and his goal is to offend. There is no right "not to be offended".
3. that it is not directed at you, but you are offended on other people's behalf.
All in all, while I am on your side, I would find it more heartfelt, if you said "you call me a hick? I'll kick your ass!" then this type of reaction.
I agree that the wording isn't ideal, but I interpreted the commenter you replied to as explaining why the original comment was getting downvoted without real responses. That is a common occurrence on HN when someone steps outside the bounds of civility in non-immediately obvious ways. It serves to give context to both the original commenter, and readers who may wonder why it was downvoted.
Also, why are you so sure that the responder is not offended on his or her own behalf? Hopefully you don't think that just because someone is commenting on HN that they would never be associated with "hicks". I find HN has people of more backgrounds than most folks realize, and as a person with a family who would certainly be categorized that way by many (southern, rural, working-class), I find your insinuation that it would be somehow more "authentic" to threaten violence as far more patronizing and stereotyping than the original comment even.
I was offended on my own behalf. I grew up in a rural, Southern area where I only ever heard 'hick' used by outsiders as a slur against locals. Certainly I have also seen rural people "reclaim" the term, but that doesn't give outsiders the right to use it.
I also find the insinuation that I should have threatened violence patronizing and prejudiced. The parent comment also included an example of how I "should" talk to sound more "authentic". Textbook prejudice.
The rural hospitals typically serve a population that otherwise would be several hours travel from the nearest "real" hospital, and typically have a catchment area of 1-2 hours travel. Many of these hospitals are located in towns with populations of a few thousand people. Even when heavily subsidized, the economics of maintaining these hospitals is very poor, especially as populations decline. Maintaining a fleet of doctors and facilities that are increasingly rarely used is expensive. And even with the current distribution of rural hospitals, it is not uncommon for people to live several hours from the nearest hospital.
It is essentially a math problem. To ensure that virtually everyone lives within N hours of a hospital, you would need to build an enormous number of hospitals that each service a population of a few thousand people unless N is quite large. This has an extremely high cost per capita, most of which is wasted because they are often very underutilized, which does nothing to help reduce healthcare costs. And you can't force these people to move to more urbanized areas of the country either. The other challenge is finding enough doctors willing to work in a tiny remote town. Few people want to live in these areas and so many doctors that do work in these hospitals are effectively required to commute from a city that is hours away -- it is not a desirable assignment for most.