Sunday, December 11, 2016

The urban-rural divide and the health of people in both settings

I recently wrote about the impact of the massive vote for Donald Trump by “white working class” voters and how it will have repercussions for their health, as well as that of others, if the policies advocated by the Republican majority (as exemplified by Secretary of HHS nominee Rep. Tom Price) are implemented. And there is little doubt that they will be implemented, but slowly, so people are less aware of what is being done to them. As Medicare is increasingly privatized, as vouchers that cannot cover the cost of health insurance for those with chronic disease are implemented, “Medicare for all” will increasingly seem a poor idea. And people’s health will suffer. I wrote about the cynicism of the AMA and the AAMC in endorsing Mr. Price; they are doing more than “kissing the ring”, as a colleague suggested. They are lauding the fact that one of “theirs”, a doctor, will be in this role, not an insurance executive. But if anyone had a doubt about whether having an “MD” at the end of your name guarantees a concern for people’s health, Mr. Price is the poster child for “not so”.

The other big divide demonstrated by the election is urban-rural, and this one is also real. A majority of the people in the US are jammed into small geographic areas, urban islands. Maps that portray “red states” and “blue states” seem to be an ocean of red because of physical size; think New Jersey  (population about 9 million, with 8700 square miles, more than 1000 people/sq mi) vs. Montana (just over 1 million, in 147,000 square miles, less than 7 people/sq mi). The contrast is even greater if we look at counties; most of the population of even “blue” states is concentrated in a few urban counties, although, conversely, there are many “blue” seas and islands in “red” states, cities like Houston, Dallas, San Antonio, St. Louis, Kansas City, etc. The media has recently been awash in articles about the way that our Electoral College system advantages rural areas; because of the 2-Senate-seat-per-state rule, a Wyoming voter has 5 times the clout of a Californian. See, for example, Steven Johnson’s “Why blue states are the real Tea Party” in the NY Times, December 4, 2016. He points out that at the time of the writing of the Constitution, the urban northern states were in debt while the southern states were solvent – largely through the magic of the free labor of slavery. Now cities are the engines of our economy; they are where ambitious and educated young people go, leaving rural areas increasing older and poorer (as well as whiter).

But we need to remember that there is tremendous need in rural America, as there is in the inner city. Rural areas are poor, and underserved both medically and in terms of social services (as well as, of course, in the other things you’d expect – access to groceries, for example). Those rural areas that are located in “red” states are even worse off, because those states spend far less on health care and social services in the first place so that their more isolated communities are in the worst shape. And yet, as Johnson points out, they get far more federal aid for tax dollar contributed: New Jersey receives $0.61 on the dollar while Wyoming gets $1.11. The Trump campaign, and the Republican Party, strongly appealed to voters in these areas, but Trump and his proposed cabinet all live and work in cities; they are not rural billionaires. Tom Price is a suburban doctor; he does not deliver care to the rural poor, as do Rural Health Clinics.

So there is tremendous need in rural communities, but their political clout, which is both unfair and anti-democratic, is not being used to actually help the people there, but rather to limit positive policies in urban areas. The North Carolina “bathroom law”, to force people to use the restrooms of the gender of their birth, was a reaction to the city of Charlotte (a blue “lake”) making it legal for people to use the restroom of their current gender. The most well-publicized efforts currently are threats by Trump and his people to forbid cities from declaring themselves “sanctuaries” for immigrants (see NY Times debate on whether sanctuary cities have a right to defy Trump, December 1, 2016; “yes” by Cesar Vargas and “no” by Jan C. Ting). These cities are trying to exert their local control over such important issues, while states (generally supported by rural populations that do not actually have to deal with these problems) try to restrict their ability to do so. These hypocrites are against government regulation when it comes to their rights to carry guns or graze their cattle on public land (things they want to do), but are all for it when it comes to things important to others, like deciding who can marry, where one can go to the bathroom, whether people can get an abortion or even contraception. “Those who deny freedom to others,” said Abraham Lincoln, “deserve it not for themselves”, which I first learned as a young stamp collector; it appears at the 4 cent American Credo stamp.

If the selective interpretation of what “freedom” means is not enough, if rampant discrimination and bigotry is not enough, there are other, health related, concerns that go with this divide. For example, federal funds for HIV care go to the area where patients are from. However, a large percentage of gay HIV patients leave those areas for the cities where they are more accepted. Thus the cost of providing that care is borne by the cities, while the money flows to the rural areas where services are not available – and often the victims themselves are not welcome.

A recent article published in Science Direct by Jason Beckfield and Clare Bambra, “Shorter lives in stingier states: Social policy shortcomings help explain the US mortality disadvantage” demonstrates that the lack of social services in the US leads to shorter lives than in other Organization for Economic Cooperation and Development (OECD) countries, i.e., the rich countries. The “highlights” of their study are that:
• The US combines a laggard welfare state with shorter life expectancy compared to the OECD.
• Fixed-effects models show associations between life expectancy and social policy generosity.
• US life expectancy would be 3.77 years longer if the US welfare state were just average
In this article “state” refers to nation-states, comparing the US to other OECD countries, but similar differences can be seen among the US states, again depending upon their social services, including public health and access to health care. This is supported by a new study from the Commonwealth Fund which finds that “adults in the U.S. are more likely than those in the 10 other countries to go without needed health care because of costs”. A third of U.S. adults “went without recommended care, did not see a doctor when sick, or failed to fill a prescription because of costs”, as compared to as few as 7-8% in other countries. They were also the “most likely to report material hardship. Fifteen percent said they worried about having enough money for nutritious food and 16 percent struggled to afford their rent or mortgage.”

This is not good for our country, not good for our health, and not good for our lives. And as far as we can see, the new administration’s plans are not to fix it but to make it worse.

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