Episode 4: Growing up rural

September 17, 2019

Part II of our conversation with Drs. Ziller and Jonk focuses on growing up in rural areas and how this impacts long-term physical and mental health. We discuss the connections between healthcare, broadband access, and economic opportunities, and the importance of investment in rural economies.

Episode Notes

Part II of our conversation with Drs. Ziller and Jonk focuses on growing up in rural areas and how this impacts long-term physical and mental health. We discuss the connections between healthcare, broadband access, and economic opportunities, and the importance of investment in rural economies.

Our guests are Drs. Erika Ziller and Yvonne Jonk. Dr. Ziller is the Chair and Assistant Professor of Public Health at the University of Southern Maine’s Muskie School of Public Service where she teaches courses on health policy and the U.S healthcare system. She is also the Director of the Maine Rural Health Research Center, and has directed numerous studies on rural health access, coverage and health reform. Dr. Ziller has served on the editorial board of the Journal of Rural Health, and has won national awards for her contributions to this field. Dr. Jonk is an Associate Research Professor of Public Health at the University of Southern Maine’s Muskie School of Public Service, and is the Deputy Director of the Maine Rural Health Research Center. She specializes in rural health, access to health care and health insurance coverage. She is currently researching the differences in newly admitted rural and urban nursing home residents, elder abuse, and the use of health services by the aged.

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Produced by the University of Maine Graduate and Professional Center, with help from WMPG

Episode Guests

Dr. Erika Ziller is the Chair, and Assistant Professor of Public Health at the University of Southern Maine’s Muskie School of Public Service where she teaches courses on health policy and the U.S. healthcare system. She is also the Director of the Maine Rural Health Research Center, and has directed numerous studies on rural health access, coverage and health reform. Dr. Ziller has served on the editorial board of the Journal of Rural Health, and has won national awards for her contributions to this field.

Dr. Yvonne Jonk is an Associate Research Professor of Public Health at the University of Southern Maine’s Muskie School of Public Service, and is the Deputy Director of the Maine Rural Health Research Center. She specializes in rural health, access to health care and health insurance coverage. She is currently researching the differences in newly admitted rural and urban nursing home residents, elder abuse, and the use of health services by the aged.

Disclaimer

The information provided in this podcast by the University of Maine System, acting through the University of Maine Graduate and Professional Center, (the University) is for general educational and informational purposes only. The views and opinions expressed in this podcast are those of the author(s) and speaker(s) and do not represent the official policy or position of the University. Assumptions made in the analysis are not reflective of the position of any entity other than the author(s) and speaker(s) – and, since the author(s), speaker(s) and listeners are critically-thinking human beings, these views are always subject to change, revision, and rethinking at any time. All information in the podcast is provided in good faith, however the University makes no representations or warranties of any kind, express or implied, regarding the accuracy, adequacy, validity, reliability, availability or completeness of any information in the podcast and will not be liable for any errors, omissions, or delays in the information in this podcast or any losses, injuries, or damages arising from its broadcast or use. It is the listener’s responsibility to verify their own facts. Your use of the podcast and your reliance on any information in the podcast is solely at your own risk. The podcast does not contain nor is it intended to contain any legal advice. Any legal information provided is only for general informational and educational purposes, and is not a substitute for legal advice. Accordingly, before taking any actions based upon such information, the University encourages you to consult with an appropriate legal professional or licensed attorney.

Transcript

​This transcript has been lightly edited for clarity.

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The Greater Good: Episode 4

Carrie:
Welcome to the Greater Good: a podcast devoted to exploring complex and emerging issues in law, business and policy. I’m your host Carrie Wilshusen, associate dean for admissions at the University of Maine School of Law. 

Today’s episode is Part II of our conversation with Dr Ziller and Yvonne Jonk of the Maine Rural Health Research Center at the Muskie School of Public Service. We’ll explore the unique aspects of growing up rural and how it impacts physical and mental wellness. 

Erika, what does a lack of access to insurance and care look like on the ground? 

Erika:
It’s definitely a huge concern. Probably about 10 years ago I was reading the New York Times and was struck by this story that I saw of a community in West Virginia that was being visited by Remote Area Medical, which is a nonprofit organization that provides basically pop-up medical care. They’ll come into a community like a SWAT team and offer services for a day or two days and then leave again. This particular clinic was being held in the county fairgrounds and they had people being seen and treated, receiving for many of them their very first medical care in years in a barn. So they were in, you know, these remote rural places where there weren’t enough providers. They were low income people. There were dental chairs set up in these fields and more than a thousand people had come in the wee hours of the morning to get in line and wait for care. And it really had such a strong impact on me to see these visuals and to hear people’s stories and to understand that for some of them they’d been worried about this lump in their breast or their irregular heartbeat for years and had not been able to see people or have those [issues] attended to. And ironically enough, I saw the exact same story in the Washington Post last month of the same organization, the same community, the same services being provided in the same level of intense need. So that’s one kind of abstract experience that I’ve seen. But I’ve also done interviews with people in Maine, in rural parts of the state, who are uninsured and heard from them about their experiences. I remember very distinctly talking to a man who had gotten injured at work, had gotten a pretty serious gash in his arm, and he stitched it up himself without anesthetic. One of my colleagues was also conducting focus groups in the Greenville area of Maine and spoke to a man who had extracted his own tooth because of not being able to access dental care. So I mean, think about when you’re worried that something might be wrong with you, with your loved one, your child, and you just have either no place to go or you don’t have the resources to get there. It can be very traumatic. 

Carrie:

Let’s talk a little bit about the impact of this on children growing up in these communities. 

Erika:

I’ll start with the pros of growing up rural. I think Yvonne talked a lot about some of her experiences of being part of a tight knit community [in North Dakota]. Maybe some of this was growing up in the seventies and eighties, but I also distinctly remember a tremendous amount of freedom. I think that there are articles you can read in upscale parenting magazines now about the notion of free range children and that was what rural childhood was like. We left in the morning and we didn’t come home til, you know, my mother actually had a cowbell dinner bell that she would ring when it was time for me to come home and I was off with the neighbors or exploring bushy areas in the backyard. I was walking the railroad tracks and just generally independent and exploring. I think that that had a tremendously positive impact on my self-reliance, my resiliency, as a child. So there’s a tremendous amount of pluses. That said, there are also struggles, poverty being one of them. I grew up in a single parent family and we struggled a lot of the time. I know that Yvonne’s family also had their own experiences of economic struggle and those things can have a pretty damaging effect your whole life long. The idea that you are hungry as a child can carry forward and leave some scars that you have to deal with and be mindful of as you grow. So I think there’s both sides of the coin. There are some really wonderful, amazing parts of growing up rural and when there aren’t resources, some challenges. 

Yvonne:

I want to weigh in here on what Erika was talking about with the free range children, and I’d have to agree. Yes. I grew up along a riverbank and we were off, you know, swimming and beaver dams and building forts out in the forests and playing games and we were very creative. We got our hands dirty. We tore things down, built things up. I feel sorry for the kids [growing up without this]. When I moved to an urban area, my kids could not play that way. I would watch and time them, you know, when they took their bikes out – how long were they taking to come around the block and were they coming back on time? That’s as much free range as I gave them. And now you hear about startups around nature-based therapy and there’s people who specialize in and who are certified in those types of therapies. You hear about people who will take vacations and they’ll walk in the woods just to decompress. We sort of took it for granted, you know? Mom would make her fresh baked bread and we would all come in at three o’clock. We thought that it was a treat to buy store baked bread but now look at all of the movements to decrease the use of food that’s prepared with preservatives. And so it really was a healthy way to grow up. On the flip side of that though, we do have real problems in rural areas with obesity so that free range concept has become fewer and far between. I believe as our society becomes so busy, we’re so focused on other things and I don’t know that kids have as much free time as they used to. 

Carrie:

I wanted to talk about a little bit about access to mental health care because that’s such an acute problem for some people in small communities, right? 

Erika:

Absolutely. As I said earlier, access to any sort of health care provider is a challenge. So, about 20% of the population nationally give or take is rural. But only 8% of physicians ultimately decide to practice in a rural setting. That creates huge shortfalls of primary care providers but most significantly for specialty care providers. I think the rate for urban places is about nine times the number of specialty care providers per capita that there are available in rural places and among those specialty providers are mental health providers. So 60% of rural residents live in a mental health shortage area where there just are not enough mental health providers to meet the needs of that population. And that leads to all sorts of different challenges. I think we’ve seen it very significantly here in rural Maine as the opiate epidemic has unfurled. Nationwide, only half of rural people live in a community where there is access to medication assisted treatment for opiates. We’ve been working hard on improving that access in Maine, but it’s still much more challenging in rural places. And the outcomes of all of this are that rural people are more likely to report poor mental health. Like they’re just not feeling emotionally well and vibrant on a day to day basis. And the worst outcomes include higher rates of suicide in rural communities. I think the rate of suicide among rural populations is about 50% higher than that in urban. So it’s a pretty substantial, significant difference. 

Carrie:

Would you consider this a healthcare crisis? 

Erika:

Absolutely. It’s hard to know at what point we reach the level of crisis. And in some ways these issues that I’ve been talking about, not only have I been talking about them my whole 20 plus year career, but they’re things that we’ve been talking about as rural health researchers for a hundred years. I was doing some work a couple months ago where I was looking at the history of rural health research and found studies as early as the late 1800s, 1890s, and turn of the century, where they were discussing issues about disease transmission and hookworms and typhus and diphtheria and all of these things being much more prevalent and hard to manage in rural places. There were articles about rural and infant mortality and how much higher they were than in urban communities. And those things are still happening now. Some of the articles in the 1930s were talking about the distribution of rural providers and how there just weren’t enough in rural places compared to urban places. And these are the same themes that we’re seeing. So in some ways it’s hard to know if we’ve been at a low grade crisis all of this time or if something is more significant. But I think if you look at some of these metrics, the life expectancy rate, and that gap that is growing, if you look at things like maternal mortality, which is increasing and particularly in rural places, then we’re certainly seeing that things are getting worse in a lot of metrics. 

Yvonne:
So if I could weigh in there. All areas really do face challenges in terms of workforce. Hospital closures, nursing home closures. We have issues with EMS or ambulance services as well, largely driven by volunteers. And that volunteer base has been declining, which means that you have gaps in coverage. If you’re going to call 911, be careful where you are, you may not have anyone in that area that can respond to a 911 call. That’s very challenging and it’s not getting better. It’s getting worse. EMS or ambulance services are not well reimbursed unless that patient is brought in and hospitalized. So if you call 911 on that person, and they are able to stabilize that person, that ambulance service will not be reimbursed, at least not by the Medicaid policies. So then you we talked about the lack of insurance and under insurance, the policies that do not provide adequate coverage. That is also much more of an issue in rural just because of the blue collar jobs that you have. Employers who have deep top pockets, they have a handful of employees and their margins, as Erica was talking about, are very slim. You also have a lack of employment opportunities, unless you have that entrepreneurial spirit or are farming. So what will you do when you move to a rural area and that actually prevents, that’s contributing to the workforce issues. Maybe you have a spouse who has an opportunity to farm or some place in the healthcare arena that they’re working but their spouse does not have an opportunity and they care about the types of education that their children are going to be able to have. Is this public school a good quality school? And so things just snowball in terms of the choices. 

Erika:

There are certainly communities that are on the decline and their ways of life are dying. There are also rural communities all across the country that are experiencing booms and are thriving. There was a national survey that was done last year that found that more people in urban areas want to live in rural than the reverse, which really suggests to me that there is something about that way of life that is attractive to a lot of people. And I certainly really enjoy and appreciate having all of Maine’s natural resources at my back, even though I currently live in Portland. And so I think that in order to achieve that growth, we need to be making smart investments in rural places and seeing their value and what they have to offer. We need investments on the economic side but also on the healthcare side so that the two will compliment and grow together. 

Carrie:
Some people have made the decision that the rural communities are critical to invest in and that that can bring a great future for a state or a country. So what are some of the solutions that other states or countries are doing to combat this problem? 

Yvonne:

There are some foundations who have done extensive work, at least in the Midwest, to promote telehealth resources, for example. We’ve been talking about the lack of access to specialty providers, including behavioral health. And that’s actually the number one type of service that’s used. 

Carrie:

So tell us about that. Tell us about telehealth. What does that look like? 

Yvonne:

In the Midwest, we have this hub and spoke telehealth model. In South Dakota where, the hub for Avera Health is, they have a footprint throughout the Midwest and they are providing specialty services through Sioux Falls, South Dakota. They’re able to provide services [to areas] as remote as the western side of North Dakota. A patient comes into the clinic and if they have a need for a specialty type service, they are then dialing up and connecting with someone located with a provider in a very distant place, such as Sioux Falls and they are able to access and get the type of services that they need.  Providers are also connecting through the emergency department. So if their provider who is out in rural North Dakota isn’t not sure what best to do, they’re calling up another emergency physician located in Sioux Falls, for example, that has the expertise and can walk them through what they should be doing for the patient. So that has really reduced this social isolation, at least in the provider level, not only because they’re able to connect with colleagues, but also because they’re continuing education opportunities for them to connect with a larger provider community. Telehealth is very much dependent on broadband capability though. So there has been a lot of attention paid to “are the broadband services adequate in rural areas”? 

Carrie:

Are people thinking about this in Maine right now? 

Yvonne:

Yes, very much so. There are areas in Maine that do not have adequate broadband services. Some of our students have actually provided maps of when they were working on a telehealth project with us within Maine. They’ve showed us areas in Maine that do not have adequate broadband services. That will deter not only the healthcare community from locating in those areas because they don’t have a way to really communicate with the outside world, as the rest of us do, but it also deters people who, for example, might be wanting to move to a rural area. If you don’t have internet and you can’t order things off of Amazon or Apple that way, you might think twice [about moving]. 

Carrie:

I just want to clarify: is Maine an outlier in the level of crisis that we have in rural health? For health care access, where are we on the scale of having a big crisis?

Erika:

I would say that we’re pretty much par for the course. There are many states that are experiencing a worse crisis than we are. We’ve seen some of our markers deteriorating. We’ve a little bit of hospital financial crises underway. I know that a study by the University of North Carolina looked at all the critical access hospitals in the country and found that close to half of them in Maine have negative margins or pretty close. Some could be at risk of closure. In Calais, we saw the loss of maternity services. Their hospital stopped delivering babies. That’s a huge impact. I mean, think about it. Think about living in rural Maine, in the winter expecting your first baby. And how nervous you’re going to be wherever you are. You could live next door to the best hospital in the world and you would still be apprehensive about that experience. So if you take that and you multiply it by bad roads, Maine winters, and long distance driving, you know, 45 minutes to actually deliver your baby in a hospital. Those things they, you know, have a huge impact on the health and emotional wellbeing of Maine’s women. And it also makes it really hard to recruit young people from Portland or out of state and have them come and build their lives there, if there’s no place to deliver their babies. That’s a huge challenge. This actually reminded me of one of the very first studies I did with the Maine Rural Health Research Center about how a lot of hospitals in rural places were closing because of financial distress. There was a comparable crisis in the 1980s, in part due to some Medicare policy decisions. I participated in these qualitative interviews across the country. I went to Clay County, Kentucky and interviewed people in the community when their hospital had closed about what the economic impact had been. One of the people that I spoke to, just was so poignant and sticks with me, was this older woman and she said, yeah, I was born in that hospital and my kids were born in that hospital, but I don’t know where my grandkids are gonna get born. And you know that when you come from a place that is close and has traditions and your family and kids community, it’s meaningful. Those types of things really matter. 

Carrie:

Thank you for tuning in to The Greater Good. I hope you’ll join me next week for our final conversation with Drs Ziller and Jonk as we discuss solutions to access to insurance in rural areas and other critical rural health issues. 

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The information provided in this podcast by the University of Maine System acting through the University of Maine Graduate and Professional Center is for general educational and informational purposes only. The views and opinions expressed in this podcast are those of the authors and speakers and do not represent the official policy or position of the university.