Episode 5: Rural health in Maine & America vs. the world

September 24, 2019

Our third and final conversation with Drs. Ziller and Jonk of the Muskie School of Public Service explores the status of rural health in Maine and other U.S. communities, and how it compares to rural communities in other countries. We also discuss the different people and professions who are working to solve these challenges today and how we are educating public health and policy professionals for the future.

Episode Notes

Our third and final conversation with Drs. Ziller and Jonk explores the status of rural health in Maine and other U.S. communities, and how it compares to rural communities in other countries. We also discuss the different people and professions who are working to solve these challenges today and how we are educating public health and policy professionals for the future. 

​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 5

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.

This episode is our third and final conversation about rural health with Dr. Ziller and Jonk of the University of Southern Maine’s Muskie School of Public Service. We’ll be discussing rural health access to insurance and the professions and people working to solve challenges in rural communities.

So I’m going to assume that other countries have struggles the way our country has struggles around rural healthcare delivery. Are any countries building models that could teach us?

Yvonne:
There’s a set of reports that the Commonwealth Fund puts out almost every year where they rank how countries do relative to each other on a number of things, such as quality costs. And the US consistently falls at the very bottom of that heap. These other countries are, for the most part, single payer. Just because you say single payer, there’s still some variation in how that plays out in terms of how much reliance they have in the private sector versus the public sector and whether they have insurance through the private sector. A lot of these countries have supplemental policies that are offered through the private sector such as Canada, which is just north of us. Those countries tend to have universal coverage as opposed to the models that we have here in the United States. As a benchmark, we have studies that show that through Medicaid expansion, for example, we’ve reduced the rates of uninsurance. Not only is our population better off, but hospitals are less likely to close in states that have expanded Medicaid. So you have less uncompensated care because you have people who actually have coverage. So it does benefit our society to have people covered through insurance so that they can access the services when they need it and hopefully get in for more preventive care. That then prevents some of these longer term costs. The other benefit that these countries have is that if you have some market power through our negotiating power, you’re able to keep costs down. When it is the government, the federal government, who’s actually paying for health care, those countries are not facing the same level of cost. In the US we pay at least four times more for our prescription drugs and we pay a lot more for our healthcare in general than other countries. We don’t get the bang for the buck. We don’t look as good in terms of mortality rates, prevalence of disease, all these preventable issues that Erika was pointing out. We don’t fare as well as these other countries. So we have a long ways to go with trying to figure out how do we get from A to B  in an effective way, in terms of reforming our healthcare system so that we don’t pale in comparison to the other countries.

Carrie:
So the solutions are out there – we’re just not pursuing them the way we should be? Is that an accurate assessment?

Erika:
I think so. I was speaking to a woman from Brazil a couple of weeks ago and she was sharing with me their OB (obstetrics) system – their maternity hospitals. I don’t know their statistics and how well they’re doing, but it got me thinking because the way that they deliver maternity service is that their federal government owns and runs and trains all the personnel in these birthing centers. So the women in Brazil don’t give birth in hospitals the way that we think of them. They give birth in maternity hospitals. And those are all governmentally owned and deployed into every community, even in the most remote rural places. There will be one hub maternity hospital that will provide services to all the women in the villages around it that are pregnant and delivering. And this really made me think of something that Mitchell Stein, who is one of my favorite Maine health policy analysts is always saying, which is that the only way we’re going to solve the rural maternity crisis is if we treat maternity care as a public good. If we say wherever you live, you have a right to be able to deliver your baby there safely and so we as a society are going to figure out how to provide that. I think that really is the critical message here. If we care about rural communities and want to see them thrive and flourish, then we need to invest collectively as a country.

Carrie:
So you both teach at the Muskie School of Public Service, and you are therefore bringing up students to carry on your work and to work with you. Can you talk a little bit about the kinds of degrees that they’re getting to do this kind of work and maybe some of the field experiences that they’ve had?

Erika:
Sure. Within the Muskie School of Public Service, we have a graduate degree in policy, planning, and management; that’s more the public policy and community planning development, working with nonprofits. And we have a master’s degree in public health as well. That’s where Yvonne and I both sit within our MPH program. We are launching an undergraduate [degree] in public health as well. We are preparing students to basically meet the challenges of both rural and urban places in our state and beyond in terms of keeping populations healthy. Public health differs from the medical care sector in a variety of ways. One of them is that we are focused on populations. We think in terms of communities, groups of people, population, cities, the state of Maine versus delivering those one-on-one clinical services. Public health is also really focused on prevention. We teach our students to think systematically and to look at problems upstream to try and solve them before they become a crisis. That includes training students in things like health policy and advocacy for public health issues. And then the third thing that’s kind of different about public health is that it has at its core a mission of social justice. Part of what we learn how to do as public health professionals is to examine the causes and consequences of ill health and to look across populations and to identify where there are hotspots, where certain groups are experiencing much poorer health or health outcomes than other populations. We try and target resources there so that we can help equalize. So whether it’s learning about cultural competency and meeting different diverse populations and cultures where they are to help encourage their health or working at a policy level and noting that people of low income are living in much poorer housing, have poor access to water quality, those sorts of things. That’s really part of the mission of public health is to look at the sources of inequality in health and try to address them.

Carrie:
So we’ve called this podcast The Greater Good. Our goal is sharing the work that’s being done on behalf of our communities, local, national and global. To share the stories of people that are working diligently to protect and enrich their communities in ways that we don’t generally think of as serving the greater good. So it’s very clear that [for] you both, that is a big part of your mission. Is there anything that you wish people understood better about the work that you do?

Yvonne:
Well, I’d have to say that, why did we choose to work in an academic setting? For me, you know, I’ve worked in the private sector, I’ve worked also in the public sector, but my heart of hearts is really in the academic setting. And the reason is because we’re here for the greater good. We are doing our work to try to make a difference in this world. And we provide an unbiased perspective in terms of the work that we do. So we’re not in it to try to keep an organization out of the red, because that’s basically what you’re doing when you’re working for a private corporation. And not to say that that’s all bad, but in my heart of hearts, I would like to know that the work that we do does make a difference. We look at issues such as Medicaid expansion and we say, alright, so what is the impact of the expansion on uninsurance rates or on hospital closures. We want to ensure that the work that we do promotes a stronger workforce in rural areas. And so how do we get there? So much of the work that we do is driven by this desire, to ensure that people who live in rural areas have a safe, healthy, and productive life.

Carrie:

That everybody has access to their basic needs being met and [address the] equity issue.

Erika:

I would say that the one thing I would like people to understand about my work is that it’s wildly exciting and fun. You’re laughing! When I tell people that I do applied health policy research, most people, their eyes spin and they don’t know what I’m saying. And then I try to explain, well, I look at data and I try to figure out how policies might affect people. And you know what, most of them are still way lost, trying to understand what I’m doing. But I have been doing this work for more than two decades now and I’m never bored or tired. There are always new questions to answer, new problems to solve and to try and figure out what the root causes of a health problem are or how we can use policy or other mechanisms to address those. I think for anybody out there that is considering a research career, if those are things that sound exciting to you, then we should talk.

Carrie:

Do either of you have a vision for the future, specifically for Maine since that’s where you’re doing most of your work right now? Do you have a vision for how we could navigate this going forward to [where] the whole community is thriving – rural, urban, and everything in between.

Erika:
I feel like we are laying some of the groundwork and that there’s a lot of interest at the state government level as well as within local communities to try and be creative and figure out how we can do some of these things. You know, delivering health services or growing our economy in more unique and entrepreneurial ways. [Maine] Governor [Janet] Mills has created a rural health task force [Maine Rural Health Transformation Initiative] under the leadership of [Maine’s Department of Health and Human Services] Commissioner Jeanne Lambrew to try and figure out how we can meet the health needs of rural populations and think about doing things differently. Maybe the old models that we’ve used don’t work anymore, but there are new and innovative things that we could be doing on the telehealth front or other things. So I have a lot of optimism for the future. There’s a lot of smart and dedicated people all throughout the state who are thinking about these issues and working hard.

Yvonne:
Yes. I’m very excited to have come here from the Midwest where we didn’t have the greatest data sets available to us to study issues such as radon or even elder abuse. Just recently Governor Mills signed a bill trying to encourage financial institutions, for example, to report on issues of elder abuse. Maine has led the way – we passed the Senior Safe Act back in 2014 and that led to just recently, President Trump signing a bill called the Senior Safe Act that was very much patterned after Maine being the first state to implement that type of bill. So that’s really been moving the field. We have a long ways to go with elder abuse. We also have a lot of work to do with some of the environmental issues. I think that the climate here is prime for making some serious headway and it’s very encouraging. You want to be able to work in an environment that you feel is conducive to hearing the message that we have to share as researchers and it’s very exciting when that opportunity is right in front of us.

Carrie:
Well, I want to thank you both for this really great and in depth conversation about such an important issue for the state of Maine and for the country as a whole. So thank you both for joining us today.

Erika and Yvonne:

Thank you so much for having us.

Carrie:

Thank you for tuning in to The Greater Good. I hope you’ll join me next week as we speak with J. Michael Weber, Dean of the University of Maine Graduate School of Business as we talk about the future of the MBA degree and its potential as an economic driver in urban and rural areas alike.

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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.