Frontier Studio 2016: Bloustein school of Planning and...

FRONTIER STUDIO 2016:

BLOUSTEIN SCHOOL OF

PLANNING AND PUBLIC

POLICY

Prepared for the National Center for Frontier

Communities

Authors:

Frank Popper

Channing Bickford

Cameron Black

Dan Burton

Loan Dao

Sarah DeGiorgis

Steven Lubrano

Whitney Miller

Marlana Moore

Editors:

Dan Burton

Maryann Gulotta

TABLE OF CONTENTS

Drones, Drones on the Range: The Frontier’s Unmanned Aircraft System 1

DRONES, DRONES ON THE RANGE: THE

FRONTIER’S UNMANNED AIRCRAFT

SYSTEM CAMERON BLACK


TABLE OF CONTENTS

Introduction .................................................................................................................................................................. 3

Image 1: Various Drone Applications ................................................................................................................. 3

Image 2: Price Chart on Drones .......................................................................................................................... 4

Goals of project ........................................................................................................................................................ 5

Literature Review ......................................................................................................................................................... 5

Agricultural applications .......................................................................................................................................... 5

Image 3: eBee Information ................................................................................................................................. 6

Image 4: How NDVI is Measured ........................................................................................................................ 6

Public Health applications ....................................................................................................................................... 7

Wildfire applications ................................................................................................................................................ 7

Image 5: NOAA Drones Unit Logo ....................................................................................................................... 8

Image 6: Nasa Predator b-Based Ikhana Drone ................................................................................................ 8

Limitations ................................................................................................................................................................... 9

Conclusion .................................................................................................................................................................... 9

References ................................................................................................................................................................. 11


INTRODUCTION

An unmanned aircraft system (UAS) refers to the different components (support equipment, control station,

data links, etc.) required for the operation of a drone. An unmanned aircraft (UA) refers only to the aerial part of

the system, which is operated by a pilot using a remote ground control system. The Federal Aviation

Association (FAA) issues an airworthiness certificate for any UAS on the market. After a consumer purchases a

drone they must register the aircraft with the FAA if it weighs between 0.55 and 55 pounds. Subsequently, an

FAA issued pilot certificate is required to operate a civil UAS in the National Airspace System. Any aircraft

operating in the national airspace is required by law to be a certificated and registered aircraft, operators must

obtain a piloting license and receive operational consent. The FAA evaluates petitions on a case-by-case basis

for exemption under Section 333 to acquire the ability to use a drone commercially. Once a drone is registered

and the operator has a piloting certificate there are restrictions on where a drone can be flown. For instance, a

drone cannot be within 5 nautical miles of an airport with an operational control tower, 3 nautical miles of an

airport with a published instrument flight procedure, or 2 nautical miles from a heliport.1

Regulations have increased on drones recently because of their growing popularity (See Image 1). Drones have

increased in popularity because they are being used for natural disaster response, climate change reduction,

space research, extreme weather research, wildlife conservation, precision agriculture, reducing water

contamination, pest control, search and rescue, and law enforcement.2

IMAGE 1: VARIOUS DRONE APPLICATIONS

Image Source: NASA

When compared with other aerial photography equipment, it is easy to see why drones are so popular. For

example, before drones, people relied on the launch of a Landsat 8 imaging satellite for aerial photographs,

which cost approximately $855 million. A cheaper option would be a Cessna 172 airplane, but those cost

approximately $300,000. On the other hand, a professional automated mapping drone like senseFly’s eBee

RTK costs about $25,000, and cheaper still is DJI’s Phantom 3 quasi professional aerial imaging drone, which

1 (Federal Aviation Administration, 2016) 2 (Collings, 2015)

http://goo.gl/UpYkCP


costs around $1,000 (See Image 2).3 The falling prices, therefore, are one of the reasons drones have

increased in popularity.

IMAGE 2: PRICE CHART ON DRONES

Image Source: myfirstdrone.com

Drones also have the advantage of revisiting a site daily, whereas satellites in orbit can only revisit an area

every three days and airplanes must be manned by a pilot.4 Furthermore, the resolutions provided by satellites

are only good enough for large scale projects in agriculture or large scale land-use planning. However, for fine-

tuned surveying work or 3D mapping, the image resolution of satellites is low, and this is where drones have

found their niche.

Drones give accurate counts for corn fields and create high precision 3D models of infrastructure. This was

previously only possible with helicopters, but helicopters cost approximately $10,000 to rent, whereas a drone

can perform the same task for $1,000. Moreover, a UAS can be ready to fly much faster than helicopters or

airplanes, which makes it possible to react to sudden events. For example, for a farmer who wants to analyze

damage inflicted on their crops after a tornado can do so cheaply and quickly: when gathering information

quickly is a priority, drones surpass airplanes, helicopters, and satellites. Nevertheless, there are still

3 (Drone Apps., 2015) 4 (ibid.)

http://goo.gl/SBHH15


applications for which satellites and airplanes are more useful than drones because battery constraints

prevent drones from covering large areas. In the meantime a drone is the most economical option for smaller

projects like acquiring 5 hectares of agricultural imagery.5

GOALS OF PROJECT

The objective of this report is to evaluate the applications of drones in frontier communities. Based on our

research, we theorize that drones will be helpful for people living in frontier communities; however, high

pricing, technological complexities, and reliance on broadband services may make drones impractical. We

have included information on pricing and regulations to give realistic expectations of drone applicability and

have included a limitations section to analyze obstructions to drone uses on the frontier. Lastly, we provide

final thoughts in the conclusion section to further summarize the research.

LITERATURE REVIEW

AGRICULTURAL APPLICATIONS

Drones can be useful for farmers on the frontier to scout crops, monitor crop health, survey soil health before

planting, analyze nitrogen, analyze plant stress, determine drought conditions, measure leaf area index,

determine plowing depth, study phenology, classify plants, and more.6 7 Livestock operations on the frontier

can benefit from drones as well because they can be used to monitor the location, and well-being of livestock

at a lower cost. Agricultural drones on the market range in price from $1,500 to $30,000. Fixed wing drones

such as the AgEagle RAPID, PrecisionHawk Lancaste, and SenseFly eBee are preferred by farmers because

they can view more area at a faster speed and spend more time in the air than a multi-rotor platforms drones

like the DJI Phantom 3. In approximately 30 minutes a fixed wing drone can map over 100 acres giving a

wealth of information about a crop. Any infestation of pests or disease can be spotted easily and rectified

without having to scout the field on foot, which could take hours or days.8 Farmers living in frontier

communities would benefit greatly from the analyses that drones can provide on their crops.

The faster analysis that fixed wing drones can achieve makes them more expensive. They range in price from

$5,000 to $30,000, and can cost even more after they are equipped with sensors.9 One of the most

commonly used fixed-wing drones for agricultural purposes is called the Sensefly eBee, which costs $25,000.

The eBee can fly for up to 45 minutes at a time, does not require significant training or technical knowledge,

and is equipped with a 16-megapixel camera to record aerial images and a GPS tracker (See Image 3).

Because the eBee offers better control over spatial resolution of images, a vantage point unimpeded by clouds,

instant viewing of produced images, and the ability to rapidly re-map areas, this type of drone is generally more

useful than traditional methods of agricultural aerial imaging.10

5 (Drone Apps., 2015) 6 (Nixon, 2016) 7 (Tripicchio et al., 2015) 8 (Roberson, 2013) 9 (Nixon, 2016) 10 (Fornace et al., 2014)


IMAGE 3: EBEE INFORMATION

Image Source: lasergps.com

Agricultural drones can help frontier communities through their advanced imaging capabilities to assess the

health of crops. UASs equipped with multispectral imaging cameras can identify the normalized difference

vegetation index (NDVI) which can determine plant health by analyzing the plant’s reflection of different levels

of visible green and near-infrared light (NIR).11 This is accomplished through looking at the changes over a

period of time in the visible light and NIR reflected by crops to identify potential health issues. A plant that is

reflecting higher levels of green light and lower levels of red and blue light is healthy, whereas low levels of

reflected green light and higher levels of blue and red indicate a depletion in chlorophyll and poor health (See

image 4).

IMAGE 4: HOW NDVI IS MEASURED

Image Source: bestdroneforthejob.com

11 (Nixon, 2016)

http://ow.ly/4n2wzi

http://ow.ly/4n2EYs


Private companies capitalize on the UAS’s potential to improve crop yields. For example, Vine Rangers in

Northern California provides specialized service for wine grape growers by using drones to find the plant

height, plant count, plant health, presence of nutrients, presence of disease, presence of weeds, relative

biomass estimates, and 3D / volumetric data (See Image 4).12 Private drone imaging companies assist

farmers on the frontier in getting a professional analysis of their crops without having to understand how to

operate a drone. Agricultural farming giant Monsanto is also focusing on using drones to collect farming data

to optimize crop yield. According to Monsanto, these methods increase yields by roughly 5% over two years.

Corn growers have confirmed that giving more crop data to the farmers will increase America’s average corn

yield from 160 bushels an acre to 200 bushels.13 For these reasons, drones will be useful for farmers on the

frontier.

PUBLIC HEALTH APPLICATIONS

Drones have many public health applications for frontier communities, such as search and rescue missions,

mapping to predict disease spread, delivery of medical supplies and tests, disaster relief, and more. The non-

profit organization Doctors Without Borders uses drones to rescue refugees in the Mediterranean Sea.14 The

drones assist the doctors aboard rescue ships by providing surveillance that can give the crew the location of

refugees. Frontier communities can use drones in a similar manner to locate people that have gone missing.

Furthermore, health workers are using drones to collect environmental data that can assist in determining the

spread of certain diseases. For instance, the high definition imaging capabilities of drones can give information

on the moisture of soil, levels of rainfall, and vegetation, which can be used to understand mosquito habitats

and the spread of diseases such as malaria, West Nile, and the Zika virus.15 Public health workers can

understand the spread of certain disease better and how they may threaten frontier communities and drones

can be used to combat disease once they have struck communities. For example, drones have been

successfully used in Africa to deliver AIDS tests and provide results to remote locations at a faster rate than

was previously accomplished.16 This application of drones has helped to save lives because people can get

results and medication faster.

The field of public health has also used drones for disaster relief. Following the typhoon that hit the Philippines

in 2014, disaster relief organizations used drones to plan relief measures and to survey damage. Drones are

even being used to deliver medical supplies after disasters in inaccessible areas and to transfer biological

samples from rural clinics to better-equipped laboratories.17 The application of drones for delivery of medical

supplies and to provide medical assistance would be an invaluable use for people in the frontier that do not

have easy access to healthcare facilities.18 Lastly, drones have been used to predict natural disaster before

they occur. Drone researchers have used advanced 3-D cameras to predict potentially dangerous areas where

landslides may occur. The drone software helped researchers predict a landslide; consequently, they were able

to evacuate people and reduce harm to infrastructure. The key advantage of using a drone to assess these

risks is the reduction in cost.19 Frontier communities that are near fracking sites or gas pipelines would benefit

from an analysis like this because it could prevent harm to nearby communities.

WILDFIRE APPLICATIONS

12 (Nixon, 2016) 13 (Economist, 2014) 14 (Doctors Without Borders, 2015) 15 (Turk, 2014) 16 (McNeish, 2016) 17 (Fornace et al., 2014) 18 (Fornace et al., 2014) 19 (WPXI, 2016)

http://www.vinerangers.com/


Drones can be used in frontier communities to combat wildfires by being the firefighters’ eyes in the sky. An

aerial view of a wildfire provides an understanding of how the fire is structured and how the fire is changing,

and is an invaluable asset to firefighters. Drones can provide an understanding of where the fire is moving, the

hotspots behind the fire front, and potentially endangered structures nearby. A UAS can also function as a

communications relay for the field command hub, so that firefighters on foot will have a better understanding

of the fire’s movements, reducing the risk of death or harm to property. Moreover, smoke screens are a

common problem for firefighters because they impair their view, but drones equipped with infrared thermal

imaging allow the firefighters to see what lies ahead, improving awareness and enhancing the ability to make

informed decision. For example, the National Oceanic Atmospheric Association has become a certified drone

operating organization and are using drones to track wildfires.20

IMAGE 5: NOAA DRONES UNIT LOGO

Image Source: NOAA

The U.S. Forest Service uses NASA’s Predator B-based Ikhana research drone over Southern California

wildfires. The Predator B-based Ikhana has a 16-channel multispectral camera, image processor and a satellite

data link to send maps of the fire area to incident command centers on the ground immediately.21 This data is

vital to any firefighting operation.

IMAGE 6: NASA PREDATOR B-BASED IKHANA DRONE

Image Source: NASA

The fire-fighting industry can benefit greatly from the capabilities of drones through fire-monitoring support and

coordination, damage assessment, hotspot detection, wildfire mapping, emergency response, and hazardous

material investigation. Furthermore, drones can provide firefighters with valuable forestry information to

20 (AV Environment, 2016) 21 (Werner, 2015)

http://uas.noaa.gov/shout/


inventory and classify trees that are more susceptible to forest fires. The data acquired by drones to combat

wildfires is key information that can help frontier communities that are at risk of or battling wildfires.22

LIMITATIONS

Firstly, drones can be difficult to use in inclement weather. When temperatures are high it causes the drone to

overheat, and when temperatures are too low the battery will overconsume, limiting flight time. Volatile

weather can make it difficult for users to design their flight plans and notify authorities in advance.23 In

addition, the data acquisition of slower models can make analysis painstakingly time consuming when the

daily coverage is limited by the number of flights the model can accomplish.24

Furthermore, pilot reports of unmanned aircrafts have increased dramatically over the past year, from a total

of 238 sightings in all of 2014, to more than 650 by August of 2015.25 Conflicting flight patterns with planes

and helicopters is a serious problem and limits drone usage for combating forest fires because airtankers need

to fly above and disperse flame retardants. Resultantly, drones must cease all operations when any Forest

Service airtankers are operating because the risk of a drone colliding with an airtanker. The FAA has been

working closely with industry partners through the “Know Before You Fly” campaign to inform drone users

about flying rules and regulations.26 The FAA is sending out a clear message that operating drones around

airplanes and helicopters is dangerous and illegal.27 Unauthorized and unregistered users risk civil fines up to

$27,500 in addition to criminal fines of up to $250,000 and potentially three years in prison.28

For agricultural drone usage it is important to know that the FAA views all agricultural drone use as commercial

operations; therefore, the government has the right to access all data generated by the drone. For this reason,

data retention and storage policies require particular attention. Connectivity and bandwidth issues can be

problematic for farmers on the frontier because there are millions of acres of farmland in the US that have no

online connectivity or cell coverage. Thus, farmers in frontier communities should only purchase drones that

can store captured images and data in the drone without broadband.29

Lastly, farmers and ranchers might be reluctant to adopt the new drone technology because even though

drones improve crops, they reduce the role of skilled workers and reduce their competence. Farmers may be

reluctant to further reduce their role on the farm and they may distrust the companies handling their crop data.

It is practical to believe that farmers will fear the release of detailed data they provide on their harvests by

using drones.30 For example, they could believe that their commercial secrets could be sold or leaked to rival

farmers. Finally, drones may have the unintended consequence of alienating humans from the tasks that they

wish to accomplish. In the case of wildlife protection it may give operators and conservationists a false sense

of the environmental conditions that an animal is experiencing.31 Also, the increase in various drones hovering

above humans may induce anxiety out of fear for what they may be doing.

CONCLUSION

22 (Puliti et al., 2015) 23 (Fornace et al., 2014) 24 (Puliti et al., 2015) 25 (FAA, 2015) 26 (Werner, 2015) 27 (FAA, 2015) 28 (Kopstein, 2015) 29 (Nixon, 2016) 30 (Economist, 2014) 31 (Peters, 2016)


The findings of this study support that in spite of high prices, regulations, battery problems, and ethical issues,

drones will be useful for frontier communities. Studies support that drones can be useful for farmers on the

frontier to improve their crops and monitor livestock.32 Public health applications of UAVs for frontier

communities, such as search and rescue missions, mapping diseases, delivery of medical supplies, and

disaster relief have been supported to be useful for frontier communities. Lastly, drones are useful for

combating wildfires because of their ability to give information on where a fire is moving, the hotspots behind

the fire front, and potentially endangered structures nearby.33 As the world moves forward with drone

technology, it is easy to place them at the table in frontier communities. Although the limitations may preclude

widespread use of drones today, the days of frontier drone integration are not far off.

32 (Tripicchio et al, 2015) 33 (AV Environment, 2016)


REFERENCES

AV Environment. "FIRE." 2016. Web. <https://www.avinc.com/public-safety/applications/fire>.

Collings, Sophie. "10 Non-Aggressive Uses of Drones." The American Geographical Society. 19 Feb. 2015.

Web. <https://amergeog.wordpress.com/2015/02/19/10-non-aggressive-uses-of-drones/>.

Doctors Without Borders. "MSF and MOAS to Launch Lifesaving Operation for Migrants in Mediterranean." 9

Apr. 2015. Web. <http://www.doctorswithoutborders.org/article/msf-and-moas-launch-lifesaving-

operation-migrants-mediterranean>.

Drone Apps. "Price Wars: Counting the Cost of Drones, Planes and Satellites." 21 Aug. 2015. Web.

<https://droneapps.co/price-wars-the-cost-of-drones-planes-and-satellites/>.

The Economist. "Digital Disruption on the Farm." 24 May 2014. Web.

<http://www.economist.com/news/business/21602757-managers-most-traditional-industries-

distrust-promising-new-technology-digital>.

Federal Aviation Administration (FAA). "Unmanned Aircraft Systems (UAS) Frequently Asked Questions." Feb.

2016. Web. <https://www.faa.gov/uas/faq/>.

FAA. "Pilot Reports of Close Calls With Drones Soar in 2015." 12 Aug. 2015. Web.

<https://www.faa.gov/news/updates/?newsId=83445>.

Fornace, K. M., C. J. Drakeley, T. William, F. Espino, and J. Cox. "DRONES RECORD HOW THE ENVIRONMENT

SHAPES DISEASE RISK." University of Washington Conservation. 24 Oct. 2014. Web.

<http://conservationmagazine.org/2014/10/drones-record-how-the-environment-shapes-disease-

risk/>.

Kopstein, Joshua. "I'll Register My Drone When You Have to Register Your Gun." Vice. 14 Dec. 2015. Web.

<http://motherboard.vice.com/read/ill-register-my-drone-when-you-have-to-regist

McNeish, Hannah. "The First HIV-Fighting Drones Have Been Deployed in Africa." Vice. 16 Mar. 2016. Web.

Nixon, Andrew. "How To Select an Agriculture Drone: An In-Depth Buyer’s Guide. “Best Drone For The Job. 4

Apr. 2016. Web. <http://bestdroneforthejob.com/drones-for-work/agriculture-drone-buyers-guide/>

Peters, Justin. "This Expert Worries That Using Drones to Protect Wildlife Could Backfire." Future Tense. 16 Feb.

2016. Web.

<http://www.slate.com/blogs/future_tense/2016/02/16/chris_sandbrook_argues_that_using_drone

s_for_conservation_could_backfire.html?wpsrc=sh_all_dt_tw_top>.

Puliti, S.; Ørka, H.O.; Gobakken, T.; Næsset, E.Inventory of Small Forest Areas Using an Unmanned Aerial

System. Remote Sens. 2015, 7, 9632-9654.

Tripicchio, P., M. Satler, G. Dabisias, E. Ruffaldi, and C. A. Avizzano. "Towards Smart Farming and Sustainable

Agriculture with Drones." Intelligent Environments (IE), 2015 International Conference on (2015): 140-

43. Web. <http://ieeexplore.ieee.org/stamp/stamp.jsp?tp=&arnumber=7194284>.

Turk, Victoria. "Drones Create Real-Time Maps of How Diseases Spread." Vice. 22 Oct. 2014. Web.

<http://motherboard.vice.com/read/drones-create-real-time-maps-of-how-diseases-sprea>.


Roberson, Roy. "On-farm Remote Sensing Will Be More Valuable in the Future." Farm Press Blog. 23 Oct. 2013.

Web. <http://southeastfarmpress.com/blog/farm-remote-sensing-will-be-more-valuable->

Werner, Debra. "Fire Drones." Aerospace America (2015): 28-31. Web.

WPXI. "Pittsburgh Drone Developers Hope to Use New Technology to save Lives." 7 Apr. 2016. Web.

Broadband in FAR 2 Areas 13

BROADBAND IN FAR 2 AREAS STEVE LUBRANO AND WHITNEY MILLER


TABLE OF CONTENTS

Introduction ................................................................................................................................................................ 15

Defining Broadband................................................................................................................................................... 15

Challenges of Broadband in Rural Areas: Expense, Geography, Lack of Demand ................................................ 16

Inequities of Broadband in Rural Areas ................................................................................................................... 17

Figure 1: Gap by Census Blocks Ordered by Population Density (source needed) ........................................ 18

Figure 2: Investment Gap per Housing Unit by Lowest-Cost Technology for Each County (Source Needed)19

Figure 3: Location of Highest-Gap Housing Units (Source Needed) ............................................................... 20

Broadband in Tribal Areas ......................................................................................................................................... 21

Benefits of Broadband in Rural Areas ...................................................................................................................... 22

Telemedicine and Distance Learning ................................................................................................................... 23

Federal Funding ......................................................................................................................................................... 23

NTIA: Broadband USA ............................................................................................................................................ 24

Case Study: Mississippi .................................................................................................................................... 24

FCC Universal Service Health Care Programs: The Rural Health Care Program ................................................ 24

Case Study: Maine ............................................................................................................................................. 25

USDA:The Rural Broadband Access Loan and Loan Guarantee Program .......................................................... 25

Case Study: Nevada........................................................................................................................................... 25

USDA: Distance Learning and Telemedicine Grant ............................................................................................ 26

Case Study: Ute Mountain Ute Tribe reservation and Pyramid Lake Paiute Tribe ......................................... 26

USDA: Community Connect Program ................................................................................................................... 26

Case Study: Alaska ............................................................................................................................................ 26

HRSA: Telehealth Programs ...................................................................................................................................... 27

Telehealth Network Grant Program (TNGP) ......................................................................................................... 27

Telehealth Resource Center Grant Program (TRC) .............................................................................................. 27

Evidence-Based Tele-Emergency Network Grant Program (EB TNGP) ............................................................... 27

Rural Veterans Health Access Program (RVHAP) ................................................................................................. 27

Rural Child Poverty Telehealth Network Grant Program (RCPTNGP)) ................................................................. 28

Rural Health Network Development Planning Program ...................................................................................... 28

Case Study: California ....................................................................................................................................... 28

GIS Analysis ................................................................................................................................................................ 28

Conclusion .................................................................................................................................................................. 36

References ................................................................................................................................................................. 37


INTRODUCTION

This paper will discuss broadband on the frontier. For the purposes of this paper, broadband refers to high

speed internet connection as discussed in detail in the first section paper. In the next sections we will

document existing broadband access throughout the country as well as disparities in access, particularly from

an urban vs. rural perspective as well as disparities between racial and tribal groups. We will then detail the

applications for broadband, particularly those of value to frontier communities, and identify local, state and

federal funding sources. Finally, a GIS analysis of frontier broadband will depict existing broadband access,

speed and investment gaps in FAR 2 counties. This paper will reveal that frontier communities are consistently

lacking in broadband investment and facilities compared to the rest of the nation.

The Santa Fe New Mexican’s article “High-speed Internet gaps leave rural New Mexicans lacking a ‘basic right’”

recounts the frustrating internet experiences of residents in rural areas of the state. Residents of Tao pay $70

a month for internet service that provides less than optimal download speeds of 10 Megabits per second,

while in Pojoaque Valley the fastest service is 3 Mbps and costs $96 a month. In the United States overall, high

speed internet is an integral part of everyday life. However many rural communities are forced to pay more for

poorer quality internet than more urbanized areas. For example in New York City, a plan with 300 Mbps costs

about $30 less. Unfortunately, in some areas broadband is not available at all. The New Mexican article

mentions a man named Juanito Jimenez, an artist living in Tesuque. He does not have access to standard

internet options, therefore his family has to access internet using a limited Verizon data plan. This has to be

closely monitored each month so that they do not face overage charges.34

DEFINING BROADBAND

“Broadband” encompasses a wide variety of internet technologies and access typologies. In regard to internet

access, broadband refers to a fast internet connection that is continuously on, distinct from dial up access.

Broadband service is also characterized by two way transmission of data: downstream transmission, commonly

known as download, and upstream transmission, commonly known as upload. Download includes anything

received by the user, including receiving emails, visiting websites, watching videos and other uses. Uploading

includes sending emails, editing web pages, and filling out online forms among other uses.

While generally defined as faster than dial up, the exact speeds necessary to constitute broadband are in

contention and ever changing. The Federal Communications Commission (FCC) typically defines and redefines

the benchmark for broadband, or “advanced telecommunications capability” in its annual Broadband Progress

Reports as required by the Telecommunications Act of 1996. The 2015 FCC Broadband Progress Report

redefined this benchmark to 25 Mbps download and 3 Mbps upload and has stated a desire to increase it

more substantially in the near future35. The National Telecommunications and Information Administration,

however, defined “basic broadband service” as advertised download speeds of 3 Mbps and advertised upload

speeds of 768 Kbps in 201336.

Broadband also comes in a range of delivery mechanisms including Digital Subscriber Line, Cable Modem,

Fiber, Wireless, Satellite and Broadband-Over-Power-Lines37. Digital Subscriber Line or DSL utilizes copper

telephone lines to transmit data. Despite using telephone lines, DSL is distinct from dial up as it can be used

34 (Quintana, 2015) 35 (FCC, February 2015) 36 (Neville, 2013) 37 (FCC, n.d.)


without interfering with telephone use. Nationwide, approximately 74% of the population has access to DSL38

and approximately 19% of internet subscribers use DSL39. In non-urban40 areas, approximately 27% of

subscribers use DSL.

Cable modems use coaxial cables, used for television transmissions, to provide internet access. Nationwide,

about 87% of the population has access to cable modem broadband and approximately 51% of internet

subscribers use cable modem technology. In non-urban areas, approximately 39% of subscribers use cable

modem broadband.

Fiber optic technology allows for the transmission of data through light waves at very high speeds. Nationwide,

20% of the population has access to fiber optic Broadband and 8% of internet subscribers use fiber optic

Broadband. In non-urban areas, approximately 4% of internet subscribers use fiber optic Broadband.

Wireless broadband technology utilizes radio frequencies to transmit data between users and service

providers. Wireless providers can either be fixed or mobile. Fixed wireless service uses a stationary transmitter

to provide broadband. These can be long or short range and are the basis for public wifi networks. Importantly,

these are often used in rural or remote areas where wireline infrastructure is lacking or prohibitively difficult to

provide. Nationwide, approximately 34% of the population has access to fixed wireless broadband. Mobile

wireless service is typically provided by cell phone servicers at slower speeds than fixed wireless or wireline

broadband. Approximately 92% of the US population has access to mobile wireless broadband and

approximately 8% of internet subscribers use mobile wireless broadband alone. An additional 25% of

subscribers use mobile wireless broadband in conjunction with a primary fixed or wireline broadband

technology. In non-urban areas approximately 11% of internet subscribers use mobile wireless broadband

alone.

A variant of wireless broadband is satellite broadband which transmits data wirelessly through satellites rather

than radio and cell towers. Nationwide, approximately 4% of internet subscribers use satellite broadband while

8% of subscribers in non-urban areas use satellite broadband. Satellite broadband can be particularly useful

for remote areas as it requires little to no infrastructure and is widely available however it suffers from

relatively slow and inconsistent transmission speeds and is prone to interference by severe weather.

Broadband over powerline (BPL) is an emerging delivery mechanism that utilizes existing power lines to provide

internet service. This technology is highly promising but is not widely used to date.

CHALLENGES OF BROADBAND IN RURAL AREAS: EXPENSE, GEOGRAPHY, LACK OF

DEMAND

When providing broadband in rural areas, many challenges arise such as expense, geography, and lack of

demand compared to urban areas. This lack of access is referred to as the digital divide. Expense can be

directly related to topography and lack of demand. If a household or institution is located in a remote area,

there is less likely to be infrastructure in place to provide speedy and affordable internet access. There is often

not enough profit for service providers to build and maintain the infrastructure. When service providers do

manage to provide broadband, it is most likely at a higher price and slower speed than in urban areas.

Sharon Strover, professor at the University of Texas and director of the Telecommunications and Information

Policy Institute, says that speedy internet service could save people money when it comes to basic services

38 (NTIA, May 2013) 39 (US Census Bureau, 2014) 40People not in census designated “urban areas”


such as renewing a driver’s license or pursuing higher education. Fast internet is necessary to take video-

based online classes and to sign up for health care, such as on healthcare.gov. Rural hospitals use broadband

to video-conference with urban medical specialists.41 Those who lack internet access miss out on online

commerce, an important and growing part of our economy.

The topography of an area can greatly affect access to broadband. For example, in the rural West, two million

people lack broadband access due to mountains and narrow valleys. These geological features can block

signals from wireless towers and satellites and make it difficult to install fiber optic cables. Also, when

broadband is available, there is often one provider which creates a lack of competition. This combined with

lack of government incentives and the high cost of installing fiber optic cable in remote areas results in lower

quality service at higher prices. According to the FCC, hundreds of millions of dollars in federal stimulus money

has been spent over the past few years in an effort to provide more fixed broadband in rural areas. However,

there are still 14 million people in rural areas that lack broadband access. Those who lack access to fixed

broadband often use their mobile device instead. However, this limits the range of activities that can be done

online, and can be costly due to overage charges.42

Access to the internet does not guarantee usage, and this is not just due to cost. In rural areas, there tends to

be a lack of knowledge of what the internet is and its benefits. However, there are economic benefits when

rural residents use broadband. According to the NTIA, 47% of people cite lack of need or interest as a reason

for not using the internet. They view the internet as not relevant to their lives and do not believe the internet

could benefit their way of life.43 Twenty-four percent of people stated broadband was too expensive, and 15%

lacked an adequate computer. Some people do not know how to use a computer, and therefore do not know

how to use various online services. In a 2013 study, Sharon Strover found there is more rapid income growth

and slower growth of unemployment in rural counties where over 60% of people used broadband than

comparable counties where fewer people used the internet.44

INEQUITIES OF BROADBAND IN RURAL AREAS

In addition to having less access to broadband overall, non-urban areas have lower levels of use of the faster

and more advanced broadband technologies (fiber optic and cable modem) and have higher levels of use of

slower and less reliable technologies like DSL, wireless and satellite internet service. In 2015, while

approximately 17% of Americans lacked access to broadband, 53% of rural Americans did45. Additionally, rural

areas tend to have far fewer providers in the same place as non-rural areas yielding a lack of options for

consumers and higher prices due to lack of competition46. A 2015 study by the White House Council of

Economic Advisors found a positive correlation between population density and wireline broadband

competition, particularly in medium and low density areas. Moreover, the majority of economic benefits from

broadband in rural and frontier areas have not gone to rural areas; approximately 66% of economic activity and

54% of job creation resulting from rural broadband goes to urban areas47.

41 (Guerin, 2014) 42 (FCC, 2016) 43 (NTIA, 2013) 44 (Guerin, 2014) 45http://www.lightreading.com/services/broadband-services/fcc-rural-broadband-progress-slowing/d/d-id/720719 46 (FCC, March 2010) 47 (Kuttner, 2016)


Rural small businesses also experience a broadband gap48. While 2% of small businesses lack access to

broadband nationwide, 8% of rural small businesses lack access to broadband. Moreover, 11% more rural

small businesses are unsatisfied with their internet service than urban small businesses. Rural businesses are

also consistently less satisfied with the price they pay for internet and more likely to be willing to pay more for

faster service.

FIGURE 1: GAP BY CENSUS BLOCKS ORDERED BY POPULATION DENSITY (SOURCE NEEDED)

In 2010, the FCC found that an estimated 7 million households lacked “access to terrestrial broadband

infrastructure capable of meeting the National Broadband Availability Target of 4 Mbps download and 1 Mbps

upload”49 Of these, over 4 million had no broadband capability whatsoever50. The study found that an

investment gap of $23.5 billion existed across the United States. This gap represents the amount of money it

would take to make up the difference between the present value of the capital and operating costs of providing

broadband infrastructure to all unversed households and the present value of the revenue stream generated

by service provision. Broken down into census blocks, a clear inverse relationship was revealed between

population density and the investment gap in each block. Exhibit 1-C from the study (Figure 1) displays this

relationship. Counties and census blocks with the lowest population densities have the highest investment

gaps by margins approaching a tenfold difference between the two extremes. As can be seen in Exhibits 1-I

and 4-AQ, the largest investment gaps appear largely in frontier counties and states as do the majority of

“highest gap housing units.”

48 (Columbia Telecommunications Corp, 2010) 49 (FCC, April 2010) 50 (Beede and Neville, 2013)


FIGURE 2: INVESTMENT GAP PER HOUSING UNIT BY LOWEST-COST TECHNOLOGY FOR EACH

COUNTY (SOURCE NEEDED)


FIGURE 3: LOCATION OF HIGHEST-GAP HOUSING UNITS (SOURCE NEEDED)


This gap widens even further in the most rural areas. A 2013 NTIA study found that “very rural” census blocks,

characterized by population density and geographic location, had substantially lower rates of broadband

availability at all speed levels than all other census blocks51. This “availability gap” between very rural and

other census blocks can be expressed as the difference in the percentage of population with access to

broadband at a specific downstream speed tier. The gap between very rural and “suburban” census blocks,

which consistently had the best service, was roughly 35% at 3 Mbps (NTIA benchmark for “Basic Broadband

Service”), 57% at 25 Mbps (current FCC benchmark for “Advanced Telecommunications Capability) and 35% at

100 Mbps (National Broadband Plan's 2020 benchmark). In relative terms, very rural census blocks had

availability rates of two-thirds, one-fourth and one-twelfth that of suburban census blocks at 3 Mbps, 25 Mbps

and 100 Mbps, respectively. Importantly, very rural census blocks have an average population density of 11

people per square mile. As such, it is likely, particularly considering the trend revealed in this study and its

observation that “a community's proximity to a Metropolitan Statistical Area (MSA) is often more closely

associated with higher broadband speeds than is population density alone”, that the availability gap in remote

and frontier census blocks is even larger.

Recent accounts have variously stated that the rural-urban broadband gap is growing5253, stagnant or closing

at a slowing rate54 but have reached a tenuous consensus that it is not closing as quickly as it had been. An

emerging argument cites growing evidence that broadband adoption is more important than broadband

availability55. This theory argues that while the supply of broadband in rural areas falls short of that of urban

areas, it still outstrips demand for broadband service. A 2015 analysis revealed that differences in broadband

availability explains only 38% of the “adoption gap.56” FCC research reveals that in 2010, “35% of [adult]

Americans do not use broadband at home.57” Further, 22% of Americans do not use the internet at all. Of non-

adopters, 36% cite cost as a factor. Only 5% of non-adopters cited a lack of availability as their primary reason

for not having broadband. This strongly supports the notion that adoption, rather than availability, drives the

digital divide. While 71% of rural Americans have access to broadband, only 50% (compared to 68% nationally)

actually use it. A lack of availability was, however, the most cited reason for non-adoption among rural non

adopters and was cited more often on a percentage basis than among urban and suburban non adopters.

BROADBAND IN TRIBAL AREAS

Race and ethnicity are correlated with disparities in broadband use and home access. 57% of Hispanic

households and 55% of Black households have broadband at home. This is in stark contrast to Asian and

White households. Eighty-one percent of Asian households and 72% of White households had broadband at

home.58 According to the Pew Research Center, rates of Latino internet use are similar in urban, suburban and

rural areas.59 The biggest disparity exists between Native American populations living on reservations and

other Americans.

Less than 10% of homes on tribal lands have broadband internet service. Navajos are the largest tribal group

in the United States, and have been largely disconnected from the rest of the American economy.60 About 40%

51 (Whiteacre, 2013) 52 (Whiteacre, 2016) 53 (Gallardo, 2015) 54 (FCC, January 2016) 55 (Gallardo, 2015) 56 (Whiteacre, Strover, Gallardo, July 2015) 57 (Horrigan, 2010) 58 (NTIA, 2011) 59 (Livingston, 2011) 60 (Smith, 2012)

http://transition.fcc.gov/indians/


of Navajos live in poverty, and according to the census the median household income is just $24,000. Nearly

one quarter of Navajo people are unemployed, and the high school graduation rate is approximately 30%. In

theory, the internet was supposed to mitigate some of these issues. The internet would allow for Navajo

students to take online classes instead of having to travel long distances to attend school, and allow patients

to speak with doctors via video conference, increasing the convenience of medical care. Some health care

providers on the Navajo reservation do not have internet, which prohibits them from being able to look up

medical records. This has led to the wrong combination of medication being prescribed to patients. Those on

reservations can miss out on employment opportunities because they cannot connect to the internet to check

email. The internet could also alleviate poverty by allowing Navajo artisans to sell their famous handcrafted

rugs online.

Young members of the Navajo Nation are particularly impacted by the lack of internet. College students suffer

because they cannot get a broadband connection on the reservation.61 Connections are unreliable or

nonexistent. The lack of internet connectivity is also driving younger members to leave the reservation because

they want to experience what the rest of the country has. Older Navajos tend to be unsympathetic and do not

understand the urgency to be online. However, lack of connectivity impacts all members considering the fact

that without internet service, tribes cannot apply for federal grants as many of the applications are now online.

Broadband companies lack incentive to install infrastructure on tribal lands. As in other rural areas, this is

because such sparse population yields a lack of profits. On the Navajo reservation, there are only six people

per square mile, as compared to 27,000 people per square mile in New York City. However, the federal

government has subsidized telecom companies that serve tribal lands with grants and loans. This has made it

possible for some tribes to become their own internet providers. However the process can be complicated due

to the fact that tribes are sovereign nations with their own set of laws. To install broadband infrastructure,

companies have to obtain approval from the Bureau of Indian Affairs. This involves environmental and

archaeological reviews, which can take at least two years to assess. The Huffington Post article “On Tribal

Lands, Digital Divide Brings New Form of Isolation,” states that Sacred Wind Communications in Albuguerque

has brought telecommunications services to about 3,600 Navajo households, but is struggling to expand

further because of the necessity of federal approval.62 This shows that despite tribes being able to become

their own internet provider, it can be a long process that puts them behind much of the country.

BENEFITS OF BROADBAND IN RURAL AREAS

The economic impacts of broadband are large and well documented63, particularly in rural areas6465 Distance

learning and telemedicine, for example, allow frontier dwellers to overcome the traditional challenges of

distance and lack of service providers fulfill important needs. Telehealth is defined by the Health Resources

and Services Administration as “the use of electronic communication and information technologies to provide

or support long-distance clinical health care, patient and professional health-related education, public health,

and health administration.”66 Telehealth serves as an umbrella for a variety of health related activities,

including telemedicine, which refers specifically to the provision of clinical services via telecommunications

technology. Telehealth and telemedicine offer benefits to frontier residents including minimizing travel time

and expense for patients and healthcare providers, allowing those who may otherwise not seek healthcare

services due to prohibitive time and expense constraints to do so, give patients access to a wider range of

61 (ibid) 62 (ibid) 63(Connected Nation, 2012) 64 (Whiteacre, Strover, Gallardo, February 2015) 65 (Katz, Avila, Meille, 2011) 66 (National Advisory Committee on Rural Health and Human Services, 2015)


services and options and generally improve the level of care. Due to the wide range of activities encompassed

under the realm of telehealth, there is no one standard for broadband access and service.

TELEMEDICINE AND DISTANCE LEARNING

Importantly, only 11% of healthcare related community anchor institutions in frontier counties have download

speeds meeting the speed requirement for rural health clinics and small primary care practices and fewer than

30% meet the speed requirements for a solo primary care practice67.

The rural-urban broadband gap is particularly severe in healthcare. Healthcare facilities in rural areas have less

access to high speed broadband than their urban counterparts by a margin that has widened greatly in recent

years68. This gap is especially prominent among smaller, non-hospital healthcare providers that may be more

critical to healthcare in frontier communities. While rural and urban hospitals utilize telehealth at relatively

similar rates, they do so in different ways69. Rural hospitals were more likely to use telehealth for emergency

care and radiology but less likely to use it for other purposes.

Distance learning is another promising application for broadband in the frontier. At the primary and secondary

school level, distance learning can help schools expand their curriculum offerings by connecting students to

resources that cannot be provided on campus or nearby. Postsecondary distance learning lets students in

remote areas take classes online. This way they can enroll in institutions anywhere without leaving their home.

Students who otherwise would not be able to obtain quality higher education can use distance learning to

study what they want, where they want, when they want. Distance learning involves a variety of applications

and technologies including electronic textbooks, online notes, lectures and course materials, synchronous

videoconferencing, interactive instruction and online discussion forums70. These applications demand widely

different speed levels. Reading an electronic textbook requires far less bandwidth than streaming a lecture or

participating in an interactive digital classroom in which all students must be able to keep up and

communicate seamlessly.

Telecommuting represents another emerging use for broadband in frontier areas. Telecommuting allows

workers to access a greater range of employment opportunities and avoid the time and expense of commuting.

According to the Small Business Administration, 44% of rural small businesses allow telecommuting and 28%

“would encourage more telecommuting if employees had very-high-speed internet that could support

videoconferencing and other advanced features.” While a slightly smaller proportion of rural small businesses

permit telecommuting than urban small businesses, a slightly higher proportion would encourage more if there

were improved broadband capacity.

FEDERAL FUNDING

Slowly but surely federal entities have been trying to rectify the broadband gap in rural America. Nonprofits,

Native American Tribes, and health and education institutions are eligible for the following grants:

67 (National Broadband Map, 2015) 68 (Whiteacre, Wheeler, Landgraf, 2016) 69 (Ward, Ullrich, Mueller, 2014) 70 (Lai et al, 2004)


NTIA: BROADBAND USA71

Broadband USA was developed by the National Telecommunications and Information Administration (NTIA) to

guide communities in promoting and increasing broadband use and capacity. The NTIA invested over $4 billion

in the Broadband Technologies Opportunities program to build network infrastructure, establish public

computer centers, and develop digital literacy training to expand broadband adoption. This has led to more

than 113,000 miles of fiber being installed, connecting nearly 25,000 primary community institutions like

schools and libraries. Entities that have received funding also upgraded 3,000 public computer centers,

trained more than four million people and helped roughly 735,000 households sign up for broadband.

According to an independent study, grants through this program will increase economic output by as much as

$21 billion annually. By 2017 the NTIA will establish the Community Connectivity initiative which will “engage

community, corporate and civic leaders to develop and finalize a set of connectivity indicators, create a

strategic online self-assessment, and expand resources that support and accelerate local broadband planning

efforts.” This will ensure that communities have the knowledge and skills to implement broadband and

continue to improve connectivity as time goes on.

CASE STUDY: MISSISSIPPI 72

In February of 2015, the National Telecommunications and Information Administration’s Broadband USA team

conducted a workshop in Jackson, Mississippi for the purpose of expanding broadband. Only 68% of

Mississippi residents have access to download speeds of at least 25 megabits per second compared to the

United States average of 86%. This is due to the lower population densities with an average of 63 people for

every square mile compared with a national average of 87. Approximately 23% of Mississippi residents live

below the poverty line compared to 15% of Americans overall. However, Mississippi has made noteworthy

progress. In 2010, Mississippi received NTIA funding to map broadband availability and create a non-profit

public-private partnership, the Mississippi Broadband Connect Coalition, which is implementing a plan to

address broadband gaps. The NTIA gave $30 million in funding to Contact Network, a regional internet provider

doing business as InLine to increase its high-speed network. The network went from just 43 miles of fiber in 18

community anchor institutions, to more than 1,000 miles of fiber in 327 schools, public safety facilities and

other institutions. This has also encouraged local competitors to upgrade their own networks.

Improving the network has fueled new development, economic growth and jobs. It also has created

opportunities in health care and education. The University of Mississippi Medical Center indicated that

broadband enables the center to serve an aging rural population, who often live far away from healthcare

specialists. Broadband enables the center to have 165 locations that remotely connect patients with 35

medical specialties on the main center in Jackson. The Clinton Public School District has created a program

that assigns an iPad to every student in kindergarten through fourth grade and a MacBook starting in fifth

grade. Because of the improved broadband network, students were able to remotely learn by speaking with

archeologists in Afghanistan, talking with New York City fire chiefs on the anniversary of the September 11

attacks, and speaking with physicians at the University of Mississippi Medical Center and other hospitals as

part of their genetics class.

FCC UNIVERSAL SERVICE HEALTH CARE PROGRAMS: THE RURAL HEALTH CARE PROGRAM73

The rural health care program provides funding for telecommunication and broadband services. The program

provides $400 million annually through the Health Care Connect Fund, the Telecommunication Program, and

the Rural Health Care Pilot Program. The Health Care Connect Fund supports high-capacity broadband at a

71 (NTIA, January 2015) 72 (NTIA, February 2015) 73 (FCC, November 2015)


65% discount for health care providers. The Rural Healthcare Pilot Program supports statewide and regional

broadband health care provider networks with an 85% discount, and is being replaced by the Health Care

Connect Fund. The Health Care Connect Fund provides support to a consortium of public and non-profit health

care providers. After June 2014, the Telecommunications Program will no longer provide internet funding, and

will provide telecommunications funding.74 This can be applied for through The Rural Health Care Fund. The

telecommunications program makes sure that rural health care providers pay no higher than the highest

tariffed or publicly available commercial rate for similar service in the closest city in the state with a population

of 50,000 or more people, taking distance charges into account. 75

CASE STUDY: MAINE76

In 2006, The FCC selected 69 sites covering 42 states and 3 US territories to participate in the Rural Health

Care Pilot Program. This included the Rural Western and Central Maine Broadband Initiative. This included 7

sites spanning 4 Maine counties, and the New England Telehealth Consortium, which includes 305 sites over a

three-state area (Maine, New Hampshire, and Vermont). One hundred eleven of these sites are in Maine. $417

million was granted over three years to pay for 85% of eligible costs of building the broadband networks. This

included implementing the information services provided over the networks and connecting them to primary

national providers. This allowed for the consortia to purchase services and build their own broadband

infrastructure. This did not include administrative costs, which proved to be expensive.

However, there was a lead time of several years between award and disbursement. The funding did not cover

administrative costs, which were high because of inefficiencies and regulatory hurdles. The FCC is seeking to

resolve this issue in the administration of the new Healthcare Connect Fund. So far two rural healthcare

consortia in Maine have received a total of $6.6 million in funding to plan and create a broadband networks

that connect primarily nonprofit healthcare centers in Maine, New Hampshire, and Vermont.

USDA:THE RURAL BROADBAND ACCESS LOAN AND LOAN GUARANTEE PROGRAM77

The Rural Broadband Access Loan and Loan Guarantee Program (Broadband Program) furnishes loans and

loan guarantees to provide funds for the costs of infrastructure for providing broadband in eligible rural areas.

The purpose of the program is to lend to organizations that are capable of paying back loans. Also entities

should implement service that can keep up with upgrades in technology, while meeting the demands of

customers in rural America.

CASE STUDY: NEVADA78

KeyOn Communications, Inc. received a $10.1 million award to install 4G, last-mile wireless broadband and

digital phone service in 39 of the most rural communities in Nevada. The Reno-Sparks Indian Colony, Inc. was

awarded $400,000, which will enable to tribe to offer wireless broadband service to communities in a rural

reservation in Hungry Valley. The Rural Telephone Company was also awarded a $2.4 million grant/loan

project. This will extend ADSL2+ high speed broadband service to existing and new customers in the North

Fork, Tuscarora, and Jarbidge Nevada service areas. Lastly, the Arizona Nevada Tower Corporation was

awarded $7.75 million to enable the company to offer microwave radio backbone and middle- mile system to

provide significant bandwidth to wireless internet service providers, anchor institutions and businesses.

Reliable internet will be provided and enhancement of the fiber optic cable network to those living outside of

74 (USAC, n.d.) 75 (FCC, December 2015) 76 (ConnectME, 2014) 77 (USDA, n.d.) 78 (Nevada Broadband, 2010)


Washoe and Clark counties. This includes approximately 41,000 people and 186 businesses and community

institutions in 15 service areas.

USDA: DISTANCE LEARNING AND TELEMEDICINE GRANT 7980

The DLT is a competitive national grant, with a minimum grant amount of $50,000 and a maximum grant

amount is $500,000. Funding must be used for telecommunications-enabled information, audio and visual

equipment, and advanced technologies that allow for educational and medical applications in rural areas.

Grant applications must demonstrate matching contributions (in cash or in kind) of at least 15% of the total

amount of financial assistance provided.

CASE STUDY: UTE MOUNTAIN UTE TRIBE RESERVATION AND PYRAMID LAKE PAIUTE TRIBE81

$259,428 of grant funds were awarded for a distance learning project located in the Ute Mountain Ute Tribe

reservation (Towaoc, Colorado & White Mesa, Utah), which includes college and career readiness courses

along with degree programs in health care. This is especially important because there is a growing need for

professionals in this field for the over 20 hospitals in the region. The project will connect the Ute Mountain

Learning Center and the White Mesa Education Center with Utah State University Blanding campus, Southwest

Colorado Community College, and San Juan College. A total of $377,772 of grant funds were awarded to the

Pyramid Lake Paiute Tribe to provide telepharmacy services to eight remote pharmacies in Sutcliff, Nixon,

Wadsworth, McDermitt, Shurz, and Duckwater in Nevada. This is especially important because there is a

shortage of pharmacists in the Pyramid Lake Paiute’s tribal region.

USDA: COMMUNITY CONNECT PROGRAM 8283

This program is aimed at funding broadband implementation in rural communities where it is not economically

feasible for private sector providers to deliver service. The $100,000-$3,000,000 grant funds can be used for

the construction, acquisition, or leasing of infrastructure and facilities for the provision of broadband to all

residential and business customers located within the grant application’s proposed service area, including

funding for up to ten computer access points to be used in a local community center. Funds towards the

Community Center will be limited to 10% of the requested grant amount. The grant allows for funding to

provide broadband free of charge to locations defined as Critical Community Facilities for two years.

CASE STUDY: ALASKA84

Arctic Slope Telephone Association Cooperative, Inc. in the Point Hope Community was awarded $1,418,502

to the Point Hope Proposed Funded Service Area to construct a broadband network for residents and

businesses. ASTAC will provide the following services: high speed internet, local telephone service and custom

calling features, long distance telephone service, and Ethernet transport services. The funding will also enable

ASTAC to plan for the Point Hope access network to install an undersea fiber connection in 2016-2017.

79 (USDA, n.d.) 80 (USDA, 2016) 81 (USDA, 2015) 82 (USDA, n.d.) 83 (USDA, 2014) 84 (USDA, 2015)


HRSA: TELEHEALTH PROGRAMS85

The Health Resource and Service Administration offers grants through The Office for the Advancement of

Telehealth (OAT) in the Federal Office of Rural Health Policy (FORHP). This encourages the use of telehealth

technologies for health care delivery, education, and health information services. Telecommunications

technology allows clinical care to be performed from a distance. Telehealth is especially critical in rural and

other remote areas that lack sufficient health care services, especially specialty care. HRSA has the following

Telehealth grant opportunities:

TELEHEALTH NETWORK GRANT PROGRAM (TNGP)

TNGP funds are used for projects that use of telehealth networks to improve healthcare services for medically

underserved populations. The goal is to help build the human, technical, and financial capacity to implement

sustainable telehealth programs and networks. Networks can be used to:

● Expand access to, coordinate, and improve the quality of health care services;

● Improve and expand the training of health care providers; and/or

● Expand and improve the quality of health information available to health care providers, patients,

and their families.

TELEHEALTH RESOURCE CENTER GRANT PROGRAM (TRC)

The TRC program awards grants to implement and continue operation of resource centers so that health care

organizations, networks, and health care providers can create cost-effective telehealth programs to serve rural

and medically underserved areas and populations.

EVIDENCE-BASED TELE-EMERGENCY NETWORK GRANT PROGRAM (EB TNGP)

The EB TNGP supports implementation and evaluation of telehealth networks that deliver 24-hour emergency

department consultation service to rural providers that lack emergency care specialists. The EB TNGP supports

programs that track a significant volume of patient encounters to facilitate detailed analysis of patient

outcomes in rural areas.

RURAL VETERANS HEALTH ACCESS PROGRAM (RVHAP)

To deliver services to veterans in rural areas, RVHAP focuses on regional approaches, including networks,

health information exchange, telehealth, and/or telemedicine. The RVHAP provides funding to enhance mental

health services for veterans of Operation Iraqi Freedom and Operation Enduring Freedom, including:

● Crisis intervention and diagnostic assessments;

● Detection of post-traumatic stress disorder;

● Traumatic brain injury; and

● Other mental health conditions associated with veterans.

85 (HRSA, 2015)

http://www.hrsa.gov/ruralhealth/telehealth/





RURAL CHILD POVERTY TELEHEALTH NETWORK GRANT PROGRAM (RCPTNGP))

Supports established telehealth networks in the delivery of social services such as early childhood

development counseling, food and nutrition support and job counseling to rural areas.

RURAL HEALTH NETWORK DEVELOPMENT PLANNING PROGRAM86

The purpose of the Network Planning program is to assist in the creation of an integrated healthcare network.

Health care networks can be an effective strategy to help smaller rural health care providers and health care

service organizations align resources and strategies, achieve economies of scale and efficiency, and address

challenges more effectively as a group than as single providers. This can be done by “identifying a strategy to

leverage broadband connectivity to support health information technology applications in rural communities.

This may include developing partnerships to leverage broadband funding through the Federal Communications

Commission Health Care Connect program and the United States Department of Agriculture Broadband

Program.”87

CASE STUDY: CALIFORNIA88

California Telehealth Network has been awarded a $1.3 million Health Resources and Services Administration

(HRSA) grant which will be implemented by the California Telehealth Resource Center (CTRC) to expand

telehealth training and support for rural and medically underserved clinics and hospitals in California. CTRC will

collaborate with Telehealth Resource Centers across the country to provide assistance to California hospitals,

clinics, public and private health plans and community entities wanting to create and maintain telemedicine

and eHealth programs, collaboratives, and networks of care. CTRC will continue to provide quality webinars on

telehealth topics, host regional workshops, and will present a statewide conference on telehealth. CTRC is

currently working in partnership with the California Telehealth Network and the UC Davis Broadband

Technology Opportunities Program’s 15 Model eHealth Communities, as well as UC Irvine and UC San

Francisco as they extend their telehealth networks and services throughout the state.

GIS ANALYSIS

The following maps depict broadband service and access across the frontier in FAR 2 Counties based upon

data from the FCC and the National Broadband Map. Importantly, these maps and the statistics therein refer to

maximum advertised speeds which are typically higher than actual speeds, often by substantial margins89.

86 (HRSA, n.d.) 87 (ibid.) 88 (California Telehealth Network, 2012) 89 (Molla, 2014)




This map depicts

the percentage of

residents in frontier

counties with

access to download

speeds of at least

1.5 Mbps. This

speed is adequate

for streaming

standard definition

video.

Approximately 99%

of frontier residents

have access to

download speeds at

this level compared

to nearly 100% of

residents

nationwide.

This map depicts

the percentage of

residents in frontier

counties with

access to download

speeds of at least 3

Mbps. This speed is

adequate for

streaming high

definition video.

Approximately 99%

of frontier residents

have access to

download speeds

at this level

compared to nearly

100% of residents

nationwide.


____________-

This map depicts

the percentage of

residents in

frontier counties

with access to

download speeds

of at least 10

Mbps. This speed

is adequate for

videoconferencing

and E-

Government.

Approximately

97% of frontier

residents have

access to

download speeds

at this level

compared to 99%

of residents

nationwide.

_________-------

This map depicts

the percentage of

residents in

frontier counties

with access to

download speeds

of at least 25

Mbps. This

standard

represents the

FCC “Advanced

Telecom.

Capability”

Benchmark, the

working definition

of broadband

adopted in 2015.

Approximately

73% of frontier

residents have

access to

download speeds

at this level

compared to

nearly 85% of

residents

nationwide.


This map depicts

the percentage of

residents in

frontier counties

with access to

download speeds

of at least 50

Mbps. This speed

is adequate for

Telecommuting,

Distance Learning

and Telehealth.

Approximately

68% of frontier

residents have

access to

download speeds

at this level

compared to 85%

of residents

nationwide.

This map depicts

the percentage of

residents in

frontier counties

with access to

more than one

broadband

provider. Lack of

competition is

often associated

with higher prices

and lower service

quality. While

most frontier

residents have

access to at least

2 providers,

several areas are

visibly lacking in

competition.


This map

depicts frontier

Primary and

Secondary

Schools by

Broadband

access and

speed. The FCC

recommends

download

speeds of 1

Gbps for each

1,000

students.

This map

depicts frontier

libraries by

Broadband

access and

speed.


This map depicts

frontier colleges

and universities

access and speed.

The FCC

recommends

download speeds of

1 Gbps for each

1,000 students.

This map depicts

frontier medical

community anchor

institutions by

Broadband access

and speed. As

noted earlier, the

FCC recommends

download speeds of

at least 10 Mbps for

a rural health clinic

and 25 Mbps for a

clinic/large

physician practice.


This map depicts

the broadband

investment gap

in frontier

counties. As one

can see, the

largest

investment gaps

appear to occur

in the Southwest.

The total

investment gap

for frontier

counties is over

$13 billion or

57% of the total

national $23.5

billion

investment gap.

This map depicts

the broadband

investment gap

per person in

frontier counties.

As one can see,

the largest per

capita

investment gaps

appear to occur

in the

Northernmost

counties. The per

capita

investment gap

in frontier

counties is $360

compared to only

approximately

$74 nationwide

and $36 in non-

frontier counties.


This map depicts

the broadband

investment gap

per square mile

in frontier

counties. As one

can see, the

largest

investment gaps

appear to occur

in the

Northernmost

counties. The

investment gap

for frontier

counties is

approximately

$5,500 per

square mile

compared to

approximately

$6,200 per

square mile

nationwide and

$7,300 in non

frontier counties.

This map depicts

access to 25

Mbps download

speeds in

majority nonwhite

counties in the

frontier.

Approximately

81% of residents

of majority

nonwhite

counties have

access to 25

Mbps download

speeds compared

to 73% of

residents of all

frontier counties.


CONCLUSION

One can easily see that functional broadband access continues to be a challenge for frontier

communities. While most frontier areas have broadband access at low levels of quality, high speed broadband

is sorely lacking across the frontier. The significant and well documented urban-rural broadband gap grows

even larger when narrowed down to frontier areas. These counties, despite making up only a fraction of the

country’s population, represent the majority of the broadband investment gap and are disproportionately

disinvested compared to the rest of the country. Applications such as distance learning, telecommuting and

telehealth hold enormous potential for improving quality of life and service provision on the frontier, however

many frontier communities lack the necessary level of broadband service.


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Mental and Behavioral Healthcare Access on the Frontier 41

ACCESS TO MENTAL AND BEHAVIORAL

HEALTH CARE IN FRONTIER AREAS LOAN DAO AND SARAH DEGIORGIS


TABLE OF CONTENTS

INTRODUCTION .......................................................................................................................................................... 44

The Frontier and Healthcare Professional Shortage Areas ................................................................................. 44

OVERVIEW OF THE CURRENT MENTAL HEALTH CARE LANDSCAPE ....................................................................... 44

Map 1: Mental health professional shortage areas and far 2 Zip Codes ....................................................... 45

Map 2: Frontier Mental Health Professional Shortage Areas and Far 2 Zip Codes ....................................... 45

Demographics ........................................................................................................................................................ 46

Table 1: Educational Attainment in Metro and Nonmetro Areas from 2000-2014 ................................... 46

Mortality ............................................................................................................................................................. 46

Table 2: Rural and Urban Mortality Rates .................................................................................................... 47

Substance Abuse ............................................................................................................................................... 47

Table 3: Trends in Drug Use Among Rural and Urban U.S. Residents Ages 12-17 ................................... 47

Table 4: Trends in Alcohol Use Among Rural and Urban U.S. Residents Ages 12 and older .................... 47

Table 5: Trends in Methamphetamine Drug Use Among Rural and Urban U.S. Residents Ages 12 and

older ................................................................................................................................................................ 48

Table 6: Substance Abuse Among Rural Residents .................................................................................... 48

by Age and Substance Type in 2003 ............................................................................................................ 48

Table 7: Substance Abuse Treatment Admission Rates ............................................................................. 48

Mental Illness ..................................................................................................................................................... 48

Table 8: Any Mental Illness (AMI) Among Persons 18 Years of Age and Older .......................................... 49

Table 9: Past 30-day Serious Psychological Distress (SPD) Among Persons 18 Years of Age and Older 49

Types of Mental Health Care Providers ................................................................................................................ 49

Table 10: Types of Health Care Professionals ............................................................................................. 50

Table 11: Active Physicians per 100,000 People ........................................................................................ 51

CHALLENGES OF PROVIDING MENTAL HEALTH CARE IN FRONTIER REGIONS ..................................................... 51

Geographical Determinants and Long Travel Times ............................................................................................ 51

Poverty .................................................................................................................................................................... 51

Table 12: Poverty Rates by Race in Rural Areas .......................................................................................... 52

Cultural Issues ....................................................................................................................................................... 52

Stigma, Lack of Anonymity, and Stoicism ........................................................................................................ 52

CASE STUDIES OF MENTAL AND BEHAVIORAL HEALTH TREATMENT MODELS IN FRONTIER AREAS .................. 52

Behavioral Health Aides ........................................................................................................................................ 52

Telehealth .............................................................................................................................................................. 53

CONCLUSION AND HEALTH POLICY CONSIDERATIONS ........................................................................................... 53

Behavioral Health Aides Funding .......................................................................................................................... 53

Expand the Ability of Providers to Prescribe Medications ................................................................................... 54


Telehealth .............................................................................................................................................................. 54

Conclusion .............................................................................................................................................................. 54

References ................................................................................................................................................................. 55


INTRODUCTION

When looking at access to mental and behavioral health care, the small population in frontier areas translates

to a lack of health care providers. This chapter provides an overview of the state of mental and behavioral

health care access in frontier areas and a review of some innovations in mental and behavioral health care

that may warrant further investigation for use in areas with a shortage of mental health care providers.

Mental health problems are common and undertreated; it is estimated that fewer than half of all people with

mental health issues receive any treatment, and an even smaller proportion receives treatment that meets

acceptable minimal standards90. This is exacerbated in rural areas where there are fewer health care

professionals. Though data show that rural and urban populations have similar rates of clinically defined

mental health problems91, there are both cultural and geographical barriers to entry to mental health care for

rural and frontier residents in addition to a lack of providers. There is evidence that residents of rural and

frontier communities receive less talk therapy (psychotherapy) and more prescribed medications

(pharmacotherapy) than residents of urban areas, most likely due to the lack of mental health care providers in

frontier areas92. It has also been shown that rural areas have higher instances of suicide and substance abuse

than urban areas93. This chapter discusses these issues and provides a preliminary roadmap of ways to

increase access to mental health care in very rural and frontier regions.

THE FRONTIER AND HEALTHCARE PROFESSIONAL SHORTAGE AREAS

The United States Department of Health and Human Services (HHS) designates certain areas as “Health

Professional Shortage Areas” and, beyond that, “Mental Health Professional Shortage Areas” (MHPSAs) based

on geographic area, population, and facilities94. Map 1 shows the counties that are designated as FAR level

two and also the designated Mental Health Professional Shortage Areas. In addition, HHS identifies certain

MHPSAs as “frontier,” though their definition of frontier does not use the FAR methodology. Map 2 shows FAR

2 areas and also MHPSAs that are designated as frontier. Frontier areas are not the only MHPSAs, and we

have considered innovations in mental health care that come from other areas of the country, some

designated MHPSAs.

OVERVIEW OF THE CURRENT MENTAL HEALTH CARE LANDSCAPE

In this section we discuss the current state of mental health care in frontier areas, including demographics of

frontier populations and types of mental health care providers. This section is a broad overview, as frontier

areas can vary significantly in demographics. Due to small population size, any health data on frontier areas

can be hard to obtain. In the absence of true frontier data, we have substituted metro and nonmetro data.

Though a reasonable substitute for purely frontier area data, this data should be taken as estimates.

90 (Hauenstein et al., 2007) 91 (Hartley et al., 2002) 92 (Fortney et al., 2009) 93 (Nayar et al., 2013) 94 (Health Resources and Services Administration, n.d.)


MAP 1: MENTAL HEALTH PROFESSIONAL SHORTAGE AREAS AND FAR 2 ZIP CODES

MAP 2: FRONTIER MENTAL HEALTH PROFESSIONAL SHORTAGE AREAS AND FAR 2 ZIP CODES


DEMOGRAPHICS

The American frontier community has a diverse population. Compared to the country as a whole, frontier areas

tend to have a greater number of older (over 65 years) residents and fewer young (under 18 years) residents95.

This presents a challenge for health care access as the needs of an aging population must be addressed. In

addition, residents in frontier areas have lower median incomes but also lower rates of unemployment and

higher literacy rates as compared to the rest of the country. Importantly, though, frontier areas have a higher

proportion of Latino and Native American/American Indian populations and lower proportions of African

American and Asian populations. Frontier communities also have a higher percentage of non-English

speakers96.

In recent years, there has been an increase in the portion of adults with a 4-year college degree (an increase of

4 percentage points from 2000 to 2014). Additionally, the portion of adults without a high school diploma or

equivalent has declined by 9 percentage points. However, there remains a large gap in education between

urban and rural populations97. Table 1 shows the change in educational attainment rates between metro and

nonmetro areas from 2000 to 2014. These factors must be considered when considering access to mental

and behavioral health care in frontier areas. Some additional demographic factors to consider are discussed in

the next sections.

Table 1: Educational Attainment in Metro and Nonmetro Areas from 2000-2014

Nonmetro Less than High

School Diploma

High School

Diploma

Some College or

Associate’s Degree

Bachelor’s Degree or

Higher

2000 24% 36% 25% 15%

2014 15% 36% 30% 19%

Metro Less than High

School Diploma

High School

Diploma

Some College or

Associate’s Degree

Bachelor’s Degree or

Higher

2000 19% 27% 28% 26%

2014 13% 26% 29% 32%

MORTALITY

The health disparities among rural and urban populations are drastic. Rates such as chronic obstructive

pulmonary disease (COPD) are higher among those in rural counties. There are higher rates of suicide in small

rural communities than there are in inner cities. Due to the limited access to psychologists and other mental

health professionals, those living in remote areas do not receive the care they need. Small rural communities

experience a suicide rate of 20% while inner cities experience a suicide rate of 13%. Figure 3 is a comparison

of mortality rates among rural and urban counties. 98 It is worth noting that in every category listed in table 2,

mortality rates are always higher in nonmetro counties. Higher rates of suicide in rural areas may mean that

the prevalence of depression and other mental issues may be underreported in these areas99.

95 (Nayar et al., 2013) 96 Ibid 97 (USDA, US Census Bureau, n.d.) 98 (Rural Health Reform Policy Research Center, 2014) 99 (Hartley et al., 2002)


Table 2: Rural and Urban Mortality Rates100

Metro Counties Nonmetro Counties

Inner Cities

(Large

Central)

Suburban

(Large

Fringe)

Small Metro

(Population

< 1 million)

Large Rural

(Without a city >

10,000

population)

Small Rural

(With a city >

10,000)

Infant Mortality 6.8 5.7 6.7 6.8 7.0

Chronic Obstructive

Pulmonary Disease

(COPD)*

56.2 60.6 70.9 79.9 81.9

Ischemic Heart

Disease*

192.9 174.9 173.8 197.2 206.5

All Unintentional

Injuries

32.1 33.1 40.8 58.9 52.7

All Motor Vehicle

Traffic-Related

Injuries

7.9 9.3 12.1 23.3 19.5

Suicide 12.8 13.7 16.1 18.2 20.0

Data is per 100,000 Population (* Persons 20 years of age or older)

SUBSTANCE ABUSE

Coupled with this data, research suggests that the number of rural and frontier residents suffering from

substance abuse is increasing. In 1997, roughly 10% of rural residents ages 12 and older reported using

drugs. That figure increased by 3% in 2003, with roughly 13% of rural residents in the same age group

reported using drugs.

Although total trends in drug use among rural residents remain lower those in urban areas, alcohol and

methamphetamine use among rural residents are higher than in urban areas (Tables 4 and 5). In 2003,

alcohol use among rural residents ages 12 to 17 was roughly 5% higher than those in urban areas.

Additionally, methamphetamine use among rural residents ages 12 and older was roughly 0.3% higher in than

in urban areas.

100 (Rural Health Reform Policy Research Center, 2008–2011 data) 101 (NSDUH, 1979-2003) 102 (Samhsa.gov)

Table 3: Trends in Drug Use Among Rural and Urban U.S. Residents Ages 12-17101

1979 1985 1991 1997 2003

Rural 15% 13% 11% 10% 13%

Urban 22% 21% 13% 12% 15%

Table 4: Trends in Alcohol Use Among Rural and Urban U.S. Residents Ages 12 and older102

1979 1985 1991 1997 2003

Rural 52% 52% 35% 20% 31%

Urban 55% 50% 36% 29% 26%


Table 5: Trends in Methamphetamine Drug Use Among Rural and Urban U.S. Residents Ages 12 and

older103

1999 2000 2001 2002 2003

Rural 48% 42% 70% 71% 78%

Urban 54% 40% 58% 66% 49%

There are many factors that can contribute to substance abuse, including untreated mental health issues. It is

important to consider the possibility that substance abuse rates mask other behavioral and mental health

issues in addition to their complication in other areas of concern like overdose and suicide.

Rates of substance abuse vary among different age groups. For example, young adults tend to have higher

rates of substance abuse than older adults. Table 6 shows residents ages 18 to 25 have higher rates of

substance abuse compared to residences ages 26 or older.

It bears keeping in mind that surveys asking about

substance abuse suffer from respondent bias, so

these numbers should not be used to draw strong

conclusions. However, substance abuse treatment

admission rates do show some disparities between

metro and nonmetro areas. Table 7 shows that

communities in small rural areas have lower

substance abuse treatment admission rates compared to those in metropolitan areas. Table 7 makes clear

that residents of small rural areas are admitted to substance abuse treatment programs less frequently than

residents of metro areas.

Table 7: Substance Abuse Treatment Admission Rates105


Inner Cities

(Large

Central)

Suburban

(Large

Fringe)

Small Metro

(Population <

1 million)

Large Rural

(Without a city

> 10,000

population)

Small Rural

(With a city >

10,000)

Alcohol 247.8 245.2 292.7 326.8 250.3

Opiates 175.0 172.5 142.8 127.3 90.4

Cocaine 75.8 43.6 53.7 38.2 21.7

Marijuana 128.9 99.9 137.2 162.8 112.0

Stimulants 48.7 21.5 50.1 57.9 45.8

*Admissions per 100,000 population- age-adjusted

MENTAL ILLNESS

Data show that mental health issues are slightly more prevalent in rural areas. The shortage of mental health

professionals is a major problem. Additionally, cultural considerations like stigma, lack of anonymity and

stoicism can inhibit frontier residents’ use of mental health care. According to the National Survey on Drug Use

and Health (NSDUH), any mental illness (AMI) includes persons 18 or older who currently or at any time in the

103 (Samsha.gov) 104 (Scholars.unh.edu) 105 (Rural-Urban Chartbook, 2014)

Table 6: Substance Abuse Among Rural Residents

by Age and Substance Type in 2003104

Age Alcohol Drugs Alcohol and

Drugs

12-17 7% 5% 10%

18-25 18% 8% 20%

26 and older 6% 3% 7%


past year who have been diagnosable mental, behavioral, or emotional disorders. The total rates of any mental

illness in small rural areas are higher than in inner cities by 2%.

Table 8: Any Mental Illness (AMI) Among Persons 18 Years of Age and Older106


Inner Cities

(Large

Central)

Suburban

(Large

Fringe)

Small Metro

(Population <

1 million)

Large Rural

(Without a city

> 10,000

population)

Small Rural

(With a city >

10,000)

Men 13.9 14.1 15.2 15.1 15.2

Women 19.9 20.6 22.8 23.9 23.1

Total 17.0 17.5 19.0 19.6 19.2

Additionally, serious psychological distress (SPD) is an indicator of nonspecific psychological distress that is

constructed from a scale administered to adults ages 18 and older by NSDUH. This scale gathers information

on how frequently a respondent experiences symptoms of psychological distress over the last 1 month in the

past year when he or she was at his or her worst emotionally.

Again, data show that residents living in small rural counties experience serious psychological distress (SPD) at

a slightly higher rate than those in inner cities. Serious psychological distress is higher among women than

men in all regions. For example, 7% of women in small rural communities experience distress while 5% of men

experience distress.

Moreover, the national percentage of adults with serious psychological distress (SPD) was lower in metro

counties and the highest in nonmetro counties. More specifically, the regional data shows that the number of

adults who had SPD in the south was higher in nonmetro counties than in metro counties.

Table 9: Past 30-day Serious Psychological Distress (SPD) Among Persons 18 Years of Age and Older107


Inner Cities

(Large

Central)

Suburban

(Large

Fringe)

Small Metro

(Population <

1 million)

Large Rural

(Without a city

> 10,000

population)

Small Rural

(With a city >

10,000)

Men 4.1 3.5 4.1 4.6 4.9

Women 5.6 4.5 6.1 6.7 6.5

Total 4.8 4.0 5.1 5.7 5.7

TYPES OF MENTAL HEALTH CARE PROVIDERS

When looking at the state of mental health care on the frontier, it is important to consider all the providers who

may be involved in mental health care. We have compiled a list of both licensed and unlicensed providers who

may provide mental health care below.

The National Alliance on Mental Illness (NAMI) lists types of health care professionals who can and do provide

mental health treatment. Some can prescribe medication while others provide therapy.

106 (Rural-Urban Chartbook, 2014) 107 (Rural-Urban Chartbook, 2014)


Table 10: Types of Health Care Professionals108

Name Degree Ability to prescribe

medication?

Ability to provide

therapy? Notes

Primary Care

Physicians MD Yes No

Psychiatrists MD Yes Yes

Clinical Psychologists PhD or PsyD Depends on the

state Yes

School Psychologists

Psychiatric or Mental

Health Nurse

Practitioners

MA or PhD Depends on the

state Yes

Clinical Social Workers MA No Yes

Social Workers BA or BS No Yes

Counselors Varies No Yes

Pastoral Counselors Varies No Yes

Can be members of the

Association of Pastoral

Counselors (AAPC)

Peer Specialists Certification No Yes

Peer specialists have

personally experienced

mental and behavioral

health issues

Psychiatric

Pharmacists Varies No Yes

Usually work in

conjunction with a

physician

It is important to recognize that many types of professionals (and non-professionals) can provide mental and

behavioral health care. Since frontier areas have fewer licensed mental and behavioral health providers, it

might be necessary to rely on some of these non-licensed providers. NAMI points out that many Primary Care

Physicians (PCPs) provide mental and behavioral health care in areas with a mental health professional

shortage. Though PCPs can prescribe medication, they are not trained to diagnose and treat mental disorders

and a specialized trained psychiatrist is preferable in mental and behavioral health cases109. Although not

specialists, PCPs can and do provide a large amount of mental and behavioral health care.

The supply of physicians is a direct influence on healthcare. The shortage of health professionals forces

patients to travel farther to receive service. Although the number of health professionals has risen in the last

decade, many health professionals choose to practice in more populated urban areas. In 2010, differences in

physicians practicing in specialized fields such as neurology, anesthesiology, and psychiatry where the most

disparate. Central counties of metropolitan areas had roughly 263 specialists per 100,000 populations while

most rural counties had only 30 per 100,000. Additionally, the number of total physicians in small rural regions

is 77 per 100,000 populations while the number in inner cities is 380.5 per 100,000 populations.

108 (National Alliance on Mental Illness, n.d.) 109 (NAMI)


Table 11: Active Physicians per 100,000 People110


Inner Cities

(Large

Central)

Suburban

(Large

Fringe)

Small Metro

(Population <

1 million)

Large Rural

(Without a city

> 10,000

population)

Small Rural

(With a city >

10,000)

General and family

practitioners

27.0 24.5 34.2 29.6 31.6

Pediatricians 25.1 20.1 15.6 8.8 3.7

General Internists 49.6 37.1 30.5 17.9 8.9

Obstetricians and

Gynecologists

16.0 12.4 11.4 7.5 3.0

Other Specialists 262.8 174.2 169.1 80.1 30.2

All Physicians 380.5 268.4 260.8 143.9 77.3

The lack of health insurance and access to care are also factors leading to an increase in mental health

problems in rural America. National data from the year 2011 shows that residents in rural counties were more

likely to be uninsured (23 percent) than those in metropolitan areas (19 percent). Though studies have shown

that a lack of insurance does not have a significant impact on the utilization of mental health care services111,

it is a disparity between urban and rural areas that cannot be ignored.

CHALLENGES OF PROVIDING MENTAL HEALTH CARE IN FRONTIER REGIONS

Many factors such as geographical limitations and social stigmas, those facing drug addiction and other health

problems are less likely to seek help. Conflicts between community values and professional guidelines can also

limit services and resources. This section seeks to explore those areas in more detail.

GEOGRAPHICAL DETERMINANTS AND LONG TRAVEL TIMES

The geographic context of Frontier areas results in isolation, smaller population size, and limited access to

specialized jobs. As previously stated, frontier areas often suffer from a lack of specialized mental and

behavioral health care providers. Clinicians often work far from peers and patients while facing geographic

barriers. Access to sufficient roads and public transportation such as buses, trains, or taxi services make it

difficult for patients to seek medical attention112. Increasing transportation infrastructure may not be a priority

for frontier residents, but improved ride sharing services or shuttles for elderly people may warrant

consideration in the future.

POVERTY

The poverty level in frontier areas, specifically child poverty, has increased in recent years. The child poverty

rate increased from 22% in 2007 to 26% in 2014 (based on income, size, and family composition). 113 Minority

racial and ethnic groups experience the most poverty in frontier areas. From 2007 to 2009, these groups saw

an increase in poverty rates; the poverty rate among Latinos increased the most (by 2 percentage points).

110 (Rural Health Reform Policy Research Center, 2008–2011 data) 111 (Deen et al., 2012) 112 (NSDUH) 113 (USDA, 2015)


Table 11 shows the change in poverty rate among all racial and ethnic groups from 2007 to 2014. Poverty can

mean the inability to pay for doctor’s visits and medications, and also a higher probability of being uninsured.

All of these factors need to be considered when studying mental health care use and access.

CULTURAL ISSUES

Cultural issues related to mental health care and frontier residents can largely be divided into three main

groups: stigma, lack of anonymity, and stoicism. Of course these are not the only cultural issues; religion and

general culture play a part as well. For this report we have chosen to focus on the three issues listed above

because they seem to be the most prevalent from our literature review.

STIGMA, LACK OF ANONYMITY, AND STOICISM

Assessing “stigma” around mental health care issues is hard to do, and especially hard when it comes to

frontier areas. One study did specifically ask survey participants about stigma using the statement “My friends

and family will think I am crazy if I see a counselor or therapist” to which respondents answered “yes” or “no.”

This study tested participants’ views on a lack of anonymity with the statement “My friends and neighbors will

know if I see a counselor of therapist” to which respondents answered “yes” or “no.” Stoicism was assessed

using the following statement: “My problems are my own business” to which respondents answered “yes” or

“no115.” It is unclear if the methods used in this study skewed the results or not (the authors point out that

since this study asked about prior mental health care usage, the results may be limited because of temporal

biases.) Nonetheless, the study found that these cultural issues of stigma, lack of anonymity, and stoicism do

not significantly predict lower mental health care utilization116. This does not mean that these cultural issues

do not exist and mental and behavioral treatment providers should be sensitive to these and other cultural

issues when practicing in frontier areas.

CASE STUDIES OF MENTAL AND BEHAVIORAL HEALTH TREATMENT MODELS IN

FRONTIER AREAS

In this section, we discuss mental and behavioral treatment options that may not have been explored in some

frontier areas. Though we recognize that all frontier areas are very different, these case studies may warrant

further investigation for use in frontier areas with a lack of mental and behavioral health professionals.

BEHAVIORAL HEALTH AIDES

The Behavioral Health Aide (BHA) model offers a new way of providing mental and behavioral health care that

could apply to frontier areas. BHAs expand the mental health care workforce by employing local residents

114 (USDA, US Census Bureau, n.d.) 115 (Deen et al., 2012) 116 Ibid.

Table 12: Poverty Rates by Race in Rural Areas114

White Black or African

American

American

Indian or

Alaskan

Native

White, non-

Latino

Latino

2007 14% 34% 31% 13% 28%

2014 16% 37% 33% 13% 27%


instead of bringing in outside mental health professionals. BHAs have significant differences from traditional

mental and behavioral health care:

o BHAs practice in the community, making them easier to access

o Since BHAs come from the same community as their patients, their level of cultural understanding is

high

o BHAs often educate the community about behavioral health so as to reduce stigma117

Though there are numerous types of BHAs, we want to focus on one that may be particularly well-suited to

frontier areas with different cultural issues: Peer Counselors or Peer Specialists. Peer Counselors are people

who have experienced a certain behavioral health issue and who have received training in how to use their

experiences to counsel and help others experiencing something similar.118 As van Hecke (2012) and others

note, Peer Counselors can be particularly helpful in situations of cultural sensitivities, including stigma around

mental and behavioral issues119. By sharing their experiences of mental and behavioral treatment, Peer

Counselors may be very useful for patients who can be skeptical of mental health professionals or who just feel

more comfortable talking to a peer. We urge frontier area mental and behavioral health clinics to utilize the

peer counseling method as a way to access underserved populations.

TELEHEALTH

Though face-to-face contact is best for diagnoses and treatment of mental and behavioral health issues,

telehealth may be of use in areas with a lack of mental health care providers. In addition to diagnoses,

telehealth could prove important in provider-to-provider interactions120 – for instance, if a PCP sees a patient

with a behavioral or mental health issue that is outside their scope of expertise, that PCP could compare notes

with experts in that field via telehealth.

An issue with telehealth is that it is not always covered by insurance. Reimbursement policies need to be

modified in order to improve the business case for delivering evidence-based psychotherapy to rural patients via

telephones, video and computer121. For frontier areas lacking behavioral and mental health providers, a case

could be made for telehealth as a partial substitute for these providers as long as the area has sufficient internet

or broadband access.

CONCLUSION AND HEALTH POLICY CONSIDERATIONS

Though far from experts on health policy and especially frontier-specific health policy, we wanted to provide

some ideas for moving forward. We think that Behavioral Health Aides, increased prescribing ability, and

telehealth should be explored further for their applicability to frontier areas. Brief concluding remarks on those

three issues follow.

BEHAVIORAL HEALTH AIDES FUNDING

A big hurdle for the Behavioral Health Aide model is funding. Studies have shown that Behavioral Health Aides

are less expensive than traditional, licensed providers122, which may help make a case for increased funding.

117 (Van Hecke, 2012) 118 (Van Hecke, 2012) 119 Ibid 120 (Grube et al, 2016) 121 (Fortney, et al, 2009) 122 (Berner et al, 2014)


Though licensed providers are important, we argue that Behavioral Health Aides could be very helpful in

frontier areas and areas where cultural competency of licensed providers might be a concern. Behavioral

Health Aides are particularly useful in frontier areas because of these cultural issues, and that aspect of the

Behavioral Health Aide model should be emphasized when seeking funding.

EXPAND THE ABILITY OF PROVIDERS TO PRESCRIBE MEDICATIONS

Nonlicensed providers should be able to prescribe in areas, like frontier areas, with few licensed physicians.

Though medication is not the answer to all behavioral and mental health issues, it is helpful in many cases and

expanding access to medications has the potential to help a lot of people living in areas where licensed

providers may be long drives away.

TELEHEALTH

Telehealth needs to be covered by insurance in order to make it a viable alternative for use in frontier areas.

Although not all residents of frontier areas have health insurance, making telehealth services able to be

covered by insurance would still be beneficial to frontier residents. There are many applications for telehealth

that have not been explored in this chapter that may prove helpful for people in frontier areas, including

patients and health care providers. When considering frontier-specific health policy, telehealth has the

potential to provide many services for a relatively small amount of money as long as the broadband

infrastructure is already in place.

CONCLUSION

We hope this chapter serves as a helpful overview for behavioral and mental health care access in frontier

areas. Though challenging, increased behavioral and mental health care access is possible in remote areas. It

bears keeping in mind that urban and densely populated areas will always have more health care providers

because of the greater population. But those living in frontier areas should be able to access health care

services as their urban counterparts do. This chapter covers some of the challenges and innovations for

successful frontier behavioral and mental health care access.


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Bushy, A. (2009). A Landscape View of Life and Health Care in Rural Settings. Dartmouth College Press, 16-38.

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Journal of Rural Health(28), 142-151.

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CO: Western Interstate Commission for Higher Education, Mental Health Program.

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Hartley, D. P., Britain, C., & Sulzbacher, S. P. (2002). Behavioral Health: Setting the Rural Health Research

Agenda. The Journal of Rural Health, 18(S), 242-255.

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Health Treatment. Administration and Policy in Mental Health and Mental Health Services Research,

34(3), 255-267.

Health Resources and Services Administration. (n.d.). Mental Health HPSA Designation Overview. Retrieved

April 10, 2016, from US Department of Health and Human Services:

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Journal of Rural Health, 18(3), 382-383. doi:10.1111/j.1748-0361.2002.tb00900.x

Nayar, P. M., Yu, F. P., & Apenteng, B. A. (2013). Frontier America's Health System Challenges and Population

Health Outcomes. The Journal of Rural Health, 29, 258-265.

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Department Of Health And Human Services Substance Abuse and Mental Health Services

Administration Center for Behavioral Health Statistics and Quality. Retrieved from

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Food Insecurity on the Frontier 57

FOOD INSECURITY ON THE FRONTIER MARLANA MOORE, CHANNING BICKFORD & DANIEL BURTON


TABLE OF CONTENTS

Estimating Food Insecurity on the Frontier .............................................................................................................. 59

Table 1: Estimating Food Insecurity on the Frontier .................................................................................... 60

Food Insecurity in Frontier Counties ......................................................................................................................... 61

Table 2: Descriptive Statistics for Food Insecurity in Frontier Counties ..................................................... 61

Table 3: Food Insecurity and Child Food Insecurity by Frontier County ...................................................... 61

Map 1 - Food Insecurity in Frontier Counties, 2013 ........................................................................................ 62

Poverty & Frontier Counties .................................................................................................................................. 62

Table 4: Top Poverty Rates in Frontier Counties .......................................................................................... 63

Map 2: Poverty Rates in Frontier Counties, 2013 ........................................................................................... 63

Map 3: Persistent Poverty in Frontier Counties, 2013 .................................................................................... 64

Unemployment & Frontier Counties ..................................................................................................................... 65

Map 4: Unemployment in Frontier Counties, 2013 ......................................................................................... 65

Table 5: Top Frontier Counties by Unemployment ....................................................................................... 66

SNAP Rates & Frontier Counties ........................................................................................................................... 66

Map 5: SNAP Rates in Frontier Counties, 2013 .............................................................................................. 66

Table 6: Top Household Snap Rates in Frontier Counties ........................................................................... 67

Racial Breakdown of Food Insecurity in Frontier Counties ..................................................................................... 67

Table 7: Top 10 Frontier Counties with Highest African American Populations by Percent ...................... 67

Map 5: Percent Non-White in frontier counties, 2013 .................................................................................... 68

Distribution By Race: African American ................................................................................................................ 68

Table 8: Top 10 Frontier Counties with Highest African American Populations by Percent ...................... 69

Map 6: Percent African American in Frontier Counties, 2013 ........................................................................ 69

Case Study: Lower Mississippi Delta Region ....................................................................................................... 69

Distribution By Race: American Indian/ Alaska Native Population..................................................................... 70

Table 7: Top 10 Frontier Counties with Highest American Indian / Alaska Native Population by Percent

........................................................................................................................................................................ 70

Map 7: Percent American Indian / Alaska Native, 2013 ................................................................................ 71

Distribution By Ethnicity: Hispanic Population ..................................................................................................... 71

Table 9: Top 10 Frontier Counties with Highest Hispanic Population by Percent ...................................... 71

Map 8: Percent Hispanic / Latino ..................................................................................................................... 72

Conclusion .................................................................................................................................................................. 73

References ................................................................................................................................................................. 74


INTRODUCTION

To be food secure means to have access to healthy, affordable and culturally appropriate food at all times. We

normally discuss food security in context to the individuals who are food insecure, those who struggle to

nourish themselves and their families; we see this in hunger, malnutrition, and the inability of individuals and

families to get enough to eat. Isolated in remote, low density areas, frontier communities face additional

challenges that can make even accessing food incredibly difficult. For example, someone with a very low

income may be far from an emergency food provider or a county office to apply for SNAP benefits. Feeding

America, a nationwide network of food banks that provides research on food insecurity, determined the

national food insecurity rate in 2013 to be 16%. Over 400 counties with frontier communities have food

insecurity rates above the national average.

In order to establish an understanding of food insecurity, we used 2013 data from the US Census Bureau’s

American Community Survey (ACS) 5-year Estimates, USDA ERS’s county-level persistent poverty data, and

Feeding America’s Map the Meal Gap study. Feeding America conducts an annual study called Map the Meal

Gap which looks at hunger at a local level based on determinants of food insecurity such as poverty,

unemployment, and median income from the Current Population Survey, ACS, and Bureau of Labor

Statistics.123 Because Feeding America’s annual data over the past five years saw no statistically significant

changes, we used the most recent year for which data was available. In order to get a clearer idea of how food

insecurity intersects with other variables, we first gave each county a set ranking (FI Rank) based on the food

insecurity rate (FI Rate).

Our analysis had several major findings:

Over 1 million people living in frontier communities are food insecure;

Majority minority counties tend to have higher rates of food insecurity;

Counties with majority African American or American Indian/Alaska Native populations tend to face

the highest food insecurity rates; and

The Lower Mississippi Delta is the area of greatest concern on the frontier.

ESTIMATING FOOD INSECURITY ON THE FRONTIER

The frontier is a large and varied place, with various scales of geography and populations spread out across

the country. The USDA provides counts of the frontier population in every zip code, even if the entire zip code is

not designated as being on the frontier. However, the smallest geographic area at which food insecurity rates

are calculated is at the county level, and zip codes often overlap county boundaries. Census data is also not

calculated at the zip code level. In order to create a national estimate of food insecurity on the frontier, we

summed the 2010 counts of FAR 2 populations at the state level (the earliest year FAR 2 data was available)

and applied the 2010 Feeding America state level food insecurity rate. This ensures we are not missing

individuals who could be overlooked due to the location of zip code boundaries. Because food insecurity levels

for specific frontier communities could likely be higher than the state level data, this estimate should be

123 From Feeding America: “Data Sources: Feeding America (FA) uses the Current Population Survey (CPS) survey data to assess the

relationship between food insecurity and determinants of food insecurity at the state level. FA selected these variables because of their

availability at the county, congressional district, and state level and included unemployment rates, median income, poverty rates,

homeownership rates, African American percentage of the population, and Hispanic percentage of the population. Researchers drew

County and congressional district level data from the American Community Survey (ACS), with the exception of the unemployment data,

which came from the Bureau of Labor Statistics (BLS). For the child food-insecurity estimates, we use data restricted to households with

children for all variables except the unemployment rate, which includes the full population of the county.”


viewed as conservative. The estimate also provides an overview of which states have the most people living in

frontier communities and which have higher rates of food insecurity. It is important to provide this general

overview because our later data analysis uses rates as opposed to estimates of the frontier population at the

county level.

Table 1: Estimating Food Insecurity on the Frontier

State FI Rate FAR 2 Pop # FI State FI Rate FAR 2 Pop # FI

AK 15% 214,228 31,358 MT 15% 223,190 32,466

AL 19% 142,076 27,305 NC 20% 112,882 22,080

AR 19% 311,471 59,745 ND 8% 205,188 15,773

AZ 19% 316,229 59,999 NE 13% 174,285 23,213

CA 17% 222,983 38,230 NH 11% 62,410 6,785

CO 16% 449,521 69,745 NJ 14% 295 40

CT 14% 132 18 NM 19% 235,228 43,459

DE 13% 183 23 NV 18% 121,671 21,265

FL 19% 43,708 8,372 NY 14% 174,628 24,829

GA 20% 134,435 26,803 OH 18% 1,481 267

HI 14% 106,824 14,908 OK 18% 304,207 53,769

IA 13% 289,689 38,780 OR 18% 178,668 31,249

ID 17% 116,433 19,829 PA 15% 135,627 19,743

IL 15% 97,824 14,720 RI 15% 61 9

IN 16% 8,207 1,328 SC 19% 11,246 2,111

KS 15% 296,533 44,440 SD 13% 246,547 30,943

KY 17% 294,136 50,785 TN 18% 108,795 19,109

LA 17% 54,641 9,135 TX 19% 308,966 57,161

MA 12% 10,555 1,298 UT 17% 169,149 28,755

MD 13% 2,328 298 VA 12% 84,502 10,451

ME 15% 171,125 25,556 VT 14% 79,938 11,271

MI 19% 509,563 96,613 WA 16% 163,150 25,868

MN 12% 546,816 62,683 WI 13% 196,631 26,125

MO 17% 401,258 68,670 WV 15% 80,745 11,835

MS 22% 203,565 44,349 WY 12% 226,336 27,571

Grand Total 8,550,289 1,361,141

Our analysis, summarized in Table 1, estimates a total of 1.4 million food insecure people in frontier

communities. 8.5 million Americans live in FAR 2 conditions, accounting for 3% of the country’s population.

Michigan and Colorado have the highest estimates of FAR 2 food insecure individuals, while Michigan and

Minnesota have the largest frontier populations. The frontier states with the highest food insecurity rates are

largely located in the South (Mississippi, Georgia, North Carolina, Arkansas, Alabama, and Florida) while

Arizona, Michigan, and New Mexico follow close behind.

Food insecure people in frontier communities account for 15.9% of the total frontier population, which is very

close to the national average of 15.8%. Because these percentages are so close to the national average, we

cannot say that frontier communities are on the whole more food insecure than the country at large. We can

look more closely at different scales of geography and different characteristics to explore how food insecurity

manifests itself on the frontier.


FOOD INSECURITY IN FRONTIER COUNTIES

Food insecurity has a number of different indicators, including poverty, unemployment, high food costs and

lack of access to programs such as the Supplemental Nutrition Assistance Program (SNAP, formerly Food

Stamps). Hunger and poverty are generally more prevalent in rural areas compared with urban areas. Rural

areas face challenges such as higher un- and underemployment, lower levels of education, lack of available

childcare and public transportation, and an overall lack of access to resources. 124 Because frontier

communities are the most isolated of rural areas, the effects associated with these challenges are much more

severe. To uncover a clearer picture of food insecurity, we looked at food insecurity rates, persistent poverty,

unemployment and other demographic data in counties that contain frontier communities, hereafter referred

to as frontier counties.

We also included information about food insecurity in children, who disproportionately experience food

insecurity and poverty. As children are some of the most vulnerable members of our society, it is important to

understand how food insecurity affects children. Feeding America calculates food insecurity rates overall as

well as for children. The problems children retain due to food insecurity will follow them through their lives.

Food insecure children face hunger and numerous health

challenges that affect their education as well as their future job

readiness prospects.125

Across frontier counties, food insecurity tends to be normally

distributed, with the mean and median slightly below the national

average of 15.8% (Table 2). These distributions have a clear

spatial and racial component, which we will explore in later in our

analysis. Looking at food insecurity regionally, counties in the

South tend to have the highest rates of food insecurity, followed by the Southwest. While we will explore race in

another section, counties with the highest overall rates of food insecurity tend to be majority minority, with high

percentages of African American or Native American populations.

The most food insecure frontier counties are concentrated in the Lower Mississippi Delta, with the exception of

Wilcox County, Alabama (Table 3). This concentration of food insecurity is intense; approximately one in three

people in these counties do not know where their next meal is coming from. Frontier counties with high rates of

child food insecurity are not spread across Arizona, South Dakota, Texas, Alaska and Georgia. The most food

secure frontier households are geographically concentrated in North Dakota: 40 of the top 50 most food

secure frontier counties are located in North Dakota.

124 (Feeding America, 2016) 125 (Cook and Jeng, 2009)

Table 2: Descriptive Statistics for Food

Insecurity in Frontier Counties Maximum 33%

Minimum 4%

Mean 15%

Median 14%

Standard Deviation 4%

Table 3: Food Insecurity and Child Food Insecurity by Frontier County

Most Food Insecure Frontier Counties Most Child Food Insecure Frontier Counties

County Name State FI Rate FI Rank County State Child FI Rate FI Rank

Holmes MS 33% 2 Apache AZ 43% 13

Humphreys MS 33% 2 Oglala Lakota SD 39% 17

Coahoma MS 32% 4 Navajo AZ 39% 29

Leflore MS 32% 4 Sabine TX 38% 20

Sunflower MS 31% 5 Telfair GA 38% 29

Wilcox AL 30% 8 Holmes MS 37% 2

Phillips AR 30% 8 Kusilvak AK 37% 17

East Carroll LA 30% 8 Ben Hill GA 37% 29

Noxubee MS 30% 8 Zavala TX 37% 361

Quitman MS 30% 8 East Carroll LA 36% 8


MAP 1 - FOOD INSECURITY IN FRONTIER COUNTIES, 2013

POVERTY & FRONTIER COUNTIES

Poverty is an important indicator of food insecurity as a family’s available resources determine how much they

are able to spend on food. At the federal level, poverty is measured by income on a sliding scale that depends

on household size.126 Since the 1960s, the poverty rate has been measured by multiplying the cost of food for

an individual or family by three, adjusted for inflation. In 2013, the poverty threshold for an individual under 65

was $12,119, and $23,834 for a family of four.127 Based on increases in other costs of living, such as housing,

transportation, childcare and health care, the threshold for poverty is quite low. In fact, many people with

incomes above the poverty threshold still struggle to meet expenses and provide for themselves and their

families; those with incomes above the poverty threshold also struggle with food insecurity.

Examining poverty in frontier counties, the Midwest and Mountain regions (such as North Dakota, Colorado,

and Minnesota) tend to have lower poverty rates than the South and Southwest (Map 2). The same geographic

areas that struggle with food insecurity also struggle with high rates of poverty. The sole county in Minnesota

with a poverty rate in the top quantile, Mahnomen, has a majority nonwhite population primarily of Native

Americans (41%) and people with two or more races (8%). North Dakota’s three most impoverished counties

also have majority nonwhite populations: Sioux at 87%, Benson with 57% and Rolette at 80%). These counties

are the only frontier counties in Minnesota and North Dakota with majority non-white populations.

126 (National Center for Children in Poverty, 2008) 127 (US Census Bureau n.d.)


Table 4: Top Poverty Rates in Frontier Counties County State Poverty Rate FI Rate FI Rank Child FI Rate

Oglala Lakota SD 52% 26% 17 39%

Humphreys MS 44% 33% 2 35%

Corson SD 44% 21% 77 33%

Todd SD 44% 23% 41 35%

Holmes MS 42% 33% 2 37%

Ziebach SD 42% 20% 103 32%

Hudspeth TX 42% 13% 699 35%

East Carroll LA 41% 30% 8 36%

Wolfe KY 40% 22% 57 35%

Sioux ND 40% 16% 361 26%

The counties that have the highest rates of poverty have between four and five people out of ten living in

poverty. These counties also have at least 75% nonwhite populations, except for Wolfe County, Kentucky which

is 99% white. Half are located in the Upper Midwest, primarily in South Dakota. These counties have between

75 – 97% nonwhite populations; their nonwhite populations are almost wholly American Indian/Alaska Native.

The Lower Mississippi Delta counties (Humphreys, Holmes and East Carroll), with majority black populations,

all have some of the highest rates of food insecurity of the frontier counties. Hudspeth County, TX is nearly 80%

Hispanic.

MAP 2: POVERTY RATES IN FRONTIER COUNTIES, 2013


While we have associated high poverty with high rates of nonwhite populations, the pocket of poverty in

eastern Kentucky is an important exception; formerly coal country, these counties have increasingly faced poor

economic opportunity and declining populations.128

MAP 3: PERSISTENT POVERTY IN FRONTIER COUNTIES, 2013

Many frontier counties have had high poverty rates for decades. The USDA’s Economic Research Service tracks

the persistence of poverty in counties, defined as 20% or more of their population living below the federal

poverty line for the past 30 years, using decennial census data from 1990-2010.129 Persistent poverty tends to

be a rural problem, with 86% of persistent poverty counties having exclusively rural populations, 130 and over

half of all persistent poverty counties contain frontier communities.

Approximately 14% of all frontier counties are persistent poverty counties. The states with the most persistent

poverty frontier counties include Kentucky (22), Mississippi (19), Texas (14), Missouri (12) and South Dakota

(11). Many regions that face persistent poverty are ones we have discussed, such as the Lower Mississippi

128 (Lowrey, 2014) 129 (US Department of Agriculture, 2015) 130 (George, 2012)


Delta, eastern Kentucky and primarily Native American counties in the North. Others include the Southwest,

the Ozark Mountains and the South. These areas also struggle with food insecurity as shown in Map 1.

UNEMPLOYMENT & FRONTIER COUNTIES

Unemployment is a strong indicator of food insecurity, as families without a consistent income lack sufficient

resources for food.131 Rural areas generally face sluggish economic growth compared with metropolitan areas,

and by their nature of being the most remote, frontier areas are far from employment centers. Frontier

communities also tend to rely on inconsistent and seasonal employment such as in agriculture.

MAP 4: UNEMPLOYMENT IN FRONTIER COUNTIES, 2013

We examined 2013 county-level unemployment data from the US Bureau of Labor Statistics as applied to

frontier counties. Over 400 frontier counties have unemployment rates above the 2013 national rate of 7%. In

addition to the areas of need we have highlighted previously, the West (California, Oregon and Washington

State) and the Upper Peninsula region of Michigan and northern Michigan are in the top quintile of

unemployment (Map 4).

Looking at the counties with the highest rates of unemployment (Table 5), Kusilvak Census Area in Alaska has

an alarming rate of unemployment – nearly one in four people who are part of the workforce do not have a job.

Located on the peninsula on Alaska’s northwest coast, relies heavily on the fisheries in the Bering Strait and

Gulf of Alaska, which provides only seasonal employment.132 Colusa County in California’s Central Valley relies

primarily on agriculture. Apache County, Arizona, located in the state’s northwestern corner, has the highest

131 (Coleman-Jensen and Nord, 2013) 132 (Alaska Department of Labor and Workforce Development, 2016)


rate of child food insecurity in the country, in addition to being a persistent poverty county and in the top

quantile for food insecurity and poverty.

Table 5: Top Frontier Counties by Unemployment

County State UE Rate FI Rate FI Rank Child FI Rate

Kusilvak AK 24% 26% 17 37%

Wilcox AL 19% 30% 8 32%

Colusa CA 19% 15% 464 29%

Apache AZ 18% 28% 13 43%

Harlan KY 18% 23% 41 33%

Yukon-Koyukuk AK 18% 21% 77 31%

Magoffin KY 18% 22% 57 32%

Leslie KY 18% 21% 77 29%


East Carroll LA 17% 30% 8 36%

SNAP RATES & FRONTIER COUNTIES

SNAP, the Supplemental Nutrition Assistance Program, is a federal program that provides low income families

with funding and other benefits that help them improve their health and wellbeing and reduce hunger.133

Individuals eligible for SNAP can have incomes up to 130% of the poverty line, but those with higher incomes

must prove their hardship and eligibility.134

MAP 5: SNAP RATES IN FRONTIER COUNTIES, 2013

133 (Mabli, 2014) 134 (Feeding America, 2016)


While this program has been widespread and successful, it also faces challenges and cutbacks, much like

similar programs that comprise the “safety net” for the poor. Despite its critical role in providing resources for

food, the program continues to face significant funding challenges and cutbacks. As of 2016, unemployed,

childless individuals under 49 years old are limited to three months of benefits, no matter how long or arduous

their search for employment has been.135 Our mapping and analysis looks at the Census variable that tracks

households that have received SNAP benefits in the last 12 months. Counties with high household SNAP rates

may have relatively higher rates of food security because of the resources SNAP provides.

Table 6: Top Household Snap Rates in Frontier Counties

County State SNAP Rate FI Rate FI Rank Child FI Rate

Kusilvak AK 52% 26% 17 37%

Todd SD 46% 23% 41 35%

Owsley KY 44% 21% 77 30%

Oglala Lakota SD 43% 26% 17 39%

Ziebach SD 42% 20% 103 32%

Zavala TX 41% 16% 361 37%


Lee KY 40% 22% 57 34%

Lake TN 40% 23% 41 35%

Buffalo SD 40% 24% 29 35%

RACIAL BREAKDOWN OF FOOD INSECURITY IN FRONTIER COUNTIES

As our earlier analysis suggested, we have determined that race may be the most important predictor of food

insecurity in frontier counties. While frontier counties with low percentages of non-white residents are

scattered throughout the United States and particularly in the Northeast and Upper Midwest, five distinct

pockets of frontier counties have significant percentages of non-white residents. The first is along the U.S –

Mexico border, starting in California and stretching to Texas in the east where there is a large Hispanic

population (see Map 5). The second is located in the northern Great Plains and edge of the Rocky Mountains,

stretching through Montana and North Dakota and concentrating in central-western South Dakota, where there

is a large American Indian population. The third concentration is in the South, beginning in Arkansas, stretching

through central Mississippi and reaching the southern part of Alabama, where there is a high percentage of

African American population. The fourth concentration is in northern and eastern Alaska with a high American

Indian population, while in Hawaii has a racially diverse majority nonwhite population.

Table 7: Top 10 Frontier Counties with Highest African American Populations by Percent

County State FI Rank FI Rate

Child FI

Rate

% Non-

White

%

Black

%

Hispanic

% Am Indian

/ Al Native

Kusilvak AK 17 26% 37% 96% 0.2% 0.2% 91%

Oglala Lakota SD 17 26% 39% 96% 0.1% 1% 96%

Zavala TX 361 16% 37% 94% 0.3% 93% 0.1%

Todd SD 41 23% 35% 90% 0.0% 3% 80%

McKinley NM 29 24% 35% 90% 0.5% 14% 74%

Duval TX 1012 9% 26% 90% 0.7% 88% 1%

Bethel AK 77 21% 30% 89% 0.6% 1% 82%

Northwest Arctic AK 77 21% 30% 89% 0.6% 1% 81%

Sioux ND 361 16% 26% 87% 0.0% 3% 83%

Rio Arriba NM 820 12% 26% 87% 0.4% 71% 15%

135 (Center for Budget and Policy Priorities, 2016)


Counties with the highest percentage of non-white residents are most likely to be heavily American Indian or

Alaska Native with seven of the top ten counties having 80% or more of the population in this category (Table

6). The remaining three counties on this list are heavily Latino, with Rio Arriba County, New Mexico consisting

of 72% Latino and 15% American Indian/Native Alaskan. Of the counties on this list, six counties are in the top

25% of food insecure frontier counties, and all of those six counties are 80% or more Native American/Native

Alaskan. Counties with higher percentages of this population see higher rates of food insecurity.

MAP 5: PERCENT NON-WHITE IN FRONTIER COUNTIES, 2013

DISTRIBUTION BY RACE: AFRICAN AMERICAN

Nationally, African Americans are not only disproportionately impacted by unemployment and poverty, but also

food insecurity. 26% of African American households are food insecure compared 11% of White households

and 14% of all households.136 Across frontier counties the trend of higher rates of food insecurity for African

American communities holds true, as counties with high percentages of African Americans have the most

acute incidence of food insecurity. Frontier counties with high concentrations of African American populations

are located almost exclusively in the South (Map 6). Save for Phillips County, Arkansas, the top ten food

insecure counties overall are the same as in the frontier counties with the highest percentage of African

American populations; Dallas County, Louisiana is number 11 overall (Table 7).

136 Feeding America, http://www.feedingamerica.org/hunger-in-america/impact-of-hunger/african-american-hunger/african-american-

hunger-fact-sheet.html


Table 8: Top 10 Frontier Counties with Highest African American Populations by Percent

County State

FI

Rank

FI

Rate

Child FI

Rate

% Non-

White

%

Black

%

Hispanic

% AI

/ AN White

Holmes MS 2 33% 37% 84% 83% 0.2% 0.1% 16%

Coahoma MS 4 32% 34% 77% 76% 0.5% 0.1% 23%

Humphreys MS 2 33% 35% 78% 76% 2% 0.1% 22%

Sunflower MS 5 31% 33% 75% 73% 1% 0.1% 25%

Wilcox AL 8 30% 32% 73% 73% 0.2% 0.0% 27%

Leflore MS 4 32% 34% 76% 72% 2% 0.5% 25%

Noxubee MS 8 30% 33% 73% 72% 1% 0.3% 27%

East Carroll LA 8 30% 36% 73% 70% 3% 0.1% 27%

Quitman MS 8 30% 34% 71% 70% 1% 0.1% 29%

Dallas LA 11 29% 33% 71% 69% 1% 0.1% 29%

MAP 6: PERCENT AFRICAN AMERICAN IN FRONTIER COUNTIES, 2013

CASE STUDY: LOWER MISSISSIPPI DELTA REGION

A study by the Lower Mississippi Delta Nutrition Intervention Research Initiative of diet quality in the region

found that even individuals not struggling with food insecurity have nutritionally poorer diets than peers in

other regions. The diets of both food secure and food insecure individuals were far too low in fiber, and too

high in calorie dense foods (processed, fatty, and sugary foods). This study found that in the Delta race,

education, and age were more strongly correlated with the healthfulness of an individual’s diet than food


security alone was.137 The nutritional quality of the diets of residents in other frontier areas should be studied

in the same way, as underlying factors like a low density of grocery stores are similar across regions.

Rural populations in the Delta had reduced access to a healthful variety of foods, and rely on smaller and more

expensive grocery stores than their urban counterparts. The same study found that even families using SNAP

and similar food assistance programs still had a nearly 40% rate of food insecurity, and 13% of these families

experience hunger. Food insecurity rates for families with children in the Delta were twice as high as they are

nationwide, but were especially high for Black families with children. Although the food insecurity rate is higher

for Black households nationwide, Black households in the Delta were about twice as likely to be food insecure.

Even after adjusting for income and the presence of children, Black Delta households were still twice as likely

to be food insecure as White Delta households. Food insecurity seems to be more intense overall in the Delta,

and not only because of the high prevalence of low-income families, families with children, and minority

families—even within those groups the rates of food insecurity are higher than they are for their peers

nationwide.138

DISTRIBUTION BY RACE: AMERICAN INDIAN/ ALASKA NATIVE POPULATION

While American Indian/Alaska Native serves as one category, it captures a diverse set of cultures and tribes

across the country. Unfortunately, American Indian populations continue to be disproportionately affected by

poverty, hunger and food insecurity, as well as obesity and chronic disease. These communities are affected by

high unemployment and persistent poverty as well. Populations located on reservations are often far from food

retailers. American Indian families are also more likely to rely on federal assistance programs such as SNAP,

Temporary Assistance for Needy Families (TANF), and Women, Infants and Children (WIC) Special Supplement

Nutrition Program.139 Clearly, American Indian communities are in great need when looking at food insecurity

on the Frontier.

Spatially, frontier counties with high percentages of American Indian populations are nearly exclusively located

west of the Mississippi River (Map 7). The highest populations tend to be located in the Southwest, near the

border between Arizona and New Mexico, in South Dakota, and pockets of Montana and North Dakota. Oglala

Lakota County (formerly Shannon County) in the Black Hills region of South Dakota is where the Pine Ridge

Reservation is located. Almost exclusively American Indian, Oglala Lakota is one of the poorest counties in the

country; it also has one of the highest rates of child food insecurity on the frontier.140

Table 7: Top 10 Frontier Counties with Highest American Indian / Alaska Native Population by Percent

County State

FI

Rank

FI

Rate

Child FI

Rate

% Non-

White % Black

%

Hispanic

% Am Indian

/ Al Native

Oglala Lakota SD 17 26% 39% 96% 0.1% 1% 96%

Kusilvak AK 17 26% 37% 96% 0.2% 0.2% 91%

Sioux ND 361 16% 26% 87% 0.0% 3% 83%

Bethel AK 77 21% 30% 89% 0.6% 1% 82%

Northwest Arctic AK 77 21% 30% 89% 0.6% 1% 81%

Todd SD 41 23% 35% 90% 0.0% 3% 80%

Buffalo SD 29 24% 35% 83% 0.5% 1% 79%

Rolette ND 197 18% 29% 80% 0.4% 1% 77%

Dewey SD 57 22% 34% 79% 0.4% 2% 76%

McKinley NM 29 24% 35% 90% 0.5% 14% 74%

137 (Champagne, et al., 2007) 138 (Stuff, et al., 2004) 139 (Chino, Haff and Dodge Francis, 2009) 140 (Gordon and Oddo, 2012)


MAP 7: PERCENT AMERICAN INDIAN / ALASKA NATIVE, 2013

DISTRIBUTION BY ETHNICITY: HISPANIC POPULATION

Similarly to African American and American Indian populations, Hispanic and Latino families are

disproportionately food insecure; nationally, over one in five Latino families are food insecure.141 While

counties with majority African American and American Indian populations experience extreme poverty and food

insecurity, we did not find the same for frontier counties with majority Latino populations (Table 8).

Table 9: Top 10 Frontier Counties with Highest Hispanic Population by Percent

County State

FI

Rank

FI

Rate

Child FI

Rate

% Non-

White

%

Black

%

Hispanic

% Am Indian

/ Al Native

Zavala TX 361 16% 37% 93.5% 0.3% 93.2% 0.1%

Duval TX 1,012 9% 26% 89.7% 0.7% 88.3% 0.7%

Dimmit TX 978 10% 29% 86.3% 0.8% 85.8% 0.1%

Presidio TX 577 14% 33% 84.8% 0.3% 82.1% 2.5%

Mora NM 699 13% 28% 82.7% 0.1% 81.7% 2.1%

Val Verde TX 915 11% 27% 82.6% 1.2% 80.2% 0.3%

Hudspeth TX 699 13% 35% 80.1% 0.6% 79.0% 0.0%

Culberson TX 915 11% 20% 79.9% 0.6% 77.4% 0.7%

Guadalupe NM 915 11% 26% 81.9% 1.7% 76.9% 2.0%

San Miguel NM 699 13% 28% 80.6% 1.7% 76.9% 1.2%

141 (Coleman-Jensen, et al., 2015)


Of the 1,068 counties in our study, only 33 contain majority Hispanic populations; they are all located in the

West, primarily in Texas and New Mexico, but also in Colorado, California and Washington (Map 8). The

average food insecurity rate for these counties was 12%, which is below the national average of 16%. While

these are comparably low food insecurity rates, the average child food insecurity rate for these counties is

27%, meaning that more than 1 in 4 children are food insecure. Understanding food insecurity in Latino

families in frontier communities should be of concern.

Of these counties, Zavala County, Texas and Fresno County, California are the only two with food insecurity

rates above the national average. While Fresno County contains frontier and remote areas (such as a portion of

the Sierra Nevadas), it also contains the fifth largest city in California. Zavala County is located in the Winter

Garden region of southern Texas, close to the Mexican border. Primarily agricultural, the region produces

winter and early spring vegetables such as leafy greens, broccoli and strawberries with the help of irrigation.142

Its unemployment rate (14%) is about double the national average, and is comparable to agricultural Colusa

County, discussed in the unemployment section. Food insecurity in families should be of greatest concern in

Zavala County; approximately one third of the population is below the age of 18. Given a child food insecurity

rate of 37%, over 1,300 children in the county are food insecure, approximately 12% of the county’s total

population.

MAP 8: PERCENT HISPANIC / LATINO

142 (Wheelus, 2012)


CONCLUSION

Our analysis provides a general overview of food insecurity issues across counties containing frontier

communities. We estimated food insecurity at the national level; we examined food insecurity rates, poverty,

unemployment and SNAP rates across frontier counties, and we showed the intersection of majority nonwhite

counties and food insecurity across the country. We intend to lay the groundwork for further study of food

insecurity in frontier communities at more detailed geographies.

The frontier is a vast and diverse but ultimately segregated part of America, with hunger, poverty and food

insecurity primarily present in its segregated areas. Of the entire frontier, the areas with greatest food

insecurity tend to have majority non-white populations. A large portion of the African American population lives

in the Lower Mississippi Delta, facing generational poverty and little to no access to healthy food. Counties with

majority American Indian populations are segregated across the West, in reservations such as Pine Ridge in

Oglala Lakota County, South Dakota. We can also see Latino children as bearing the burden of food insecurity

in the Southwest. These findings should direct future research into food insecurity in frontier communities

across the country.


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