The 2005 Report to the Secretary: Rural Health and …s_report.pdfThe 2005 Report to the Secretary:...

The 2005 Reportto the Secretary:Rural Health and

Human Service Issues

The National AdvisoryCommittee on Rural Health and

Human Services

April 2005

The NACRHHS

i

Acknowledgements

This report is the culmination of a year’s work by the Committee. I wish to thank all of the Committee members for theirhard work but particularly the chairs of the subcommittees: Keith Mueller, Collaborations to Enhance Community andPopulation Well-Being; Glenn Steele, Access to Obstetrical Care in Rural Communities; Ron Nelson, Obesity in RuralCommunities; and Bessie Freeman-Watson, Welfare Reform in Rural Communities. I also wish to acknowledge thework of McKing Consulting’s Jake Culp and Sahira Raifullah, who drafted much of the report, and Jeff Human, JennyYingling, Debra Papanek and Felicia Pratt, who handled the logistics for the Committee’s meetings. Craig Williamsonand Deanna Durrett, two Truman Fellows with the National Rural Development Partnership, also provided invaluableassistance in gathering information for the report and in drafting key sections. I want to thank Beth Blevins for herassistance with the editing and lay-out of the report.

The Committee is deeply indebted to the work and analysis on obstetrical issues provided by Rebecca Slifkin, Katie Gauland Jennifer Groves at the Rural Health Research Center at the University of North Carolina’s Cecil G. Sheps Centerfor Health Services Research and Curt Mueller and Lan Zhao at the Walsh Center for Rural Health Analysis with theUniversity of Chicago’s National Opinion Research Center. Craig Kennedy of the National Association of CommunityHealth Centers and Gary Hart and his colleagues at the University of Washington also provided background informationthat was instrumental on this issue. I would also like to acknowledge and thank the RUPRI Center for Rural HealthPolicy Analysis at the University of Nebraska Medical Center. The Center’s director, Keith Mueller, and staff, espe-cially Michael Shambaugh-Miller and Brandi Shay, provided extensive assistance in researching and drafting the Col-laborations chapter for this report.

This report also benefited greatly from the contributions of Federal staff. This includes Marcia Brand, Jennifer Riggle,Tom Morris, Michele Pray-Gibson, Steve Hirsch, Heather Dimeris and Carrie Cochran of the Office of Rural HealthPolicy. Dennis Dudley of the Administration on Aging, Ann Barbagallo of the Administration for Children and Familiesand Robert Gibbs of the U.S. Department of Agriculture provided outstanding technical support and guidance. CarolineAyoyama and Matt Newland of the Health Resources and Services Administration and Detrice Sherman of the Centersfor Disease Control also provided assistance in the preparation of this report.

I also need to acknowledge all of the individuals connected with the Committee’s two site visits in the past year. In Juneof 2004, the Committee visited Nebraska City, Nebraska and heard from a range of health and human service providers.In September, the Committee visited Tupelo, Mississippi and a number of its surrounding communities. In particular, theCommittee acknowledges the hard work of Keith Mueller and Larry Otis for serving as hosts and organizers of thosetwo site visits. In both cases, the number of people involved is far too many to list here but I want to acknowledge thehelp of everyone connected with the site visits. The opportunity to get into the field and learn about rural health andhuman service delivery from those who are actually providing these services is critical in helping to inform this report andthe recommendations that are included.

Sincerely,

The Honorable David M. Beasley, ChairThe National Advisory Committee on Rural Health and Human Services

ii

The National Advisory Committee on RuralHealth and Human Services

ChairpersonThe Honorable David Beasley

Former GovernorSouth Carolina

Darlington, South Carolina03/01/02 – 03/31/06

Members

James R. Agras, CEOTriangle Tech GroupPittsburgh, PATerm: 03/31/03 - 03/31/07

Susan Birch, RN, MBANorthwest Colorado Visiting Nurse Association, Inc.Steamboat Springs, COTerm: 07/01/03 – 06/30/07

Evan S. Dillard, FACHEAdministratorWalker Baptist Medical CenterJasper, ALTerm: 07/01/02 – 06/30/06

Joellen Edwards, PhD, NPDean and ProfessorEast Tennessee State University College of NursingJohnson City, TNTerm: 07/01/02 – 06/30/06

Michael Enright, PhDChief of PsychologySt. John’s Medical CenterJackson Hole, WYTerm: 07/01/02 – 06/30/06

Bessie Freeman-Watson*Youth Services DirectorIsle of Wright County Office on YouthSuffolk, VATerm: 04/01/03 – 03/31/07

Joseph D. GallegosVice President for Planning and DevelopmentPresbyterian Medical Services

Albuquerque, NMTerm: 07/01/03 – 06/30/07

Julia Hayes, MS, RDAssistant Director of Minority HealthAlabama Department of Public HealthMontgomery, ALTerm: 07/01/04 – 06/30/08

Leonard W. Kaye, DSWDirector, Center on AgingProfessor, School of Social WorkCollege of Business, Public Policy and HealthUniversity of MaineOrono, METerm: 04/01/03 – 03/31/07

Michael Meit, MA, MPHExecutive DirectorUniversity of Pittsburgh Center for Rural Health PracticeBradford, PATerm: 07/01/04 – 06/30/08

Arlene Jaine Jackson Montgomery, PhDProfessor of NursingHampton UniversityNewport News, VATerm: 07/01/03 – 06/30/07

Ron L. Nelson, PA*President & CEOHealth Services AssociatesFremont, MichiganTerm: 07/01/03 – 06/30/07

Sister Janice OtisSE Idaho Community Action Agency

iii

2004-2005 Subcommittees

Collaborations

Keith Mueller, ChairTim SizeJoe GallegosLen KayeLarry Otis

TANF

Bessie Freeman Watson, ChairJim AgrasSue BirchStephanie BaileySally Richardson

Obesity

Ron Nelson, ChairRay RawsonSister Janice OtisPatti PattersonMichael MeitArlene MontgomeryJoellen Edwards

Obstetrics

Glenn Steele, ChairEvan DillardMichael EnrightHeather ReedDave BerkJulia HayesTom Ricketts

Pocatello, IDTerm: 04/01/03 – 03/31/07

The Honorable Larry OtisMayor of Tupelo, MSTupelo, MSTerm: 04/01/03 – 03/31/07

Patti J. Patterson, MD, MPHVice President for Rural & Community HealthTexas Tech University Health Sciences CenterLubbock, TXTerm: 07/01/04 – 06/30/08

Senator Raymond Rawson, DDSMajority LeaderState SenateLas Vegas, NevadaTerm: 07/01/02 – 06/30/06

Heather Reed, MARural Health AdministratorOhio Department of HealthPrimary Care and Rural Health ProgramColumbus, OHTerm: 07/01/03 – 06/30/07

Thomas C. Ricketts III, PhDDeputy DirectorCecil G. Sheps Center for Health Sciences ResearchUniversity of North Carolina School of Public HealthChapel Hill, NCTerm: 07/01/04 – 06/30/08

Tim Size, MBAExecutive DirectorRural Wisconsin Health CooperativeSauk City, WITerm: 07/01/03 – 06/30/07

Glenn D. Steele, MD, PhD*President & CEOGeisinger Health SystemDanville, PATerm: 07/01/02 – 06/30/06

Members Whose Terms Expired in 2004

Stephanie Bailey, BC, MD, MSHSADirector of HealthMetro Davidson County Health Dept.Nashville, TN

Dave BerkConsultant

Rural Health Financial ServicesAnacortes, WA

Keith Mueller, PhD*Professor and HeadDept. of Preventive and Societal MedicineUniversity of Nebraska Medical CenterOmaha City, NE

Sally RichardsonExecutive DirectorCenter for Healthcare Policy and ResearchRobert C. Byrd Health Sciences CenterWest Virginia University, Charleston DivisionCharleston, WV

*Subcommittee Chairs

iv

About the Committee

The National Advisory Committee on Rural Health and Human Services (NACRHHS) is a 21-member citizens’panel of nationally recognized rural health and human service experts that provides recommendations on rural issues tothe Secretary of the Department of Health and Human Services. The Committee was chartered in 1987 to advise theSecretary on ways to address health and human service problems in rural America.

The Committee is chaired by former South Carolina Governor David Beasley. The Committee’s private and public-sector members reflect wide-ranging, first-hand experience with rural issues—in medicine, nursing, administration,finance, law, research, business, public health, aging, welfare and human service issues.

Each year, the Committee selects several issues on which to focus. Background documents are prepared for theCommittee by both staff and contractors to help inform its members. The Committee then produces a report withrecommendations on those issues for the Secretary by the end of the year. In addition to the report, the Committeealso may produce white papers on select policy issues. The Committee also sends letters to the Secretary after eachmeeting. These letters serve as a vehicle for the Committee to raise other issues with the Secretary separate and apartfrom the report process.

The Committee meets three times a year. The first meeting is held in early winter in Washington, D.C. The Committeethen meets twice in the field (in June and September). The Washington, D.C. meeting usually coincides with theopening of a Congressional session and serves as a starting point for setting the Committee’s agenda for the comingyear. The field visits include ongoing work on the yearly topics with some time devoted to site visits and presentationsby the host community.

v

Table of Contents

EXECUTIVE SUMMARY ............................................................................................... 1

INTRODUCTION ............................................................................................................ 5References ...................................................................................................................... 6

COLLABORATIONS TO ENHANCE COMMUNITY AND POPULATION WELL-BEING .......................................................................................................................... 7Recommendations .........................................................................................................19References .....................................................................................................................20

ACCESS TO OBSTETRICAL CARE IN RURAL COMMUNITIES .......................23Recommendations .........................................................................................................32References .....................................................................................................................33

OBESITY IN RURAL COMMUNITIES ......................................................................35Recommendations .........................................................................................................44References .....................................................................................................................45

WELFARE REFORM IN RURAL COMMUNITIES .................................................47Recommendations .........................................................................................................55References .....................................................................................................................56

ACRONYMS USED ........................................................................................................59

1 2005 NACRHHS Report

Executive Summary

This is the 2005 Report to the Secretary of the U.S.Department of Health and Human Services (HHS) bythe National Advisory Committee on Rural Health andHuman Services (NACRHHS). This year’s report fea-tures a chapter that focuses on collaborations in ruralcommunities, as well as issue-specific chapters on ac-cess to obstetrical services in rural communities, obe-sity in rural communities and welfare reform in ruralcommunities. All four chapters represent particular ar-eas of interest for the Committee that were identified atits March 2004 meeting.

Collaborations to EnhanceCommunity and Population

Well-BeingThe purpose of this chapter is to suggest a policy andprogram agenda for HHS that would foster collabora-tions among community organizations and local ruralleaders to improve the well-being of the community andits residents. The NACRHHS has established the fol-lowing principles to guide the development of collabo-rative relationships that advance community health andwell-being:

• Genuinely engage people in the community in allprograms and in collaboration/coordination acrossprograms.

• Measure expected outcomes of program interventionsand demand accountability for those outcomes.

• Target resources effectively by following an inte-grated strategy focused on community-wide goals andobjectives.

• Support local leaders who believe in an action modelthat integrates the activities of multiple programs.

• Discourage redundancy across programs as they areimplemented in rural communities.

The NACRHHS collected information and observedsuccessful examples of local collaborations in South-east Nebraska and Tupelo, Mississippi. In addition,through reviewing current literature and the experiencesof its members, NACRHHS learned of other examplesin which local organizations overcame obstacles to col-laboration and were able to merge resources for inde-pendent sources of support on behalf of common goals.An important indicator of local success in collaborationis strong, creative and consistent leadership. TheNACRHHS examined models of local leadership, in-cluding strategies for recruitment and programs for train-ing. Those models, summarized in this chapter, gener-ated suggestions for rethinking the administration ofFederal programs.

Actions the Secretary should undertake would includethe following:

• Create common reporting requirements for programsthat are linked at the local level.

• Encourage programs in other Federal agencies to par-ticipate in multi-sector collaborations.

• Facilitate interagency cooperation that allows forsingle lines of accountability for funds.

The Committee makes the following recommendations:

• The Secretary should support the creation of a Webresource page for “models that work,” showing suc-cessful collaborations in rural places.

• The Secretary should support research that will fur-ther specify opportunities and barriers.

• The Secretary should support leadership developmentfor rural community organizations and residents.

• The Secretary should require grant recipients engagedin direct delivery of services to demonstrate an effecton community development.


Access to Obstetrical Services inRural Communities

Access to obstetrical (OB) services is an increasing prob-lem in many rural communities. Current data show adisparity in access to OB care between urban and ruralareas of the country. The ratio of physicians trained inobstetrics to women of childbearing age is higher inurban areas than in rural communities, and this ratiowill only worsen as fewer physicians choose obstetricsand even fewer elect to practice in rural settings.

Several factors influence the rural physician supply,such as excessive professional demands on physicianswho practice obstetrics in rural areas, physician pay-ment issues and the increasing cost of malpractice in-surance. If these issues are left unchecked, rural com-munities will see an even greater erosion of OB ser-vices. Limited accessibility to OB care will affect deci-sions that families must make on where to live and raisetheir children and will subsequently have a negative in-fluence on rural economic growth.

This chapter reports some of the difficult problemsthat rural hospitals face in maintaining OB services.During the Committee’s site visits this past year, ruralhospital administrators and medical staffs stressed theimportance of OB services to the mission of a rural com-munity hospital. The Committee visited several hospi-tals that were managing to maintain OB services in theface of significant financial loss. Some of the mostimportant challenges rural hospitals face involve physi-cian shortages, shortages of non-physician providers,low Medicaid payments and declining birth rates in theircommunities.

The Committee describes programs and authoritiesof HHS that are helping to strengthen OB care in ruralcommunities. It believes that the Department can placea greater emphasis on rural concerns in its administra-tion of some of these programs.

The Committee makes several recommendations, in-cluding:

• The Secretary should increase support through TitleVII for medical schools that have distinct programsand a proven track record for training physicians topractice obstetrics in rural areas.

• The Secretary should make the recruitment and place-ment of physicians trained in obstetrics a major goalof the National Health Service Corps.

• The Secretary should support programs to create hos-pital and physician networks that will sustain andimprove access to OB care in rural areas.

• The Secretary should, under Section 301 of the Pub-lic Health Service Act, promote the development ofdemonstration projects that use a team approach toproviding OB services in rural communities, involv-ing physicians, clinical nurse midwives and other non-physician providers.

• The Secretary should work with States to increaseMedicaid reimbursement for OB services in high-needrural areas.

• The Secretary should address the malpractice insur-ance issue by supporting legislation that would ex-tend the Federal Tort Claims Act to rural OB provid-ers in federally designated shortage areas.

Obesity in Rural CommunitiesObesity kills approximately 400,000 Americans eachyear. In March 2004 the Centers for Disease Controland Prevention (CDC) released a study predicting thatthe overweight epidemic soon will become the leadingpreventable cause of death of Americans, outrankingtobacco use. Being overweight or obese increases therisk of individuals developing diabetes, heart diseaseand other health problems.

Obesity trends tracked by the CDC show that moreand more Americans are becoming obese, with ruralAmericans leading the way. Health status and provi-sion of health services are worse in rural America foralmost any disease or health issue, and obesity is noexception. The reasons are due to the unique character-istics of rural health care: more dependence on Medi-care, which does not cover the full range of preventa-tive health care services; lack of coordination of localproviders; socio-economic disadvantage; geographicisolation; provider shortages; lack of transportation; andlifestyle changes.

When national obesity data are examined to comparerural and metropolitan areas, rural Americans have a


higher incidence of obesity than their metro counter-parts. While it is true that rural areas have had lowerrates of overweight and obesity in the past due to thephysical nature of rural occupations, this is no longerthe case because those occupations are continuing todecrease. Obesity is now more common in low-incomeand rural populations due to a number of factors, in-cluding the high cost or limited availability of nutritiousfoods and recreational activities.

Programs to increase physical activity, improve dietand increase the success of smoking cessation are moreimportant than ever. Especially in the often-forgottenrural areas of the Nation, basic public health must bepromoted across the lifespan, and prevention of obesitymust be acknowledged as a public health concern.

To begin addressing the growing challenge of obe-sity in rural communities, the Committee makes sev-eral recommendations to the Secretary, including:

• The Secretary should encourage the States to reviseMedicaid policy. Medicaid should follow Medicareand remove all references to obesity not being an ill-ness.

• The Secretary should make refinements to theHealthierUS community grant program so that ruralconcerns can be more thoroughly represented.

• The Secretary should ensure that the next publica-tion of the CDC Chartbook includes more rural-spe-cific data and that other, future publications includereferences to rural.

• The Secretary should ensure that rural residents areseen as a separate and unique segment of the popula-tion in funding, research and data collection.

Welfare Reform in RuralCommunities

In 1996, Congress passed the Personal Responsibilityand Work Opportunity Reconciliation Act (PRWORA),dramatically changing the Nation’s welfare system froma program designed to provide income maintenance toone focused on moving families into the workforce. TheAct replaced the entitlement program, Aid to Familieswith Dependent Children (AFDC), and several other

associated programs with Temporary Assistance forNeedy Families (TANF), a $16.5 billion Federal blockgrant. The new program gave significant authority andflexibility to the States, yet it established Federal workrequirements for welfare recipients (30 hours/week) andmandated a five-year lifetime limit on the receipt of cashassistance.

In the years following the implementation of TANF,welfare caseloads significantly declined in both urbanand rural areas as the rate of employment for low-in-come families, especially single mothers, drasticallyincreased. However, some TANF recipients still struggleto find and keep a job and to lift their families out ofpoverty. These families often deal with a number ofobstacles, including lack of education or job experience,drug and alcohol abuse, domestic violence, disabilitiesand health problems. Yet rural TANF recipients faceadditional barriers in moving from welfare to work, suchas a lack of public transportation systems, few child careservices, and limited employment and training opportu-nities.

Transportation: Transportation is often cited by wel-fare recipients as the number one obstacle to leavingpublic assistance, and public transportation in rural com-munities is rare. Forty percent of rural communitieshave no public transit system at all, and another 28 per-cent have very limited services available. Private ve-hicle ownership is often the primary mode of transpor-tation, but more than half of the rural poor do not owntheir own cars.

Child Care: Like transportation, reliable child care hasbeen proven essential to moving welfare recipients intowork; however, rural communities commonly have ashortage of child care providers. Rural areas have fewertrained child care professionals and fewer available slotsat child care centers than urban areas.

Labor Markets: Rural communities typically havehigher rates of unemployment and underemploymentthan urban areas, and the majority of available positionsare in low-wage industries. Many rural jobs tend to betemporary, part-time or seasonal, and do not present theopportunity or security of long-term career development.

Studies have shown that the more barriers a welfareclient faces the more difficult it is for the client to suc-


cessfully find employment and leave welfare. RuralTANF recipients often face many barriers. Therefore,the Committee believes it is vital for HHS, in collabo-ration with other agencies and organizations, to con-tinue to address the obstacles of transportation, childcare and job and training opportunities in rural commu-nities.

To aid rural low-income families, the Committee makesseveral recommendations, including:

• The Secretary should work with the Administrationfor Children and Families (ACF) to provide targetedtechnical assistance that would encourage States toaddress the transportation, child care, and employ-ment and training needs of rural TANF recipients.

• The Secretary should emphasize collaboration andencourage States to utilize best practices, such as thoseidentified by ACF.

• The Secretary should strengthen leadership amongFederal partnerships and collaborations, such as withthe Coordinating Council on Access and Mobility,which addresses the transportation needs of ruralAmericans; with Head Start, Early Head Start, childcare and TANF; and with the Internal Revenue Ser-vice on the Earned Income Tax Credit, which pro-vides tax breaks to low-income families.


Introduction

The 2005 Report to the Secretary from the NationalAdvisory Committee on Rural Health and Human Ser-vices is the product of several meetings and much workover the past year. The 21-member Committee, madeup of rural health and human service experts from acrossthe country, met in Washington, D.C. in February of2004 to begin work on the 2005 Report. At this meet-ing, members identified possible issues to bring to theattention of the Secretary. In addition, the Committeeheard testimony from a range of health and human ser-vice experts on key issues affecting rural communities.From within the Department of Health and Human Ser-vices (HHS), the Committee heard presentations byWade Horn, Assistant Secretary for Children and Fami-lies, and Elizabeth Duke, Administrator of the HealthResources and Services Administration (HRSA). Otherpresenters included Marcia Brand of HRSA’s FederalOffice of Rural Health Policy, Jennifer Bell, a memberof the Senate Finance Committee majority staff, andChuck Fluharty, Director of the Rural Policy ResearchInstitute. The Committee also heard from a panel ofrural association experts that included Alan Morgan,Vice President of Governmental Affairs for the NationalRural Health Association, Sandy Markwood, ExecutiveDirector of the National Association of Area Agencieson Aging, and Gary Cyphers of the American PublicHuman Services Association.

After hearing testimony from these experts, the Com-mittee decided to modify the format of its annual re-port. Typically, the Committee’s report focuses on sev-eral individual topics that affect the delivery of healthand human services in rural communities. This year,the report includes three chapters that each focus on aspecific rural issue. However, the 2005 Report beginswith a chapter that is broader and more crosscutting.This particular chapter examines the issue of collabora-tion in rural communities and the need to develop pub-lic policies that foster the ability to work across pro-grams and disciplines to better serve the unique needsof rural communities.

This idea of collaboration is not necessarily new. Foryears, rural advocates have talked about the need formore of a cross-sector approach to assist rural commu-nities. The interest in this issue has only increased overthe years with the advent of block granting in the 1980sand the continued growth of Federal programs that serverural communities. The idea of collaboration to betterserve rural communities received additional support af-ter the release of the report “One Department ServingRural America” in 2002 from HHS. That report to theSecretary from the Department’s Rural Task Force iden-tified approximately 220 programs within HHS thatserve rural communities. All members of the Commit-tee noted the challenges rural communities face in try-ing to navigate across that daunting number of programs.Therefore, in an effort to build on the attention that theHHS report garnered, the Committee decided to take amore in-depth look at the idea of collaboration.

As in previous years, the report also looks more in-tensely at some specific issues affecting rural commu-nities. Through the work of subcommittees, the Com-mittee examined the barriers to obstetrical care in ruralcommunities, the impact of growing rates of obesity onrural communities, and how welfare reform, specificallythe Temporary Assistance for Needy Families (TANF)program, can better meet the needs of rural communi-ties as they seek to help residents make the transitionfrom welfare to work.

After selecting these topics at the first meeting, theCommittee continued to investigate these issues by con-ducting two site visits to rural communities. The Com-mittee visited Nebraska City, located in the southeast-ern corner of Nebraska, in June and Tupelo, located inthe northeast corner of Mississippi, in September. Bothmeetings afforded the Committee uniquely different per-spectives on challenges rural communities face in pro-viding health and human services.

The Nebraska City field meeting emphasized thegeographic isolation of the upper Midwest region of theUnited States as an area populated by very small towns


with agriculture-based economies. Nebraska’s totalpopulation is 1.6 million, with the majority of the peopleliving in the eastern part of the State. Ironically, byNebraska standards, that section of the State, which ispredominately rural, is considered relatively populouscompared to the western half, which is mostly a frontierarea. Nebraska City, a town of approximately 7,000people, lies in the east on the Nebraska-Iowa border andis tightly linked to both Omaha and Lincoln, Nebraska’stwo metropolitan areas.

The Tupelo site visit provided a very different pic-ture of rural America than that of Nebraska City. Tu-pelo has one of the larger populations of any rural areain the country. Under new standards developed by theOffice of Management and Budget (OMB), Tupelo is aperfect example of those areas now identified as“micropolitan.”

Prior to the 2000 census, the primary way to delin-eate geographic areas was to identify those areas thatare metropolitan, cities of more than 50,000 people andtheir outlying suburbs, and then to categorize all otherareas as non-metropolitan.1 The standardized defini-tions of metropolitan areas were first issued in the 1950sas a means to create uniformity among different Fed-eral entities by providing one nationally accepted defi-nition. While these determinations offered a workablenational standard, it also left rural areas relatively unde-fined. For the 2000 census, the OMB added the“micropolitan” category, creating a new and more pre-cise way to define those areas with less than 50,000 inpopulation.2

Tupelo, population 34,211, sits in the middle of a 16-county area in Northeast Mississippi and is home to moreof the area’s residents than any other town. Tupelo isthe primary center of commerce for the area, with a di-versified economy that serves as an anchor for the re-gion and a 650-licensed-bed hospital.

These kinds of communities have always existed, butthe creation of a demographic term that clearly identi-fies them can help to provide insight into the importantroles these communities can play in supporting the ru-ral areas that surround them. These communities canhelp provide the resources and infrastructure necessaryto build meaningful networks of health and human ser-vice providers that support rural communities on a re-gional level.

Tupelo may be one of the more well-known examplesof regional community development. Public policy ex-perts have lauded the accomplishments of this commu-nity, which over the past 100 years has transformed it-self from one of the poorest counties in America to amodel for rural economic development. “The TupeloModel” is often cited as an example of what one com-munity can do to revitalize a region.3

The designation of Tupelo as a micropolitan area re-flects the latest move by the Federal government towardsthe spatial analysis of community. Smaller than metro-politan areas, these regions are based on the premisethat one centralized location or place acts as the focusfor a multi-county area—politically, culturally and eco-nomically. It is obvious that this is the situation in Tu-pelo. It is not so obvious that this situation exists inSoutheastern Nebraska. This reality supports theCommittee’s belief that “rural” is not just a small scaleof “urban” and, therefore, solutions to rural problemsneed to be tailored to the local context.

References

1 “Guide to the 2002 Economic Census.” U.S. Census Bu-reau. Available at: http://www.census.gov/econ/census02/guide/g02geo2.htm.

2 “Main Street America Gets a New Moniker.” The WallStreet Journal; Aug. 23, 2004. Available at: http://www.realestatejournal.com/relocation/relocation/20040823-mccarthy.html.

3 Putnam RD, Feldstein LM, Cohen D. Better Together:Restoring the American Community. New York: Simon &Schuster; 2003.


Collaborations to Enhance Community andPopulation Well-Being

PurposeThe purpose of this chapter is to suggest a policy andprogram agenda that would foster collaborations amongcommunity organizations and local rural leaders to im-prove the well-being of their community and its resi-dents. The National Advisory Committee on RuralHealth and Human Services (NACRHHS) believes thatsustaining rural communities requires effective localcollaborations in which federally funded programs andpayment systems are a significant but not exclusive part.Any strategy to improve and sustain the quality of lifein rural communities must include coordination amongservice providers and local leaders in multiple sectors(e.g., health and human services, transportation, educa-tion, economic development) so that programs are ad-ditive not duplicative, complementary not contradictory,and focused on individual and community outcomes notprocesses.

Why The Committee ChoseThis Topic

The Committee’s support for local collaborations is di-rectly related to “One Department Serving RuralAmerica,” the July 2002 Report to the Secretary of theU.S. Department of Health and Human Services (HHS)from the Department’s Rural Health Task Force. Thatreport put forth five goals that focus on communities,populations and policy efforts that combine the work ofotherwise disparate programs:

1. Improving rural communities’ access to quality healthand human services

2. Strengthening rural families

3. Strengthening rural communities and supporting eco-nomic development

4. Partnering with State, local and Tribal governmentsto support rural communities

5. Supporting rural policy and decision making and en-suring a rural voice in the consultative process

The HHS Rural Task Force Report to the Secretaryacknowledged the importance of coordinating programsin rural communities and the need for broad consider-ation of relevant programs.

The strong relationship between adequate income,sufficient food, strong social networks and good healthnecessitates coordination among various health care and

Terminology

Collaboration: Two or more local organiza-tions taking action based on decisions theyreach together.

Community: An aggregation of individuals ina geographic space that includes at least onepublic entity for general governance. In ru-ral America, a community is typically a localgovernment jurisdiction and surrounding area.

Integration: Two or more organizations arrangeto have at least one service from each con-tribute to the same program. Integration canbe as minimal or extensive as the organiza-tions desire. A memorandum of understand-ing or similar document may be used to com-bine services; a separate organization may beformed to operate a new program that com-bines services from multiple organizations,or organizations may merge into a new for-mal governance structure. In any of these ar-rangements, the connection of related servicesis seamless to the end user.

Services: Those activities that deliver value di-rectly to clients of a local organization.


social service agencies. This coordination is especiallyimportant in rural communities, where services and pro-viders are limited in numbers. In many rural communi-ties, service providers often make alliances with oneanother and exhibit extraordinary resourcefulness andresilience.1

More than 225 HHS programs are available to ruralcommunities. The Rural Policy Research Institute(RUPRI) Center for Rural Health Policy Analysis pre-pared an inventory of these programs for theNACRHHS, which is available through the Rural As-sistance Center at http://www.raconline.org/pdf/rural-hhs-programs.pdf. The NACRHHS concurs with theHHS Rural Task Force recommendations that thereshould be a formal structure within HHS to coordinaterural policy initiatives and a process to include a spe-cific focus or crosscutting discussion about serving ru-ral America as new policies/programs are developed.

The NACRHHS has learned, through site visits and lit-erature reviews, that even in the short time since theTask Force completed its work, innovative efforts havesucceeded at the State and local levels that have achievedcoordination across programs. What remains is to makecoordination a reality at all levels in the Federal system.

Just as HHS has taken the initiative within the Fed-eral government to push for community-based, compre-hensive policy, the NACRHHS believes that local healthand human service leaders will take the initiative to pushfor broad-based community collaborations. With healthand human services as a starting point, community col-laborations can quickly incorporate economic develop-ment, housing, education, transportation and other sec-tors representing essential services.

Achieving the Rural Task Force’s goals requires acomprehensive perspective on who should be engagedin collaborations to benefit the community. Commu-

Aim Population Health Definition Example of Community Program

Safe Avoid accidents and injuries from hazards Community planning to enhance trafficthat may be in the community safety

Effective Pursue community-wide interventions to en- Community planning to encourage exercisehance health based on scientific knowledge and policies to encourage nutritious food in

schools

Patient- and Com- Ensure that stakeholders (education, business Establishment of population health pro-munity-Centered transportation, health care) are respectful grams for minority populations responsive

of community needs, preferences, and values to ethnic cultural and language issues

Timely Ensure early intervention to prevent or delay Education programs on importance of nutri-

onset and progression of disease tion and exercise

Efficient Seek efficient allocation of community Development of public policy that encourages

resources to maximize health impact for the a balance between personal health care andcommunity community health improvement programs

Equitable Provide all community residents with an Creation of partnerships across sectors to raiseenvironment that promotes health awareness of environmental forces that im-

pact health

Figure 1. Application of IOM’s Six Aims to Community Collaboration


nity well-being is not the exclusive purview of any par-ticular sector or revenue stream. Successful collabora-tions achieve objectives that improve service deliveryand, subsequently, community health. Throughout thisdiscussion, the NACRHHS intends “collaboration” tomean two or more local organizations taking actionbased on decisions they reach together. (At the sametime, “collaborations” are multiple actions initiated byand among various groups.)

The NACRHHS believes collaboration is a means toa broad-based goal: healthy rural communities. Thegoal can be realized, at least in part, by achieving thesix aims the Institute of Medicine (IOM) developed toguide policies and actions that close the chasm betweenthe current health care delivery system’s level of qual-ity and a system of optimum quality. The IOM’s Com-mittee on the Future of Rural Health Care applied thoseaims to the broader goal of community well-being. Indoing so, they recognized the importance of an inclu-sive approach that reaches beyond traditional health caredelivery:

The Committee believes rural communities mustbuild a population health focus into decision mak-ing as well as in other key areas (e.g., religiousinstitutions, agricultural extensions, rural coop-eratives, education, community and environmen-tal planning) that influence population health.Most important, rural communities must reori-ent their quality improvement strategies from anexclusively patient- and provider-centric ap-proach to one that also addresses the problemsand needs of rural communities and populations.2

Figure 1 on the preceding page shows theCommittee’s application of the six aims of the IOM’sCrossing the Quality Chasm report to community col-laboration.

Chapter Organization

The NACRHHS collected information during site vis-its to Nebraska and Mississippi detailing experienceslocal agencies had in creating community-wide initia-tives that integrate the resources of multiple programs.The Committee also reviewed the literature and, in thischapter, presents other examples of successful local col-

laborations. The NACRHHS recognizes that local lead-ership is important to successful collaboration. Fromthe site visits and the literature, the Committee learnedmore about how to develop and sustain the capacity forlocal leadership. The Committee’s purpose was to drawlessons from these local experiences that would informthe Secretary about initiatives Federal agencies couldundertake to further enhance cross-program integration.

Making Collaborations WorkLocally: Examples, Barriers, and

Incentives

Examples of Collaborations

The NACRHHS learned that successful local collabo-rations advance community interests across a numberof policy sectors, demonstrating the role of health andhuman services as a catalyst for other activities, or viceversa. Any number of configurations constitute collabo-rations, as illustrated in the text box (see next page) onthe Eastern Maine Transportation Collective (EMTC),which describes how almost 30 different entities fromseveral sectors collaborated to ensure public transpor-tation services for the elderly and others. This collabo-ration includes a university program and is facilitatedby the local United Way.

Blue Valley Community Action Partnership

Collaborations can take the form of “one-stop” servicedelivery, offering clients access to a variety of programsin one location. Such collaboration exists in SoutheastNebraska, through the Blue Valley Community ActionPartnership (BVCA). BVCA is a community-based,private, not-for-profit corporation serving 15 countiesin Nebraska and Kansas. BVCA partners with variouscommunity and religious groups, public entities, schoolsand local businesses to offer more than 30 programs inthe following areas: health services, family services anddevelopment, child development, children and youthservices, outreach services (including case manage-ment), nutrition services, emergency services, crisis in-tervention, housing services and development, transpor-tation services and rural development.


BVCA was the first multi-agency family resourcecenter in Nebraska, as well as the first multi-countypublic health system (a partnership between public andprivate entities). Current collaborations include the fol-lowing:

• Health Services Program. The BVCA collaborateswith several county health departments to offer a widerange of health services, health screenings and finan-cial assistance. Collaborations also occur with localclinics, churches and hospitals to offer minority healthservices, immunizations and lead screening. Casemanagement is a vital component of the Health Ser-vices Program, integrating multiple services into onevisit.

• Gage County Safe Schools/Healthy Students. Thisprogram is funded collaboratively by the departmentsof Education, Justice and Health and Human Services.

Locally, mental health providers, hospitals, police andthe school districts in Gage County are collaboratingto address six issues: a safe school environment; al-cohol, tobacco, drug and violence prevention; men-tal illness prevention and treatment; early childhoodservices; reading levels among students; and safeschool policies.

• Housing Development. BVCA is collaborating withprivate investors, local lenders, government and quasi-government partners to develop affordable housingfor families.

Community Hospitals and Community Health Cen-ters Collaborations

Collaborations can occur within a more narrowly de-fined scope of services, such as those delivered by twoor more health care providers. A study of five collabo-

In August 2003, almost 30 social service, health care,transportation, State and academic organizationsunited to form the Eastern Maine Transportation Col-laborative (EMTC). EMTC’s purpose is twofold:(1) to better understand problems that older adults inrural areas experience when they need transporta-tion to access health care, and (2) to advocate forimprovements in local and regional transportationpolicies and programs. EMTC is an ongoing multi-county organizational collaboration. Additional or-ganizations have continued to join the collaborativeeffort over time. Its member agencies span three largerural counties and include Community Action Pro-grams, Area Agencies on Aging, community healthadvisory committees, health care systems and hos-pitals, community health centers, State and local de-partments of transportation, Senior Corps programs,both Medicaid-reimbursed and volunteer transpor-tation services, and the University of Maine Centeron Aging. The United Way of Eastern Maine facili-tates the work of the EMTC.

During the summer of 2004, EMTC applied forand received a $36,000 planning grant award fromthe Maine Health Access Foundation to carry out a

comprehensive community analysis of the transpor-tation needs of older adults in Washington, Hancockand Penobscot counties who regularly require chroniccare medical services. A deciding factor in theEMTC’s receipt of the award was the extent of col-laboration evidenced in their work. The Universityof Maine Center on Aging will perform the needsassessment, with local health and social service agen-cies assisting in identifying key stakeholders in eightcommunities where intensive case studies will be car-ried out to better understand the special challengesto accessing chronic care services. The project willidentify roadblocks to health care access includingthe availability of affordable health transportation op-tions in the designated geographic region. Assess-ment will focus on older patients seeking chronic careservices in the areas of physical and occupationalrehabilitation, renal dialysis, diabetes and cancer care.The project team will work toward designing a coor-dinated and systematic strategy of scheduling patienttransportation across multiple services and buildinga comprehensive database of transportation programsboth large and small that is Internet accessible.

The Eastern Maine Transportation Collaborative


rations between community hospitals and CommunityHealth Centers (CHCs) illustrates both this type of col-laboration and a variety of organizational arrangements:

• A CHC assumes responsibility for outpatient careoperations of the hospital, on the same campus, un-der the Medical Director of the CHC who is alsoMedical Chief of Staff of the hospital; a joint foun-dation supports both entities.

• Two entities supply joint care coordination in homehealth, disease prevention programs, outpatient ser-vices, hospice and mental health, electronic medicalrecords shared between the CHC and the emergencyroom of the hospital.

• Two CHCs and a regional hospital form a separate501(c)(3) network, sharing management informationsystems to create an integrated delivery system witha focus on disease management, quality improvement,increasing access and supporting hospital and com-munity pharmacies.

• A regional CHC collaborates with three hospitals forphysician recruitment, wellness promotion programsand regional dialysis/cancer treatment.

• A CHC, regional hospital and Critical Access Hospi-tal (CAH) are affiliated to handle tertiary referrals atthe regional hospital and geriatric services at the CAH,and to share inpatient/discharge case management;they also jointly participate in disease managementcollaboratives for diabetes and cardiovascular condi-tions.3

Even in these examples, collaborations reached be-yond the narrow boundaries of a single sector to incor-porate other sectors. One of the collaborations in thestudy works with congregate housing for the elderly, alogical connection for health care providers focused ongeriatric services. The collaborations used funding frommultiple HHS programs: the Federal Office of RuralHealth Policy (ORHP), the Rural Hospital FlexibilityGrant Program that assists CAHs, and the Bureau ofPrimary Health Care’s special funds for diseasecollaboratives. Secure funding from patient care result-ing from CHC status and CAH certification helped thesecollaborations create a stable fiscal environment for pro-

viders, which allowed management to spend energieson tasks other than meeting monthly payroll.

CREATE

Local collaborations connecting services across a broadarray of sectors might be supported by local sources offunding, aggregated in a local community foundation.The NACRHHS found an example of this in Missis-sippi, with the Christian Research Education ActionTechnical Enterprises (CREATE) Foundation that wasstarted by a local newspaper owner, George McLean, in1972 and now serves as an administrative entity witheight county affiliates.

The community spirit represented by CREATE hasroots back to the 1940s when community leaders cametogether to create a dairy industry that, by the 1950s,was generating millions of dollars of revenue for Tu-pelo. Now Lee County is home to facilities from 202firms, including 17 Fortune 500 companies. The NorthMississippi Medical Center, which is headquartered inTupelo, is the largest non-urban medical center in thecountry.4 The Community Development Foundation hasbeen active since the 1940s and, among its activities,conducts an annual leadership institute. CREATE is nowan umbrella foundation capable of managing funds forother organizations such as the Boy Scouts, United Way,the Good Samaritan Health Services free clinic and theSanctuary Hospice House.

In 2003, the CREATE Foundation completed a stra-tegic planning exercise. Using its Commission on theFuture of Northeast Mississippi (created in 1995), thefoundation will invest more than $1 million over a five-year period in a regional workforce development effort.The project’s focus areas are an indication of the breadthof activities, consistent with what the NACRHHS haslearned, that contribute to healthy communities built andmaintained through collaborative efforts: workforcedevelopment, economic development and social envi-ronment.

The Commission will measure its success throughState of the Region reports that include indicators of thestate of the economy, education, public safety, socialenvironment, health, housing and infrastructure. Ex-amples include the following:

Economy: Employment composition (from the Claritasdata base)


Education: Graduation rate (MS Department of Edu-cation)

Public Safety: Traffic fatalities (MS Department of Pub-lic Safety Planning)

Social Environment: Births to single teens (MS De-partment of Health)

Health: Percentage receiving prenatal care (MS Depart-ment of Health)

Housing: Percentage of owner-occupied housing(Claritas)

Infrastructure: Airport departures (from two regionalairports)

The Commission works well as a multi-county en-tity that brings public and private organizations togetherto make programs happen. The Commission itself pro-vides no direct services, nor does it develop its own pro-grams. Each of the 16 counties in the region is repre-sented on the board of directors of the Commission. Aconsistent theme of the Commission, and of CREATE,is that all activities are regional, on behalf of all 16 coun-ties. CREATE makes that commitment obvious to allcounties by providing a fund of $100,000 for eachcounty.

The NACRHHS identified several elements ofCREATE’s success that can be incorporated by othercollaborations:

• Having a clear, consistent message that “communitydevelopment precedes economic development” (theimportance of this message was highlighted in a re-cent description of “The Tupelo Model”: “that treat-ing town and region as an interdependent commu-nity would be more productive than focusing on nar-rower interests, that community development is thesturdiest foundation for economic development.”5

• Having a forum such as the Commission for buildingtrust among key stakeholders.

• Anchoring activities and measuring progress, by hav-ing a set of valid indicators of community well-be-ing.

• Having support of local media (for Northeast Missis-sippi, the Tupelo newspaper)

• Creating influence through the power of conveningwithout interfering with program operations.

• Taking advantage of dynamic, committed local lead-ership.

• Having a vision for the future that is broader thanany single activity, such as creating jobs solely forthe purpose of creating jobs (e.g., focusing on thequality of life in the community, including the qual-ity of the jobs created).

The role for health and human services in buildingand sustaining this successful collaboration was obvi-ous and manifold. First, the regional medical center is apowerful economic and social force as well as being alarge health care provider. The center encourages re-gional collaboration through such efforts as sharingworkforce projects with local colleges so that careerpaths are available to students, working with local clin-ics and hospitals in the 16-county region and financinga residency program. A social environmental task forceworks on issues that cut across all sectors, with a majorfocus on racial reconciliation in the region.

Panhandle Partnership

Collaboration is not meaningful unless it yields out-comes that meet community-wide objectives. A two-step process is involved. The first step is to create thepossibility for successful collaboration by bringing or-ganizations together and providing resources to enablethem to work toward common objectives. TheCREATE Foundation is an example of a permanent in-frastructure designed for this purpose. Another exampleis the Panhandle Partnership for Health and Human Ser-vices (Panhandle Partnership) in Nebraska. This small,non-profit organization applies for grant funds to sup-port the activities of regional agencies that work towardcommon objectives. For example, the Panhandle Part-nership recently received a grant award from the Agencyfor Healthcare Research and Quality to establish an elec-tronic medical record that will link the information sys-tems of eight hospitals in a nine-county region. Thegrant was made possible because the partnership pro-


vided a forum for those hospitals to develop the plan.In human services, the same framework has facilitateda children’s outreach program and a Native Americanhealth project.6

The Panhandle Partnership is a 501(c)3 organizationmade up of more than 60 agencies and organizations. Itdoes not provide services, nor does it compete with ex-isting agencies. Instead, its primary function is to bringagencies together to maximize the use of their resources.Examples of the Panhandle Partnership’s projects in-clude the following:

• Service Point Information System - A central clientdatabase that is available at every service point. Todate, 16 agencies participate, with over 9,000unduplicated clients.

• Children’s Outreach Program - A home-visit programfor newborns.

• Comprehensive Community Planning Process - Aprocess that includes all of the Panhandle communi-ties.

Barriers to Collaboration

Collaboration takes significant time investment by in-volved parties and sizeable resource investments fromlocal and Federal levels. Collaboration does not occurovernight. Trust must be built, common ground mustbe established and a vested interest must be made byparticipating parties in order for collaboration to occur.In Mississippi, the Committee learned that nearly 10years of building trust preceded the development of theCREATE Foundation’s strategic plan in 2003. Oncethe initial foundation for collaboration is built, othersystem-wide and program-wide barriers challenge ser-vice delivery collaboration.

Challenges to collaboration in rural areas include alack of resources at the community level, lack of estab-lished communication between parties, long travel dis-tances and a low population base (and therefore a smallclient base). In addition to these barriers, sometimescommunities simply do not want to collaborate. Thecommunities may have a history of mistrust or compe-tition, and thus any efforts to collaborate are futile.

Federal grants tend to be categorical and lack the flex-ibility needed for collaborative service delivery. The

result is territorial service delivery instead of client-fo-cused service delivery. Furthermore, if services are be-ing delivered in an integrated manner, challenges mayarise with the varied requirements for time reporting,evaluation, data reporting or technology. For example:

• Payment for services is often denied when a casemanager conducts a home visit that covers multipleprograms. Thus, the need exists for accountable, yetflexible, time reporting that recognizes the cost sav-ings of delivering a variety of program servicesthrough one case management visit.

• If BVCA conducts a home visit for multiple programs,the caseworker has to complete separate paperworkfor each program and enter the data into separate re-porting systems. A need exists for blended technol-ogy instead of the current system of multiple, dupli-cative data entry.

Incentives for Collaboration

One of the primary incentives for service delivery col-laboration is to better serve the client. For example,families often struggle with multiple issues simulta-neously. By offering integrated case management ser-vices, as the BVCA does, a case manager can visit afamily and cover a variety of issues from several pro-grams. Further, that case manager can continue to workwith the family, which means continuity of services in asingle point of contact with less family disruption.

A second incentive for service delivery integrationis the efficient use of financial and personnel resources.At the funding level, collaboration can mean signifi-cant cost savings for federally funded programs. Cross-training personnel across a variety of programs can meansignificant cost savings to the funders, as well as to theprogram administrators at the local level (a more effi-cient use of personnel means more money to use else-where for additional services). In the instance of a cross-trained case manager in rural Southeast Nebraska, moneyis saved because only one case manager is used to covera variety of programs, and only one case manager isincurring travel expenses. Cross-training is also effec-tive because rural areas may not have enough clients ina program to justify a case manager dedicated to thatprogram. However, in consideration of the variety ofneeds clients may have, and thus the variety of programs


they may need access to, a cross-trained case managercould deliver those needed services across a variety ofprograms.

A third incentive, obvious in Northeast Mississippi,is to link collaboration with broad goals of communitywell-being that include community development andeconomic development. When George McLean startedgetting local businesses and others to contribute tocollaborative efforts, he did so based on the best inter-ests of the community. That theme has continued withthe commission’s current workforce objectives, whichalso emphasize activities in each of the 16 counties inthe region.

A fourth incentive is to encourage and facilitate theefforts of strong local leaders. In the two communitiesthe Committee visited, the influence of a small group ofleaders, and at times a single individual, was obvious.

Sustaining Local Collaboration: Leader-ship Development

Well-known preconditions for successful collaborationreported in the research literature and reaffirmed by theCommittee’s site visits can be encouraged by federallysupported public investments. Foremost among themis the development of local leadership and leadershiptraining for those who are in positions to influence col-laboration but who lack the skills.

The Heartland Center for Leadership Development(Heartland Center) in Nebraska is an independent, non-profit organization that focuses on leadership training,citizen participation, community planning, facilitation,evaluation and curriculum development.

The Heartland Center developed the Home TownCompetitiveness (HTC) approach for rural communi-ties to build and revitalize their communities.7 HTCfocuses on assets that exist in the community and buildson those assets in four strategic areas:

• Mobilize local leaders. HTC encourages rural com-munities to think beyond the “usual suspects” andinclude women, minorities and youth in decision-making and leadership roles.

• Capture wealth transfer. Wealth often disappears fromthe place it was created when inherited by a benefi-ciary who no longer resides in the community. HTC

sets a target of converting at least five percent of thelocal wealth transfer into charitable assets that canthen be used to fund community and economic de-velopment efforts.

• Energize entrepreneurship. HTC encourages ruralcommunities to foster local growth by (1) planningbusiness ownership succession, (2) assisting entre-preneurial companies that have the potential to breakthrough to a larger market, and (3) using local chari-table assets to support entrepreneurship development.

• Attract young people. HTC teaches communities howto engage youth before they leave, and how to attractyouth through career opportunities, business transferand entrepreneurial support.

Five sites across Nebraska are using the HTC ap-proach. The Heartland Center conducted its first HTCacademy in February 2004. The Center is currently re-sponding to requests from around the country to engagecommunities in leadership development. The HeartlandCenter has published a booklet focused on building lo-cal leadership.8 They also suggest 10 ideas for recruit-ing new community leaders:

1. Ask the question, “Who’s not here?”2. Look for skills, not names3. Try involvement by degrees4. Appeal to self-interests5. Use a wide-angle lens6. Define the task7. Use current leaders to recruit new leaders8. Create a history of efficient use of people’s time9. Offer membership premiums10. Market your wares9

Other Leadership Building Activities

The University of Massachusetts offers a special pro-gram, the Master Teacher in Family Life Program, toteach “natural leaders within poor communities the in-formation and skills they need” to create a communitysystem with fellow residents about important issues thatinclude health and education, and to create and sustaina network for people to use their knowledge to makechanges in their lives.10 The W. K. Kellogg Foundationhas a special set of instructional modules on its Web


site for developing community capacity and sustainingcommunity-based initiatives. The first chapter of the“Developing Community Capacity” module is “Lead-ership: Building Capacity to Lead a Community-BasedProcess.” The chapter describes the skills that are neededand provides case studies. The learning objectives forthe chapter include the following:

• Comprehend the essentials of the new kind of leader-ship required for collaborative community efforts andthe difference between traditional forms of leader-ship and this new model.

• Understand the primary role of the new leader.

• Recognize the skills and attributes needed by an ef-fective collaborative leader.

• Become aware of traps to avoid in exercising col-laborative leadership. 11

The Role of Foundations in FosteringLeadership Development

Rural areas often face challenges in fostering leader-ship in their communities, as we heard from Milan Wall,Co-Director of the Heartland Center. Rural areas areattempting to find new, non-traditional leaders; keep andattract young people to their communities; capturewealth; and promote entrepreneurship, all in an effortto develop leaders within rural communities. This re-quires significant resources. Thus, community founda-tions can play a vital role in promoting leadership de-velopment. One such example is the Nebraska Com-munity Foundation. (See text box).

The Results: Creative Local Leadershipfrom a Variety of Sources

A case example of creative leadership in New Mexicowas summarized for the NACRRHS. In the four cor-ners region of the State, specifically the community ofFarmington, a 30 to 40 year history of conflict is com-ing to a close thanks to the efforts of two leaders with ashared vision of improving the regional economythrough collaborative programming. The region in-cludes both civic and Tribal jurisdictions whose historyincludes discrimination so obvious that in the 1970s the

U.S. Department of Justice conducted an investigation.In 2000, the mayor of Farmington and the vice chair-man of the Navajo Tribe developed a friendship thatenabled them to jointly examine problems in the com-munity. They convened nine organizations and signedan agreement creating a new health authority. In thespring of 2001, they received funding through the Com-munity Action Program that helped them maintain mo-mentum for the activities of the new authority. Thanksto the experiences of the Community Action Programgrant, the Navajo Nation has brought together othermayors to address regional problems in economic de-velopment, housing and roads. They have solidified a

The Nebraska CommunityFoundation

The Nebraska Community Foundation helps mo-bilize charitable giving to 147 Nebraska commu-nities through over 160 component funds. Withcurrent assets exceeding $18.6 million, the Foun-dation has reinvested over $40 million during itsten-year history. Thus far, most of the funds havebeen used for specific small projects, such as smallgrants to fire departments and youth activities. TheFoundation participated in a few larger projects,most notably the Home Town Competitivenessprogram, which is now in five Nebraska sites. Theprogram is a “come-back/give-back” approach thatencourages young people and entrepreneurs toreturn to rural communities, and it solicits contri-butions from people who have left the commu-nity.1 This program focuses on building the lead-ers that communities need to continue with com-prehensive economic development. The NebraskaCommunity Foundation is an exemplary effort toclaim some of the generational wealth that willtransfer either to the next generation or to chari-table causes during the next 50 years. A five per-cent capture of that wealth in rural Nebraska wouldyield approximately $5 billion.

1 Hendee D. “For rural residents, charity begins athometowns.” Omaha World-Herald; November 15,2004.


commitment to collaborative work that achieves com-mon goals.

Another example is Chuck McCauley, a physician atthe Marshfield Clinic in Marshfield, Wisconsin, whobecame a local leader after recognizing that obesity wasa community problem that needed community solutions.Dr. McCauley was instrumental in launching a commu-nity program, “Healthy Lifestyles.” Key to the successof the program was the fact that it originated with a phy-sician and the clinic in which he worked. In September2001, the clinic launched Healthy Lifestyles, with a$100,000 budget. The school system was an early part-ner in the community collaboration, believing that thebest starting point in the community was with children.Private businesses in the community were among thenext organizations to participate, with one firm map-ping out a one-mile walking path on its grounds for useby a walking club.12 Also, leadership from the medicalcommunity was essential. The program’s success canbe attributed to the effort of one leader with credibilityand standing in the community to address the issue.

Sustaining a Community Vision:The Role of Health and HumanServices in Integrating Programs

Across Sectors

Meeting the needs of rural residents for health care andsocial services should be seen as an element of a broadermission to build sustainable rural communities that cre-ate the best possible quality of life for everyone. TheNACRHHS recognizes a shift occurring in public policyresponding to rural needs, from a focus on land-basedagricultural policy to human capital-based comprehen-sive development policies. The 2001 Annual Report ofthe Center for Rural America described an emergingconsensus that policies for a “new rural America” wouldhave three focal points: places, collaboration and re-gional competitiveness.13 The NACRHHS believes thefocus of that report, on business and economic develop-ment policy, should be applied to health and human ser-vice policy, and that advocates of a new rural policyshould incorporate health and human service policy intotheir models.

The NACRHHS agrees with Charles Fluharty, Di-

rector of the Rural Policy Research Institute, that thehealth (and human service) sector is well positioned toprovide leadership in communities across the countryto establish new linkages across local community orga-nizations that will advance rural policies and programs.Mr. Fluharty sees the health sector as critical to achiev-ing new directions in rural policy because the sector isahead of many others in having what is needed: visionfor healthy communities, community-based orientation,local and national leadership, linkages across the Fed-eral system (National, State, and local) and multi-sec-tor, multi-jurisdictional understandings.14

The importance of thinking of health and human ser-vice programs and policies as integral to overall com-munity development is obvious when considering, forexample, welfare reform. The human service policy ofhelping people find opportunities to work and end par-ticipation in public welfare has to be integrated withhealth care programs aimed at increasing opportunitiesto purchase health insurance and/or opportunities to re-ceive health care services at little or no cost. Anotherchapter in this report addresses issues and programsspecific to the reauthorization of the Temporary Assis-tance for Needy Families program, which is part of afabric of approaches to local community development.

Ideally, health and human service programs wouldestablish collaborative relationships with programs intransportation, justice, economic development, housingand education. The Safe Schools Healthy Students pro-gram in Gage County, Nebraska, combines support fromthe Department of Health and Human Services withsupport from the Department of Education and Depart-ment of Justice to create a single, integrated program.The Panhandle Partnership in Nebraska includes over60 separate agencies and organizations that coordinateprograms under this nonprofit umbrella to ensure opti-mum use of resources. The NACRHHS believes thatthe Secretary can continue to provide leadership in ru-ral policy development by demonstrating successfulcollaborations in health and human service programsthat will be models for extending collaborations acrosssectors. The objective is better rural policy focused oncommunity and individual well-being. As the Rural TaskForce said in its report, health care and social servicesare “essential for the health and well-being” of ruralcommunities and the well-being of rural residents.15

These services are central to the success of rural econo-


mies, both directly through jobs and revenue, and indi-rectly through additional economic activity generatedby those services.

Sustained community collaborations can achieve agreat deal to continuously advance community health.Collaborations produce traits that, if successfully nur-tured, contribute to sustaining community improvementefforts: individual empowerment (active involvementof people in solving the problems that affect their lives),building social ties (building trust and a sense of com-munity across social dividing lines) and synergy (com-bining knowledge, skills and resources of a diverse groupof people).16 Collaborations that produce these traitsalso will be assuring their continued success becauselocal citizens will continue to identify next steps to en-hance the quality of their lives through community ac-tion. Lasker and Weiss argue that collaborations of com-munity groups and individuals can do the following:

• Obtain more accurate information about concerns,priorities and trade-offs people in the community arewilling to make.

• Look at issues in relation to each other and thecommunity’s goals, and know how services and pro-grams relate to each other.

• Challenge accepted wisdom to understand root causesof problems and discover innovative solutions.

• Understand the local context, including communityvalues, politics, assets and history.17

Local collaborations can develop strategies to buildon local community assets and connect multiple services,programs, policies and sectors. Leadership is a key vari-able that explains the success of community collabora-tions:

Community collaborations appear to benefit fromhaving leaders and staffs who believe deeply inthe capacity of diverse people and organizationsto work together to identify, understand, and solvecommunity problems. These kinds of individu-als understand and appreciate different perspec-tives, are able to bridge diverse cultures, and arecomfortable sharing ideas, resources, andpower.18

The NACRHHS believes HHS programs should de-vote a portion of their resources (budgets) to leadershipdevelopment and continuing management programs forcommunity leaders.

Well-led successful community collaborations be-come part of what scholars identify as the communityenvironment that contributes to community health. Suchcollaborations can influence all 12 dimensions of whatM.H. Hillemeier and colleagues identify as the contex-tual characteristics for community health19:

• Psychosocial• Behavioral• Transport• Economic• Employment• Education• Political• Environmental• Housing• Medical• Governmental• Public health

Those authors offer indicators and sources of datafor each characteristic that could be used to assess theprogress of community collaborations. For example,measures of environmental hazards could be used toestablish targets for programs implemented by localcollaborations led by health and human service sectorleaders.

As discussed earlier, the CREATE Foundation inMississippi provides support to the Commission on theFuture of Northeast Mississippi. The Commission as-sesses conditions in the region, determines key issuesfacing the region and recommends strategies to addressthose issues. Consistent with the recommendations ofHillemeier and colleagues, the Commission tracks indi-cators in seven topics affecting community health:economy, education, public safety, social environment,health, housing and infrastructure.


Actions and SpecificRecommendations to Facilitate

CollaborationsHHS could do much to foster collaborations among lo-cally based organizations. Because health and humanservices are essential for community health and well-being, organizations and individuals in this sector havethe opportunity to spearhead collaborations that inte-grate activities across sectors. While the Federal gov-ernment cannot force community organizations into last-ing collaborations (which require trust and working re-lationships that cannot be mandated), it can help estab-lish a policy environment in which collaborations flour-ish. Existing HHS programs can be used for this pur-pose, and new programs could be established withinexisting authority.

Actions

As recognized by the report One Department ServingRural America and the creation of the Secretary’s RuralTask Force within HHS, achieving the objectives of ef-fective collaborations will require a new way of admin-istering many of the programs in the Department andother Federal agencies. The details of specific programsneed not necessarily change, but the intersection of pro-grams needs to be explicitly recognized and new poli-cies and procedures adopted that bring those programstogether at the local level in new and creative ways.The following actions by the Secretary would encour-age a new relationship among Federal programs, to thebenefit of local action through successful collaboration:

• Create common reporting requirements for programsthat are linked at the local level.

When two or more programs under the Secretary’s ju-risdiction are implemented at the local level by the samecommunity collaboration, those programs should be in-structed to develop a consolidated reporting format.Local agencies should be allowed flexibility to co-minglefunding from multiple programs to develop creative lo-cal programs that advance and sustain community de-velopment. The value of this flexibility was evident atBVCA, where multiple programs and services were

delivered through one agency via one case manager visit,which in turn meant a better use of staff and money in aformat that was client-centered. Additional ideas in-clude combining funds provided through informationtechnology grants (such as the new programs funded bythe Agency for Healthcare Research and Quality) withgrant funds for telemedicine projects (through the Of-fice for the Advancement of Telehealth), special grantsto Community Health Centers and grants to small ruralhospitals to develop information networks that improvequality of care for rural residents as they receive ser-vices from multiple providers.

• Encourage programs in other Federal agencies toparticipate in multi-sector collaborations.

The Secretary should consult directly with other Cabi-net Secretaries to issue directives to programs imple-mented through local action stating that they must allassess the effects they have on local collaborations andact based on those assessments to encourage collabora-tions. For example, housing programs, transportationfunding, rural development projects and programs inearly child development all contribute to the type ofcommunity-based collaboration for local developmentthe NACRHHS learned of in Tupelo, Mississippi. Fed-eral programs should explicitly recognize the contribu-tion to local collaboration as well as the traditional mea-sures of program outputs and outcomes.

• Facilitate interagency cooperation that allows forsingle lines of accountability for funds.

The Secretary should work with other Cabinet Secre-taries to develop a memorandum of understanding thatFederal agencies can use to follow a consolidated re-porting system to meet requirements that localcollaboratives be accountable for use of Federal funds.Those systems should include reporting achievementsusing measures of success for collaborations and broad-based measures of impact on the community. For ex-ample, the program the NACRHHS learned of in South-east Nebraska combined funds from three Federal de-partments, but still had to report back to each depart-ment using that department’s reporting format.


Specific Recommendations

The following are specific recommendations the Secre-tary should undertake to further local collaborations thatwill enhance the impact of the Department’s programs.

• The Secretary should support the creation of a Webresource page for “models that work,” showing suc-cessful collaborations in rural places.

The Federal Office of Rural Health Policy (ORHP)should build this recommendation into its cooperativeagreement with the Rural Assistance Center (RAC). Aspecial page should be built that is devoted to describ-ing successful rural-based collaborations and that canbe accessed in one step from the home page of the RACWeb site. The funding to RAC should support a report-ing function to collect and present information regard-ing those collaborations.

• The Secretary should support research that will fur-ther specify opportunities and barriers.

ORHP should dedicate a portion of its research budgetto further specify opportunities for and barriers to col-laboration, funding activity either through its researchcenters or its solicitation of independent research pro-posals. Researchers should develop models that explainreasons collaborations are successful, with success be-ing defined, in part, as long-term sustainability. Re-search findings should identify barriers to successful col-laborations as well as community, Tribal, State and Fed-eral actions that facilitate successful collaborations.

• The Secretary should support leadership developmentfor rural community organizations and residents.

The Secretary should instruct all agencies with programssupporting local service delivery to include funds forleadership development in their grant-making portfo-lios. The ORHP program for rural leaders should becontinued. The Secretary should consider supportingregional leadership academies by combining current pro-grams from separate entities in HHS. The Secretaryshould encourage private foundations to expand theirefforts to train future leaders. The Nebraska Commu-nity Foundation is one example of the important andcrucial role a foundation can play in fostering leader-

ship development in rural areas.

• The Secretary should require grant recipients engagedin direct delivery of services to demonstrate an effecton community development.

The Secretary should require that all grant applicationsin programs supporting service delivery in rural areasinclude an analysis of how the program will relate tobroad-based efforts in community development.CREATE, in Mississippi, is measuring its success basedon community indicators, such as the economy, educa-tion, public safety, social environment, health, housingand infrastructure.

Next StepsThe NACRHHS intends to continue to support localcollaborations that work to achieve a broad-based pro-gram of activities that contribute to community devel-opment in rural America. The NACRHHS intends tomonitor several initiatives that contribute to a growingnational consensus about the value of integrating other-wise disparate activities into cohesive programs at thelocal level:

• Follow-up activities resulting from the IOM report,Quality Through Collaboration: The Future of RuralHealth Care, including those initiated by other orga-nizations such as the National Rural Health Associa-tion and State offices of rural health.

• Demonstrations of the applicability of the Programof All-Inclusive Care for the Elderly model in ruralareas.

• Collaborations between CAHs and CHCs.

• Rural entrepreneurship programs.

• Activities of organizations that share the goal of inte-grated activities and collaborations across sectors,including the Rural Policy Research Institute, theNational Rural Health Association, the National Or-ganization of State Offices of Rural Health and orga-nizations representing local and State governmentofficials.

The NACRHHS intends to monitor related initiatives


that are not directly engaged in promoting collabora-tions but that do influence community development.These include the following:

• Pay-for-performance initiatives affecting health andhuman services.

• Advances in leadership training.

• Measures of quality in health and human services thatare influenced by variables other than direct servicedelivery (e.g., outcomes measured at both the indi-vidual and community levels).

The realization that programs across sectors are tar-geting the same goal—sustained healthy communities—is not new. However, pressures to be cost-effective andaccountable for measurable outcomes are greater nowthan ever before. This creates an opportunity to baseaccountability on the effects of programs on communi-ties, which in turn creates pressure to combine programsthat target the same population for the same purpose.The NACRHHS believes the health and human servicesector can lead a reinvigorated attention to community(population and infrastructure) outcomes that focuseson successful collaborations.

References

1 HHS Rural Task Force. “One Department Serving RuralAmerica.” Report to the Secretary; July 2002. Availableat: http://ruralhealth.hrsa.gov/PublicReport.htm.

2 Committee on the Future of Rural Health Care. Qualitythrough Collaboration: The Future of Rural Health. Wash-ington, DC: National Academies Press; 2004.

3 Wilhide SD. “Rural CHC/Hospital Collaboration: AnOpportunity to Improve Community Health Status.” Pre-sentation at 2004 Critical Access Hospital Conference;October 6-8, 2004; Kansas City, MO. Available at: http://www.dhh.state.la.us/offices/publications/pubs-88/Steve%20Wilhide%20PP%20Show.pdf.

4 Putnam RD, Feldstein LM. “The Tupelo Model: Build-ing Community First.” In: Better Together: Restoring theAmerican Community. New York: Simon & Schuster; 2003.

5 ibid.

6 Palm D. “Building an Integrated Rural Health DeliverySystem: The Nebraska Panhandle Experience.” Presenta-tion to the National Rural Health Association Board; Au-gust 11, 2004.

7 “Home Town Competitiveness: A Blueprint for Com-munity Builders” handout. Received from Milan Wall, Co-Director of The Heartland Center for Leadership Devel-opment. See also: http://www.heartlandcenter.info.

8 Wall M, Luther V. “Building Local Leadership: How toStart a Program for Your Town or County.” Lincoln, NE:Heartland Center for Leadership Development; 2001.

9 Wall M, Luther V. “Ten Ideas for Recruiting New Lead-ers.” Lincoln, NE: Heartland Center for Leadership De-velopment; 2001.

10 Slinsky, MD. “Building Communities of Support forFamilies in Poverty.” Cooperative Extension, Universityof Massachusetts; May 25, 1994. Available at: http://crs.uvm.edu/nnco/communsupp.

11 Trasolini S, Chrislip D, Larson CE. “Leadership: Build-ing Capacity to Lead a Community-based Process.” In:Bandeh J, Kaye G, Wolff T, Trasolini S, Cassidy A. De-veloping Community Capacity. Battle Creek, MI: W. K.Kellogg Foundation; 2004.


12 Johnson M, Fauber J. “Marshfield Mobilizes to FightFat: Citywide Effort Offers Blueprint for How to BattleObesity Epidemic, Experts Say.” Milwaukee Journal Sen-tinel; July 9, 2003.

13 Center for the Study of Rural America. “A New Focuson Rural America: New Paths for Rural Policy.” AnnualReport 2001. Kansas City, MO: Federal Reserve Bank;2001. Available at: http://www.kc.frb.org/RuralCenter/annreport/CenterAR-2001.pdf.

14 Fluharty CW. “Toward a Community-Based Rural Policyfor Our Nation.” Presentation to the Nebraska Rural Asso-ciation Annual Conference, September 3, 2003; Kearney,NE. Available at: http://www.rupri.org/presentations.

15 HHS Rural Task Force. “One Department Serving RuralAmerica.”

16 Lasker RD, Weiss ES. “Broadening Participation in Com-munity Problem Solving: A Multidisciplinary Model toSupport Collaborative Practice and Research.” J UrbanHealth. March 2003; (80,1).

17 ibid.

18 ibid.

19 Hillemeier MH, Lynch J, Harper S, Casper M. “Measur-ing Contextual Characteristics for Community Health.”Health Services Research. December 2003; 38(6, Part II).


Access to Obstetrical Services in RuralCommunities


The Committee chose this topic out of a growing con-cern for the viability of obstetrical (OB) services in ru-ral communities throughout the country, a concern thatwas heightened by the Committee’s recent visits to ru-ral hospitals and conversations with physicians work-ing hard to maintain these services.

The challenges of sustaining OB care in rural areasare in many ways similar to those of other specialty ser-vices, such as anesthesiology, general surgery and be-havioral health. A recent paper on the general surgeryworkforce in rural America found wide disparities inthe distribution of general surgeons between urban andrural areas and highlighted issues related to malpracticecosts, the gender shift in general surgery, lifestyle de-mands and other concerns that will be discussed in thischapter on OB care. 1 Hence, some of the Committee’sobservations and recommendations on OB care are rel-evant to other specialty services in rural areas. It mustbe said, however, that OB care has a singular impor-tance to the social and economic life of rural communi-ties. In addition, the Committee believes any discus-sion of OB care includes both prenatal and neonatal care,which are critically important to rural communities. The

Committee’s appreciation for these relationships wasalso an important factor in its selection of rural OB careas a topic for this report.

In their testimony before the Committee, rural hos-pital officials and independent physicians practicing inrural areas repeatedly emphasized the importance of OBcare to the health of their communities. They empha-sized that rural families want assurance that prenatal careand OB services will be readily accessible where theylive. Local access to these services is among the mostimportant factors that young married couples may con-sider when deciding where to live and raise their chil-dren.

In order to maintain their status in the community,small rural community hospitals are struggling to pro-vide OB care when financial loss from providing thoseservices is severe. Many rural hospital administratorsbelieve that OB care is a service that helps to define themission of a community hospital and strengthens localsupport for the entire range of other hospital services.

The economic impact of limited or non-existent OBcare in rural communities is difficult to measure; how-ever, it is apparent that this particular service is espe-cially vital to rural communities that are trying to createand sustain a favorable climate for business and eco-nomic growth. Local access to OB care can be a sig-nificant consideration for businesses that wish to locatein communities where they can recruit and retain a stableworkforce and provide a favorable climate for workingfamilies.

Many rural physicians are also struggling to main-tain OB care in their practices. They are confrontedwith significant issues related to declining birth rates,low reimbursement, excessive professional demands andthe rising costs of malpractice insurance. Most physi-cians the Committee encountered were reluctant to aban-don the struggle because of their strong commitment tothe community, their emphasis on treating the entire fam-ily and their desire to maintain continuity of care fortheir patients.

The Geisinger Health System is the sole providerof OB services for a town in Pennsylvania wherethere is a national manufacturing company with2,300 employees. There are 240 annual deliver-ies. OB admissions are 10 percent of the busi-ness for the local community hospital. WithoutOB services in town, the hospital would not beviable and the manufacturing plant would begone.

Geisinger Health System


Physicians were concerned about the potential riskswhen expectant mothers need to travel long distancesto deliver their babies. The risks are magnified whenthere are complications with pregnancy that cannot al-ways be anticipated. In extreme situations, delayed ac-cess to OB care can become a life or death issue forboth mother and child.

Apart from the possible health risks, geographic iso-lation from OB care is also an economic considerationfor expectant parents. When long-distance travel forcare is necessary—it is not uncommon for some fami-lies to travel more than 100 miles in rural and frontierareas—there are costs associated with travel and losthours of work, child-care and other issues.

The Committee believes that the access issues iden-

tified in this chapter are likely to become more pro-nounced in the coming years, as fewer physicians chooseto train for obstetrics and some decide to drop obstet-rics from their practices. Also, many new physicianstrained in obstetrics will be seeking a more stablelifestyle environment than can be offered in small ruralcommunities.

What We KnowWhile a typical small rural community might have ahospital with less than 25 beds, staffed by one or twofamily physicians who provide OB services, existingsystems for providing OB services in rural areas differwidely from place to place. The strengths and weak-

National Total NonMetro Metro

# Counties 3,141 2,287 73% 854 27%

Fem 15-44 Pop 61,576,997 10,976,843 18% 50,600,154 82%

OB/GYN FTEs 36,973 3,624 10% 33,348 90%

FP w/obg secondary spec FTEs 1,112 399 36% 713 64%

CNM FTEs 2,399 376 16% 2,023 84%

Tot Provider FTEs 40,483 4,399 11% 36,084 89%

OB/GYN per 10K Fem 15-44 6.00 3.30 6.59

FP w/obg Per 10K Fem 15-44 0.18 0.36 0.14

CNM Per 10K Fem 15-44 0.39 0.34 0.40

Tot Prov Per 10K Fem 15-44 6.57 4.01 7.13

Notes:Date Created: July 20, 2004Created by: Southeast Regional Center for Health Workforce Studies, Cecil G. Sheps Center for Health Services Research, UNC-CH CNM Data Source: American College of Certified Nurse Midwives (May 1999) Physician Data Source: BPHC’s Application Submission and Processing System (ASAPS) National Physician Listing, a compilationof December, 2001 data from AMA Master File, AOA Master File, NHSC Participant Listing. Physician data include clinicallyactive, non-federal MDs and DOs.

Table 1. National Totals by Metro/NonMetro for OB/GYNs, Family Practice with OB/GSecondary Specialty, and CNM

n % of tot n % of tot


nesses of any given system will depend on many differ-ent variables, including the availability and training oflocal physicians, geographic location, referral arrange-ments among providers, relationships between hospi-tals and physicians, and other factors. The ideal systemwill have the full range of prenatal and OB servicesreadily accessible in the local community, includingspecialty care. The reality in most rural communities isquite different.

Obstetricians are not found in most small rural andfrontier communities. Further, the number of rural ob-stetricians has been decreasing since the early 1980s. 2

Low birth rates, professional isolation and lifestyle is-sues are some of the most significant factors limitingtheir availability in rural areas. In Nebraska, it is notuncommon for rural patients to travel 50 miles or moreto see an obstetrician. If obstetricians are not present,emergency transportation from rural communities to

larger hospital centers is required when there are com-plications of pregnancy that cannot be managed by lo-cal providers. While relevant data on birth outcomesare not available, there is a legitimate concern that inac-cessibility to specialists in OB care services may hinderthe quality of care.

When specialized OB care is unavailable in a rural

community, this type of care is most likely performed

by family physicians, often working with nurses, phy-

sician assistants and other non-physician health care

providers. Some States also issue licenses to Certified

Nurse Midwives (CNMs). The Committee has seen

first-hand the dedication and skill of all of these provid-

ers in maintaining high quality OB care despite finan-

cial loss, severe restrictions on personal lifestyle, de-

clining birth rates and significant increases in the cost

of malpractice insurance.

Alaskaand Hawaiinot to scale

Presence of OB Providers(Number of Counties)

Sources: American College of Certified Nurse Midwives, 1999; ApplicationSubmission and Processing System (ASAPS) National Physician Listing, a com-pilation of December, 2001 data from AMA Master File, AOA Master File,NHSC Participant Listing.

* Note: “OBG Provider” includes active, nonfederal MDs and DOs withOB/GYN as primary specialty, family practice as primary specialty andOB/GYN as secondary specialty, or Certified Nurse Midwives (CNMs).

Produced by: Southeast Regional Center for Health Workforce Studies,Cecil G. Sheps Center for Health Services Research, UNC-Chapel Hill.

Presence of Obstetric Care Providers, 2001*

No OB providers (1,817)At Least 1 OB provider (1,324)


Workforce Issues

Supply

Access to OB care in rural areas cannot be sustained orimproved without an increase in the number of physi-cians trained in obstetrics. There are chronic shortagesof obstetricians, as well as family physicians trained inhigh-risk obstetrics. Data on obstetricians compiled bythe Sheps Center for Health Services Research at theUniversity of North Carolina in July 2004 reveal strik-ing contrasts between urban and rural areas in the avail-ability and ratio of these providers to women of child-bearing age. In metropolitan areas, the ratio of OB/GYNs per 10,000 women ages 15-44 is 6.59, while thesame ratio in non-metropolitan areas is 3.30. When onecombines OB/GYNs with family physicians who havea sub-specialty in OB, and with CNMs, the ratio for allof these providers per 10,000 women is 7.3 in metro-politan areas and 4.01 in rural areas. The total numberof full-time equivalent providers (OB/GYNs, familypractitioners with OB sub-specialty and CNMs) was36,084 in metropolitan areas and 4,399 in non-metro-politan areas. The data also show that the ratio of pro-viders to women of childbearing years in rural areasdeclines as a function of distance from metropolitan ar-eas.3

There are no current or reliable data on the numberof family physicians practicing obstetrics in rural areasor on the number who have chosen to drop this service.However, family physicians who practice obstetrics havetestified to the Committee that they may not be able toreplace themselves with younger physicians trained inobstetrics. In Mississippi, the Committee learned thatthe State does not have a program to train new familyphysicians in high-risk obstetrics. Moreover, establishedphysicians in Mississippi and other States reported thatthey are seeing fewer family physicians who have a sub-specialty in obstetrics. The reasons most often citedwere the higher costs of malpractice insurance for OBcare and the reluctance of new physicians to be con-stantly on-call.

In rural areas there are also well-documented short-ages of CNMs, certified nurse practitioners and othernon-physician providers. CNMs are licensed in only17 States, despite evidence that they can provide qual-ity care to OB patients. Further, they may experience

difficulty in obtaining hospital privileges or finding phy-sicians who will meet State requirements for their su-pervision.

Lifestyle Issues

Rural physicians testifying before the Committee spokeabout the harsh demands of rural obstetrics. They talkedabout the burden of being on-call 24 hours a day and onweekends, with no back-up support and only uncertainaccess to specialists. Most of these physicians were sac-rificing time with their families to keep obstetrics in theirpractices. The demands were such that some physiciansfound it difficult to schedule training and educationalopportunities required to maintain and upgrade theirskills. The Committee visited a physician in Nebraskawho had not traveled beyond the borders of his countyfor many years. While this example may be extreme,there is little question that the practice of obstetrics in-creases on-call time for physicians and often contrib-utes to rural physician “burnout.” Many rural physi-cians have dropped obstetrics to maintain a more rea-sonable lifestyle. The same lifestyle concerns apply toCNMs, nurse practitioners and other non-physician pro-viders in OB care.

Practice styles can ameliorate some of the lifestyleburdens on physicians. In one rural community visitedby the Committee a solo physician was working closelywith a certified nurse practitioner in providing OB care.The nurse was heavily involved with prenatal care, as-sisted with deliveries and provided triage for the morecomplicated cases. When non-physician providers arepresent there is a sharing of the burdens associated withOB care, but physicians are still responsible for day-to-day supervision of these midlevel providers. Also, non-physician providers are not fully trained to manage someof the more difficult and unforeseen complications thatcan arise during pregnancy and deliveries. In general,the Committee believes that a team approach to obstet-rics can help sustain this service in rural communities.

Gender Shift

Overall, there is a downward trend in popularity of OBspecialty training nationwide. At the same time, thegender composition of the OB/GYN workforce haschanged rapidly over the past 20 years. The percentageof women in the OB workforce has increased from 12


percent in 1980 to 32 percent in 2000, and it is pro-jected to increase to 50 percent by 2014.4 The gendershift may make it harder for rural communities to re-cruit physicians trained in obstetrics. Rural practice sites,with their unrelenting demands on a physician’s timeand energy, (especially in smaller and more remote com-munities) may be less attractive to women who wanttime to raise their families while pursuing a rewardingcareer. The lack of day care services and other supportsystems are also major barriers to the recruitment offemale physicians in rural areas.

Training

Some highly experienced rural physicians visited by theCommittee during the past year expressed concern aboutthe training of current residents in family practice. Theyobserved that some new family physicians do not havesufficient experience in performing Cesarean sectionsto feel comfortable with the procedure, particularly in

settings where specialty back-up support is not readilyavailable. The training they receive in obstetrics is of-ten based on an urban practice model that assumes readyaccess to specialty services in obstetrics. The mainpolicy implication of these observations is that familymedicine residencies need to make Cesarean sectiontraining available to residents who are planning to prac-tice in rural areas.

Obstetrics in Rural HospitalsMany small rural hospitals continue to offer OB caredespite low birth rates and lower payments than in ur-ban facilities. In the majority of rural hospitals thereare no obstetricians on staff and the responsibility fallsupon family physicians. Maintaining OB services re-quires family physicians who are capable and comfort-able with performing Cesarean sections, particularly onan emergency basis. Two of the most difficult aspectsof obstetrics for both hospitals and physicians are the

Source: OSCAR, 2004.Produced by: Southeast Regional Center for Health Workforce Studies,Cecil G. Sheps Center for Health Services Research, UNC-Chapel Hill.

Alaskaand Hawaiinot to scale

Counties with Hospitals(Number of Counties)

Has no hospitals (634)

Has a hospital, but none providing OB services (577)

Has a hospital that provides OB services (1,930)

Presence of Hospitals Providing OB Services, 2003


unpredictable timing of deliveries and the uncertaintiesof complications. No matter how well screened, somewomen will require emergency interventions. If physi-cians who can perform Cesarean sections are not alwaysavailable, OB care usually cannot be sustained.

According to an ongoing study by the Walsh Centerfor Rural Health Analysis in Washington, D.C., of the2,306 rural counties in the United States with adequatedata, 117 counties lost local access to OB services inthe six years between 1994 and 2000. A 1996 survey ofrural hospitals in Washington State showed that hospi-tals no longer providing OB services listed three mainreasons: 1) an inadequate number of deliveries; 2) aninsufficient number of obstetrically active physicians;and 3) the excessive costs of providing OB services.5

According to data from the Rural Hospital FlexibilityProgram tracking project, few federally certified ruralCritical Access Hospitals reported discontinuing servicesover the past two years, with the exception of OB care,which was dropped by more than five percent of thesehospitals. The effects on communities where hospitalshave closed or abandoned OB services have not beenadequately studied.

Rural hospitals must contend with low reimburse-ment rates for obstetrics under the Medicaid program.Hospital administrators testifying before the Commit-tee stated that the rates are rarely high enough to covercosts and that Medicaid patients were an increasing per-centage of their total cases. A second critical issue forhospitals is the decreasing willingness of local physi-cians to deliver babies and the difficulties of maintain-ing birthing services when physicians leave the com-munity. The Committee visited a community in Ne-braska where two physician practices were providingOB care at the hospital. If one of those physicians wasto leave, the system could not be sustained.

Yet another challenge that rural hospitals and physi-cians face is that of predicting complications from preg-nancy and the resulting need for higher level services atbirth. Washington State has developed a regionalizedhospital system for perinatal services to deal with thisissue. 6 The system identifies patients at higher risk andrefers them to an appropriate facility.

In Mississippi, the Committee visited the North Mis-sissippi Medical Center, a hospital that has employedall of the obstetricians on staff and is paying the cost oftheir malpractice insurance. This was the only way the

hospital could sustain its OB services. Most small ruralhospitals do not have sufficient capital or revenue toadopt this approach on their own. The Committee be-lieves that hospital networks for OB care, or even for-mally constituted regional systems of care with desig-nated birthing centers, are viable alternatives for hospi-tals and physicians struggling to maintain obstetrics intheir rural communities. Networks that would concen-trate OB services in fewer locations appear to make sensewhen birth rates are low and travel distances are rea-sonable. Examples of such networks are already in placein some States and may be used as models for others.

Malpractice Insurance

Medical malpractice insurance and reform is currentlya contentious topic nationwide but it is undoubtedly partof any discussion of OB care. Yet, a full discussion ofthe issue would exceed the scope of this report. There-fore, the Committee wishes to provide only brief com-ments.

In conducting a literature review, the Committee dis-covered a wealth of analysis and information on the topicof medical malpractice insurance; however, much of thisinformation appeared only to reflect the strong divisionsin the debate on the issue. While one cannot refute thatthere has been a rise in the cost of malpractice insur-ance and, subsequently, an increased burden on practi-tioners, the Committee found no definite national con-sensus that malpractice rates are driving out physicians,although the debate has been more contentious in someStates. In addition, national research has not revealedany differences between urban and rural areas in eitherthe extent or the impact of the situation.

The UHHS Brown Memorial Hospital, a Criti-cal Access Hospital in Ohio, recently closed itsOB service due to the lack of professionals inobstetrics and the crisis in malpractice costs. Atthe beginning of 2004 they had four OB provid-ers, but only one provider who would be avail-able in the coming year. The lack of anesthesiaproviders was also an issue.

UHHS Brown Memorial Hospital


Because the increases in malpractice insurance varyacross the country, many State studies have been con-ducted in recent years and have documented physicianresponses to the rate increases, including physicianspracticing in rural areas. A new survey of family prac-tice physicians and obstetricians in Washington Statefound that rate increases and fears of litigation were thereasons many physicians in the State were discontinu-ing provision of high-risk services, including OB care.Fifty-one percent of the physicians in the survey saidthey were less willing to perform procedures with po-tentially greater liability.7

Family physicians who met with the Committee havesaid that malpractice insurance costs may be the mainfactor in forcing them to abandon OB care. While theissue does not seem to flow evenly across urban andrural boundaries, the loss of even one physician practic-ing obstetrics in a small rural community can create amajor access problem for rural families. The Commit-tee believes that the potential impact of the issue on ac-cess to OB care in rural areas is great, and that stepsmust be taken to closely monitor the situation in ruralareas over the coming months and years.

Some States have dealt with the challenge by plac-ing limits on malpractice awards and/or creating Statemalpractice insurance pools. The Federal Tort ClaimsAct has been extended to cover malpractice costs forFederally Qualified Health Centers (FQHCs) and theCommittee has a recommendation to expand this cov-

erage to other settings. The Department of Health andHuman Services (HHS) can play a role in advocatingstrategies for dealing with the issue, monitoring the ef-fects of the insurance increases on access to care in ru-ral areas and sharing best practices.

Low Birth Rates and OutcomesDeclining birth rates are the reality in many rural com-munities. As stated previously, it is one of the majorreasons that OB care is hard to sustain. It places finan-cial strains on providers and makes it more difficult forproviders to maintain their skills. The Committee isalso aware that low birth rates could have a negativeimpact on the quality of care that women receive. TheCommittee was unable to find any data on the volume/outcome relationship in obstetrics to suggest problemsat this time. In fact, some studies have shown little orno relationship between volume and outcomes whencomparing rural and urban areas.8 However, the Com-mittee believes that data on this issue need to be col-lected and analyzed as part of ongoing efforts in perfor-mance measurement and quality assurance. Ultimately,the healthcare system must address both improved ac-cess to care and decreased costs. Further, it is impor-tant to define the appropriate scope of services at thelocal level that will strengthen outcomes in ways thatare cost efficient.

Federal ProgramsThe Committee believes that maintaining and improv-ing access to OB care in rural communities should be aprimary objective of Federal programs that support therural healthcare delivery system. There are several pro-grams in HHS that can be used effectively to addressthis objective. One of these is the Healthy CommunityAccess Program authorized by Section 340 (J) of thePublic Health Service Act and administered by the Bu-reau of Primary Health Care in the Health Resourcesand Services Administration (HRSA). Providers eli-gible for the program include FQHCs, hospitals withlow-income utilization rates of greater than 25 percent,public health departments and private organizations thathave traditionally served the medically uninsured orunderinsured. The program can assist a consortia ofproviders to develop or strengthen integrated commu-

Some States are concerned about the low volumeof births in rural areas and the impact on hospi-tals and other providers. In Minnesota last year,the State provided grants to 27 small hospitals toimplement a low-volume training program in OBservices. The program helps physicians andnurses maintain adequate skill and comfort lev-els, and will develop best practices for OB ser-vices in rural areas. Maryland has a highly regu-lated hospital system that establishes minimumthresholds for births that hospitals must meet inorder to provide birthing services.

Low Volume OB Services


nity healthcare delivery systems that coordinate servicesfor individuals who are uninsured or underinsured. Theprogram seems especially suited for hospitals and otherproviders in rural communities that are seeking oppor-tunities to better meet community needs for OB care,particularly for low-income populations that representa large percentage of OB patients in many small ruralhospitals.

The Rural Network Development Program adminis-tered by the HRSA Office of Rural Health Policy(ORHP) has similar goals and objectives. The programsupports rural hospitals and other providers who cometogether in partnership arrangements to develop moreefficient and effective healthcare delivery systems intheir communities. ORHP also administers the RuralHospital Flexibility Grant Program, which supports des-ignated Critical Access Hospitals in rural areas that arerequired to establish relationships with larger hospitalsin other communities. Both programs could be utilizedto support new and innovative delivery systems for OBcare that would address the problems of low patientvolumes, physician shortages and long-distance travelto obtain specialty care.

The Maternal and Child Health (MCH) ServicesBlock Grant Program (Title V), administered by theMaternal and Child Health Bureau (MCHB) in HRSA,provides funding to enable each State to promote thehealth of mothers and infants by providing prenatal, OBand postpartum care for women. However, States de-termine how MCH funds are administered at the Statelevel and there are no requirements or set-aside fundsfor rural communities.

As part of the Title V Grant, the Special Projects ofRegional and National Significance (SPRANS) and theCommunity Integrated Service Systems (CISS) are dis-cretionary grants that further support perinatal services.SPRANS funding, authorized by Sections 501 and 502,is comprised of 15 percent of the Title V Grant fundingfor MCH special projects, including MCH professionaltraining and OB services. CISS, authorized by Section501(a)(3), designates a 12.75 percent of the Title V Grantamount appropriated above $600 million for six catego-ries of grants, including projects that increase the par-ticipation of obstetricians and pediatricians under theTitle V Program.

The MCHB also oversees three additional grant pro-grams that support OB services, administered by the

Division of Research, Training and Education (DRTE)and the Division of Healthy Start and Perinatal Systems(DHSPS). The MCH Research Program, administeredby DRTE, supports research to improve health servicesfor mothers and children. The findings are published inleading medical journals such as the Journal of theAmerican Medical Association (JAMA), Obstetrics andGynecology, and Pediatrics. The MCH Training Pro-gram, also administered by DRTE, provides funding toinstitutions of higher learning to support the training ofpublic health professionals in MCH. Continuation ofresearch and professional training in rural communitiesis the foundation of providing quality OB services tothis population. DHSPS administers the Healthy StartInitiative to address disparities in perinatal health bysupporting local, community coalitions of women, theirfamilies, health care providers, businesses and variouspublic and private organizations. All of these programsmight offer some resources to rural communities to fo-cus on increasing access to OB care. However, becauseall communities are eligible for these grants, there is agreat deal of competition for these funds. MCH doesnot track the percentage of grants that flow to rural com-munities either through its discretionary programs orthrough the block grant.

In 2004 the Governor of Virginia convened aworking group on OB services in rural areas. Thegroup reported that OB care had reached a crisislevel and called for immediate steps to improveaccess to medical care for pregnant Medicaid pa-tients. The Group found that, of the women whogave birth in rural Virginia, 65 percent chose orwere forced to obtain OB care in metropolitanareas. The working group is seeking a 45 per-cent increase for Medicaid reimbursements tooffset years of stagnant rates that have added tothe financial crises of some doctors who provideOB services. For more information on the work-ing group, see their web site at:h t t p : / / w w . d m a s . v i r g i n i a . g o v /prexecutive_directive_rural_obstetrical_care.htm.

Virginia Working Group on OBServices


Federal programs supporting telecommunicationprojects in rural areas also can address issues of OBcare. There are several applications of this technologythat have become available, including fetal monitoringsystems that allow physicians in remote areas to receivespecialty consultations from large birthing centers inurban areas. HHS should place greater emphasis onOB care in its management of these programs.

The rapid expansion of FQHCs over the past fewyears has resulted in an increasing number of centerslocated in rural areas, and with that expansion has comeimproved access to prenatal care and OB services forthousands of low-income patients. In 1995, the FederalTort Claims Act created a medical malpractice insur-ance program that offers full coverage for the centers atno cost to grantees that participate. Health centers canapply to be deemed as Federal employees for the pur-pose of medical malpractice and thereby become im-mune from lawsuits. After meeting specific criteria,the need for “deemed” centers to purchase private medi-cal malpractice insurance is eliminated, thus freeingmore funds for services to those who need them. Theprogram recently has been expanded to cover free clin-ics that meet certain Federal requirements. The Com-mittee believes that the Department should give seriousconsideration to working with the Congress to developlegislation that would expand this program to other ru-ral providers. For example, small rural hospitals thatmeet very specific criteria related to a low volume ofOB patients, high rates of medical malpractice insur-ance premiums, proven provider shortages, geographicisolation from alternative care sites and specialty care,etc., could be made eligible for the program. Likewise,federally certified Rural Health Clinics could be madeeligible if they provide OB care and meet the specificcriteria. The expansion could be designed to addressthe needs of rural communities that have either lost OBservices or are on the brink of loss. The Committeewould be interested in working with the Department toexplore this possibility.

On the supply side, the National Health Service Corps(NHSC) in HRSA continues to achieve great success inplacing primary care physicians in rural medically un-derserved areas of the country. While the number ofphysician placements has been increasing in recent years,many rural areas remain underserved and limited ac-cess to OB care is a leading indicator in the designation

Dr. Barb Patridge and her colleagues atGeorgetown Family Health Center inGeorgetown, Ohio, a clinical site of SouthernOhio Health Services Network (SOHSN), havedeveloped a successful approach to recruitmentand retention of OB/GYNs in their rural com-munity.

Georgetown Health Center, a Federally Quali-fied Health Center, has overcome the same bar-riers many rural providers face, including the ab-sence of a nearby training program and the re-luctance of physicians to commit to a commu-nity where professional responsibilities exceedthose of urban physicians. In addition, reim-bursements are lower and social isolation is al-ways an issue.

Dr. Patridge was a National Health ServiceCorps (NHSC) scholar 16 years ago and stayedwhen her service obligation ended. Since thenshe has become an integral part of the commu-nity and is the core of an OB/GYN staff that stilldraws from the NHSC as well as from a varietyof State residency programs and recruiting com-panies, and by word of mouth. The recruitmentprocess begins when medical students from theUniversity of Cincinnati rotate with cliniciansin one of SOHSN’s 13 sites. This enhances thefamiliarity with rural settings and gives SOHSNa broad applicant pool when vacancies occur.The Network also then offers assistance withmedical liability and provides practice adminis-tration services to reduce the paperwork burdenon physicians. As a result, SOHSN has built astaff of five female OB/GYNs of varying levelsof experience and longevity with SOHSN, giv-ing each woman a variety of interaction withpeers in her own community. SOHSN had morethan 175,000 patient visits in 2000, serving fivecounties in rural southern Ohio.

Rural OB/GYNRecruitment and Retention


of underserved areas. The Committee believes that theNHSC program must be aggressive in identifying ruralcommunities that lack OB services and placing physi-cians in these locations. Further, the program shouldfocus its recruitment efforts on family practitioners whohave sub-specialty training in obstetrics.

In its previous reports, the Committee has made sev-eral recommendations on the Department’s long-stand-ing support for primary care training programs in medi-cal schools. Some medical schools have a proven trackrecord for training physicians to practice in rural set-tings and have a significant percentage of graduateselecting rural practice. These programs should receivestrong support from the Department. Moreover, theCommittee believes that improving access to OB carein rural areas should be a clearly stated objective forthese programs, and that program managers should lookfor ways to utilize these programs more effectively tofurther this objective.

The Committee understands that recent increases inmalpractice insurance premiums have created a grow-ing concern in many States, both rural and urban. TheFederal interest in this situation is evidenced by legisla-tion currently under consideration by the Congress thatwould place caps on malpractice insurance awards. TheCommittee believes that this is an important issue formany rural communities. The Department should con-tinue to work closely with the States, health professionassociations and other groups to address this issue.

Recommendations• The Secretary should increase support for medical

schools that have distinct programs and a proventrack record for training physicians to practice ob-stetrics in rural areas.

An increased supply of rural physicians trained in ob-stetrics is essential to sustaining these services in hun-dreds of small rural communities. The Secretary shouldincrease or reallocate funds under Title VII of the Pub-lic Health Service act to target medical schools that trainobstetricians and family physicians for rural practice,especially those that provide residents in family medi-cine with training in high-risk obstetrics. Family phy-sicians are more likely to practice in rural areas thanobstetricians, and programs that prepare them for high-

risk obstetrics must be supported. Support for the train-ing of CNMs and nurse practitioners who are interestedin obstetrics also should be increased.

• The Secretary should make the recruitment and place-ment of physicians trained in obstetrics a major goalfor the National Health Service Corps.

The Committee believes that the National Health Ser-vice Corps must focus more attention on rural areas thatlack adequate OB services. Recruitment efforts shouldfocus on physicians who are trained in obstetrics andwho are willing to deliver babies in the communitiesthey serve. Additional incentives for new physiciansare also needed and should be explored. One approachwould be to pay the malpractice insurance costs of newCorps physicians who are fulfilling their obligation inareas with measurable and pronounced shortages of OBcare providers.

• The Secretary should support programs to create hos-pital and physician networks that will sustain andimprove access to OB services in rural areas.

There are several existing grant programs in the De-partment (Healthy Community Access, Rural NetworkDevelopment, Rural Hospital Flexibility Grants) thatshould be used to promote the development of hospitaland physician networks in OB care. The Committeebelieves that OB services in many small rural hospitalsand physician practices will be unsustainable over time,given the issues discussed in this report. Providers needencouragement and incentives to find more sustainableand efficient strategies for maintaining access to OBcare. Existing grant programs should be more aggres-sive in encouraging and funding grant applications thataddress the problem.

• The Secretary should use existing authorities underSection 301 of the Public Health Service Act to pro-mote the development of team approaches to OB careinvolving physicians, nurse practitioners, CertifiedNurse Midwives and other non-physician providers.

The Secretary should use this demonstration authorityto develop a model program that supports regional ap-proaches to improving access to OB care in rural com-munities through networking and an emphasis on using


interdisciplinary teams in several rural areas as a pilotproject.

• The Secretary should work toward increasing Med-icaid payments for OB services.

The Committee understands that Medicaid payments forservices are determined by the States; however, the Sec-retary does have authority over State Medicaid waiversthat affect the scope of services that Medicaid providesand the populations served. The Secretary should ex-plore ways in which the waiver approval process couldbe used to provide incentives for the States to increasepayments and improve access to OB services in ruralareas.

• The Secretary should address the malpractice insur-ance issue by supporting legislation that will extendthe Federal Tort Claims Act to rural OB providers infederally designated shortage areas.

The malpractice insurance program for FQHCs and FreeClinics should be extended to cover rural hospitals andphysicians providing OB services in underserved ruralareas. The Committee believes that the current systemfor designating Health Professional Shortage Areas(HPSAs) may not be able to identify the rural areas mostunderserved by OB services. Data are available to iden-tify rural areas that have the lowest ratios of OB provid-ers to women of childbearing age, which may be a moreeffective access measure. Another approach would beto give greater weight to OB services as a variable usedin the HPSA designation process. The method used mustbe limited to those rural areas where access to OB careis most severely limited by provider shortages.

References

1 Thompson MJ, Lynge DC, Larson EH, Tachawachira P,Hart LG. “Characterizing the General Surgery Workforcein Rural America.” Rural Health Research Center, Uni-versity of Washington School of Medicine. May 2004.

2 Peck J, Alexander K. “Maternal, Infant, and Child Healthin Rural Areas: A Literature Review.” Rural HealthyPeople 2010. U.S. Department of Health and Human Ser-vices. Washington, D.C: U.S. Government Printing Office;November 2000.

3 Unpublished data provided by the Sheps Center for HealthResearch, University of North Carolina at Chapel Hill,Chapel Hill, N.C.

4 Benedetti TJ, Baldwin LM, Andrilla CH, Hart LG. TheProductivity of Washington State's Obstetrician-Gynecolo-gist Workforce: Does Gender Make a Difference? ObstetGynecol. March 2004;103(3).

5 Norris TE, Reese JW, Pirani MJ, Rosenblatt RA, WAMIRural Health Research Center. Are Rural Family Physi-cians Comfortable Performing Cesarean Sections? J FamPract. November 1996; 43(5).

6 Nesbitt TH, Larson EH, Rosenblatt, Roger A, Hart GL.“Local Access to Obstetric Care In Rural Areas: Effect onPrenatal Care, Birth Outcomes, and Costs.” WAMI RuralHealth Research Center. Seattle, Washington; August 1993.

7 Washington State Medical Education and Research Foun-dation. “Overview of Survey of Physicians on MedicalLiability.” 2004. Available at: http://www.yesoni330.org/documents/I330_ResearchOverview.pdf.

8 Larson EH, Hart GL, Rosenblatt RA. “Is Rural Residencea Risk Factor for Poor Birth Outcome?” WAMI RuralHealth Research Center. Seattle, Washington; December1995.


Obesity in Rural Communities


The alarming increase in the prevalence of obesity makesit one of the most important health and social issues ofour time. In his 2001 “Call to Action to Prevent andDecrease Overweight and Obesity,” the Surgeon Gen-eral reports that an astonishing 64 percent of Ameri-cans (approximately 129.6 million) are overweight orobese. Nine million of those are children.1 This epi-demic has staggering implications for individuals, fami-lies, businesses, the health care system and our societyoverall. A report from the Centers for Disease Controland Prevention (CDC) predicts that if current trendscontinue, our children will be the first generation in his-tory with a shorter life expectancy than their parents.The figure on the next page, “Obesity Trends amongU.S. Adults,” reveals how, over time, the U.S. popula-tion has become more and more overweight. Much ofthe increase has occurred in rural areas.2

Obesity is defined by the CDC as an excessively highamount of body fat in relation to lean body mass.3 Theterm “overweight” refers to an increase in body weightin relation to height, measured by Body Mass Index(BMI). Adults with BMIs of 25 or more are consideredoverweight and adults with BMIs of 30 or more are con-sidered obese. In 2002, researchers at RAND comparedthe effects of obesity, smoking, heavy drinking and pov-erty on chronic health conditions and health expendi-tures. Their finding: “Obesity is the most serious prob-lem. It is linked to a big increase in chronic health con-ditions and significantly higher health expenditures. Andit affects more people than smoking, heavy drinking, orpoverty.”4

The RAND research on obesity reveals that obeseindividuals spend 36 percent more dollars than the gen-eral population on health services, such as in-patient care,doctor’s visits and medications, and 77 percent moredollars on medications than daily smokers and heavy

drinkers. Only aging has a greater effect—and only onexpenditures for medications.5

Being overweight or obese increases an individual’srisk of developing diabetes and heart disease. Excessbody weight is also associated with an increased risk ofdeveloping an ever-growing list of diseases and poorhealth conditions. In a research review conducted bythe American Obesity Association, obesity also is listedas an independent risk factor or an aggravating agentfor 32 co-morbidities or health conditions including:birth defects, breast cancer, cardiovascular disease, co-lon cancer, diabetes mellitus, end stage renal disease,gallbladder disease, impaired immune response, liverdisease, renal cancer, rheumatoid arthritis, stroke andsurgical complications.6

In December 2004 the CDC announced that obesityis the second leading cause of preventable death ofAmericans, ranking after tobacco use. The agency re-ports the number of obesity deaths at 400,000, comparedwith 435,000 from tobacco.7 The report cites deathsdue to poor diet and physical inactivity rose by 33 per-cent over the past decade.8 In 2000 alone, 17 percent ofall deaths were related to poor diet and physical inactiv-ity.9

As the obesity epidemic continues, it will further di-minish quality of life and place greater stress on bothproviders and payers of health care and medical treat-ment. Total direct and indirect costs, including medicalcosts and lost productivity due to America’s overweightand obesity epidemic, are estimated to be $117 billionnationally for 2000.10 In a study released earlier thisyear, researchers at RTI International and the CDC re-ported that obesity-attributable medical expenditures inthe U.S. were an estimated $75 billion in 2003. Ap-proximately half of these costs are paid through Medi-care and Medicaid,11 thus increasing the urgency of ad-dressing obesity nationwide.

The economic impact of obesity at the State levelwas reported by the CDC in a January 21, 2004 pressrelease entitled, “Obesity Costs States Billions in Medi-


Obesity Trends Among U.S. Adults(Obesity=BMI~ 30 lbs. overweight for 5’4” woman)

1985 2001

Source: The Centers for Disease Control, http://www.cdc.gov/

cal Expenses.” The estimates of the percentage of an-nual medical expenditures attributable to obesity rangedfrom four percent in Arizona to 6.7 percent in Alaska.For Medicare expenditures, the percentage ranges from3.9 percent for Arizona to 9.8 percent for Delaware. ForMedicaid recipients, the percentages range from 7.7percent in Rhode Island to 15.7 percent in Indiana. 12

Why is Obesity Important toRural America?

Trends tracked by the CDC show that Americans areincreasingly becoming obese, with rural America lead-ing the way.13 Health status and the availability of healthservices are worse in rural America for almost any dis-ease or health issue one can name, and obesity is noexception. While the obesity epidemic is probablyrooted in the interplay of very complex cultural and so-cietal factors, the unique characteristics of rural publichealth and health care services also are likely contribu-tors. Examples of these contributors are the lack of lo-cal public health capacities, changing lifestyles, depen-

dence on Medicare, lack of knowledge or information,lack of coordination of local providers, socio-economicdisadvantage, geographic isolation, provider shortagesand lack of transportation.

Small rural hospitals are heavily dependent on theMedicare payment structure. Until recently, Medicareexplicitly stated in its Medicare Coverage Issues Manualthat “obesity cannot be considered an illness.” Thus,obesity-related services were not reimbursable underMedicare. With the removal of this language, policiescan be changed to allow Medicare coverage of obesity-related treatments.

Because of isolation and multiple responsibilities,administrators of small rural hospitals may have diffi-culty maintaining current knowledge of services cov-ered by Medicare that are related to obesity preventionor treatment. Some services, such as nutrition counsel-ing, are covered but may not be incorporated into Medi-care billing by rural hospitals or clinics. During a re-cent site visit to Nebraska, Committee members spokewith the director of a fitness program for Medicare re-cipients who suffer from diseases associated with obe-sity; the director was unaware that Medicare would re-


TABLE 1Percentage of Adults with Obesity in the U.S. by State

U.S. States 1991 (%) 1998 (%) 2000 (%) 2001 (%)Alabama 13.2 20.7 23.5 23.4Alaska 13.1 20.7 20.5 21.0Arizona 11.0 12.7 18.8 17.9Arkansas 12.7 19.2 22.6 21.7California 10.0 16.8 19.2 20.9Colorado 8.4 14.0 13.8 14.4Connecticut 10.9 14.7 16.9 17.3Delaware 14.9 16.6 16.2 20.0District of Columbia 15.2 19.9 21.2 19.9Florida 10.1 17.4 18.1 18.4Georgia 9.2 18.7 20.9 22.1Hawaii 10.4 15.3 15.1 17.6Idaho 11.7 16.0 18.4 20.0Illinois 12.7 17.9 20.9 20.5Indiana 14.8 19.5 21.3 24.0Iowa 14.4 19.3 20.8 21.8Kansas No data 17.3 20.1 21.0Kentucky 12.7 19.9 22.3 24.2Louisiana 15.7 21.3 22.8 23.3Maine 12.1 17.0 19.7 19.0Maryland 11.2 19.8 19.5 19.8Massachusetts 8.8 13.8 16.4 16.1Michigan 15.2 20.7 21.8 24.4Minnesota 10.6 15.7 16.8 19.2Mississippi 15.7 22.0 24.3 25.9Missouri 12.0 19.8 21.6 22.5Montana 9.5 14.7 15.2 18.2Nebraska 12.5 17.5 20.6 20.1Nevada No data 13.4 17.2 19.1New Hampshire 10.4 14.7 17.1 19.0New Jersey 9.7 15.2 17.6 19.0New Mexico 7.8 14.7 18.8 18.8New York 12.8 15.9 17.2 19.7North Carolina 13.0 19.0 21.3 22.4North Dakota 12.9 18.7 19.8 19.9Ohio 14.9 19.5 21.0 21.8Oklahoma 11.9 18.7 19.0 22.1Oregon 11.2 17.8 21.0 20.7Pennsylvania 14.4 19.0 20.7 21.4Rhode Island 9.1 16.2 16.8 17.3South Carolina 13.8 20.2 21.5 21.7South Dakota 12.8 15.4 19.2 20.6Tennessee 12.1 18.5 22.7 22.6Texas 12.7 19.9 22.7 23.8Utah 9.7 15.3 18.5 18.4Vermont 10.0 14.4 17.7 17.1Virginia 10.1 18.2 17.5 20.0Washington 9.9 17.6 18.5 18.9West Virginia 15.2 22.9 22.8 24.6Wisconsin 12.7 17.9 19.4 21.9Wyoming No data 14.5 17.6 19.2

Source: CDC, Behavioral Risk Factor Surveillance System, 1991-2001.

imburse for the services of a nutri-tionist. In addition, expertise in obe-sity prevention and treatment may belimited in rural communities and ac-cess to such services may require longor arduous travel in areas where pub-lic transportation is not available. TheCommittee applauds Medicare’s newobesity coverage but urges the De-partment of Health and Human Ser-vices (HHS) to make sure providersare aware of the change.

Poverty is a determinant of nutri-tional quality and poor health. In aHarvard University study of U.S.counties, life expectancy was de-creased by as much as 15 years in thepoorest communities.14 The Ameri-can College of Physicians reports that46 percent of Mexican-Americanwomen living below the poverty lineare overweight compared with 40 per-cent of those living above the pov-erty line; comparable figures for non-Hispanic women are 39 percent and25 percent for women below andabove the poverty line, respectively.15

When compared to urban or sub-urban areas, rural America generallyexperiences higher unemployment,lower education levels and more pov-erty. Forty-eight of the 50 counties(96 percent) with the highest child-poverty rates are in rural America.Low incomes limit the ability to pur-chase and prepare adequate meals,which can translate into poor nutri-tion and overweight. Rural areas of-ten lack transportation systems thatmight otherwise facilitate use of foodstamps or access to a food bank or asupermarket with low-cost, nutritiousfood.16 Unfortunately, in poorer ru-ral households, low-cost, high-fatfoods are often standard fare.

Obesity in rural America can alsobe attributed to changes in the rural


The vast majority of households in America arefood secure. According to the U.S. Departmentof Agriculture Foreign Agricultural Service, foodsecurity means that all people at all times haveaccess to enough food for an active, healthy life.At a minimum, food security includes the readyavailability of nutritionally adequate and safefoods and the assured ability to acquire accept-able foods in socially acceptable ways (for ex-ample, without resorting to use of emergency foodsupplies, scavenging, stealing and other copingstrategies).

However obstacles to obtaining food are facedby those individuals living in rural and remotelocations, those with high unemployment and highpoverty rates. U.S. migrant and seasonal farmworkers also may have difficulty getting accessto food. Low incomes and difficult working con-ditions limit their ability to purchase and prepareadequate meals. Because migrant labor campsare in rural areas, workers often lack transporta-tion that would enable them to purchase variedand reasonably priced foods.1

Food insecurity may coexist with obesity. Re-search by David Holben, a professor at Ohio Uni-versity who researches food security, suggests thatpeople without a steady diet are more likely to beoverweight. In fact, his studies have shown thatobesity was greater among food-scarce house-holds compared with households that had enoughfood, and, surprisingly, obesity increased as lev-els of food security worsened. Reasons for thiscounterintuitive relationship have yet to be fullystudied. However, Holben offers a few possibleexplanations: people overeat when they have foodbecause meals often are few and far between; thelack of education regarding which foods are nu-tritious; and the belief that healthy food is not af-fordable.2

1 Foreign Agriculture Service, U.S. Department of Ag-riculture Foreign Agricultural Service. “Discussion Pa-per on Domestic Food Security” February 13, 1998.Available at: http://www.fas.usda.gov/icd/summit/1998/discussi.html.

2 For more information on Holben’s research, see:h t t p : / / w w w . h h s . o h i o u . e d u / h c s /staffdetail.asp?section=HCS&id=HolbenDavid.

Food Scarcityway of life. Over time, work in many traditional rural-based industries has become much less physically de-manding than even a few decades ago. In many areas,the family farm, where a few human beings performmost of the labor, has been replaced with corporate“mega” farms, where machinery and automation per-form the vast majority of the tasks. This is true of thefishing, logging and livestock industries, as well. Atthe same time, telemarketing, mail order, and various“live” support and telephone survey organizations haveset up operation in rural areas because it is less expen-sive than in urban or suburban areas. Thus, rural resi-dents have, over time, gone from a lifestyle with vigor-ous physical demands to a much more sedentary one.

In addition to the diminished quality of life for over-weight or obese individuals and the staggering systemiccosts associated with treating the sequelae, there areserious economic reasons for rural America to addressits obesity problem. For example, manufacturing andfood processing companies have often sought rural lo-cations because of favorable economic factors but thesecompanies have found that obesity is costly. To addressthese issues, employers in rural McKean County, Penn-sylvania, have come together as a group to implementand evaluate employer-sponsored health promotion ef-forts and their impact on the health of the community atlarge. HealthWorks for the Bradford Region, as thegroup has come to be known, has focused its initial ef-forts on the issues of nutrition and physical inactivitybased on rising health insurance premiums and associ-ated healthcare and productivity costs borne by areaemployers.

What Is Known About RuralObesity

When national obesity data are examined, rural Ameri-cans have a higher incidence of obesity than their met-ropolitan counterparts.17 While it is true that rural areashave had lower rates of overweight and obese people inthe past due to the physical nature of rural occupations,this is no longer the case.18 Obesity is now more com-mon in low-income and rural populations—where ac-cess to low-cost nutritious foods and recreational ac-tivities may be limited.

Contrary to the image of bucolic, healthful living,


Women

Metropolitan counties

NOTES: Obesity is defined as BMI > 30 based on self-reported height and weight. Percents are age adjusted. See related Health,United States, 2001, Table 69.

SOURCE: Centers for Disease Control and Prevention, National Center for Health Statistics, National Interview Survey.

Nonmetropolitan counties

ALargecentral

BLargefringe

CSmall

DCity

> 10,000

ENo city

> 10,000

Obesity Disparities, Health, United States, 2001 Rural and Urban Chart Book, CDC

Men

most rural communities lack coordinated recreationalactivities and organized activities. In addition, individu-als often cannot walk to complete errands because dis-tances are so great. Even if there were destinations closeby, most rural areas lack sidewalks and streetlights,making walking dangerous. The economic decline ofrural downtown shopping districts has further inhibitedactivity in rural areas by reducing access to nearby shop-ping and recreation.

Culture influences the perception of what is healthy,attractive and desirable. In some cultures, a fat baby isa healthy baby and therefore, formula and bottle feedingsare encouraged long past the infant’s true nutritionalneed. In other cultures, if a man has a large belly, it is asign that he is successful. These cultural influences stiflethe message that being overweight is unhealthy and nota condition to be admired. In some rural areas wherethe majority of the adult population is overweight, be-

ing plump or even fat is not seen as being unusual oreven undesirable.

Cultural influences also affect the reasons individu-als do not seek or achieve care—belief systems, stigma,lack of culturally competent care and limited accessi-bility, availability and affordability of public health andhealth care services all contribute to reasons why anindividual will or will not attempt to access the healthcaresystem. To be effective, information on how to utilizecommunity public health and healthcare services andsupport programs must be available and culturally ap-propriate. Often, weight loss programs are not well in-tegrated into primary care services, much less incorpo-rated into the context of a culturally competent plan.19

The culture created by advertisers includes messagesthat urge consumption of large quantities of foods withlittle nutritional value. At the same time, our culturereveres celebrities who are overly thin, achieved by


Racial / Ethnic Group 1988 to 1994 1999 to 2000 1988 to 1994 1999 to 2000

Black (non-Hispanic) 62.5 69.6 30.2 39.9

Mexican American 67.4 73.4 28.4 34.4

White (non-Hispanic) 52.6 62.3 21.2 28.7

Overweight(BMI > 25)

Prevalence (%)

Obesity(BMI > 30)

Prevalence (%)

Increase in Overweight and Obesity Prevalence Among U.S. Adults*By Racial/Ethnic Group

Source: CDC, National Center for Health Statistics, National Health and Nutrition Examination Survey. Flegal et.al. JAMA. 2002; 288:1723-7 and IJO. 1998;22:39-47. *Ages 20 and older for 1999 to 2000 and ages 20 to 74 for1988 to 1994.

means that are, probably, equally unhealthy. Our cul-ture also promotes inactivity in the form of television,videogames and spectator sports. No longer does lei-sure time include physical activity as a matter of course.Indeed, it is the exception for people to get out and movearound.

Ethnicity does carry with it certain risk factors forobesity. The prevalence of adult obesity between 1991and 2001 increased from 12 percent to 20.9 percent. Thisincrease was just slightly higher among men and mostpronounced among minorities.20 Obesity in the U.S.continues to escalate, particularly in minority popula-tions (African Americans, Hispanics and Native Ameri-cans) and individuals with low incomes.21

Mexican American and black (non-Hispanic) adultsin the U.S. are considerably more overweight and obesethan white (non-Hispanic) adults.22 Researchers havefound that among rural Native Americans in Oklahoma,for example, the prevalence of obesity, high blood pres-sure, diabetes and heart disease was higher than in thegeneral population.23 The highest rates were reportedfor American Indians in Arizona, at 80 percent forwomen and 67 percent for men in 1995, according toresearchers of the Strong Heart Study. (Rather than us-ing the standard definition for overweight, this studydefined overweight as a BMI > 27.8 for men and > 27.3for women, possibly understating the problem.)24 Cul-tural factors that influence dietary and exercise behav-iors are reported to play a major role in the develop-

ment of excess weight in minority groups.25

In many cases, the lack of resources and the geo-graphic isolation of rural communities make it difficultfor them to attract services and providers of any kind,let alone those specializing in diet, nutrition, weight lossand exercise. Aside from rural areas popular amongwealthier retirees, providers of any specialized services,such as those related to weight control, are often over-whelmed with clients. In addition, local providers inrural areas have little time available in heavy patientworkloads to share current information about prevent-ing or combating obesity. Finally, rural public healthgenerally lacks the capacity to track health issues, suchas obesity, and then develop resources to address them.Federal grant funds to address obesity issues rarely makeit to rural communities and there are fewer local re-sources available compared to metropolitan areas.

What Is the Community’s Role?

Despite the barriers and difficulties in addressing obe-sity in rural areas, some community-based initiativesare underway. There are rural school-based programsthat focus on preventing diabetes, making lunches nu-tritious and increasing physical activity. One such pro-gram is being implemented on behalf of Native Ameri-can school children by the University of Nebraska Medi-cal Center in Omaha, Nebraska and the Whirling Thun-der Wellness and Diabetes Program in Winnebago, Ne-


The CDC reports that four percent of children (age6 to 11) in 1963 through 1974 were overweight.In 2000 the prevalence was 15 percent.1 Oneknown factor contributing to overweight childrenis poverty, which is of particular concern for ruralcommunities since one in five children in ruralAmerica lives below the poverty line.2

In response to the increased prevalence of obe-sity, the Institute of Medicine’s Committee on Pre-vention of Obesity in Children and Youth has de-veloped a comprehensive national strategy that rec-ommends specific actions for families, schools,industry, communities and government.

For the first time, blood pressure is now a medi-cal concern for young children. The National HighBlood Pressure Education Program WorkingGroup on High Blood Pressure in Children andAdolescents now recommends that blood pressurescreening for hypertension and prehypertensionbegin as early as age three. This recommendationwas fueled by the strong association of hyperten-sion with obesity and the marked increase in theprevalence of childhood obesity.3

In any discussion of obesity, the idea of pre-venting the problem early in the life of a child iscritically important. Attempting to “fix” the na-tional epidemic by only treating obese adults willbe nearly impossible. Prevention is recognized asthe key to reducing obesity rates in many ruralstates. Indiana, for example, is targeting the riskfactors and causes of obesity among children: pa-rental obesity and behaviors, sedentary behaviors,caloric intake, low socioeconomic status, low birthweight, formula feeding, genetics and the environ-ment. These areas are being tackled throughIndiana’s Childhood Obesity Strategic Plan. Theareas of focus of the plan all stress the importanceof prevention.

1 CDC Behavioral Risk Factor Surveillance System(BRFSS) and National Health and Nutrition Examina-tion Survey (NHANES) 1999-2000.

2 “Poverty Tightens Grip on Mississippi Delta.” Wash-ington Post; July 17, 2004.

3 “The Fourth Report on the Diagnosis, Evaluation, andTreatment of High Blood Pressure in Children and Ado-lescents.” Pediatrics; August 2004; 114 (2).

Childhood Obesitybraska. This program implements a physical activityintervention to prevent or reduce obesity in the schoolchildren of the community.26

Twenty-eight States have legislation pending thatwould limit the vending and sale of non-nutritious foodsand beverages in schools. While none of these mea-sures has been enacted,27 individual school districts inmany areas have already implemented a policy thatwould eliminate the sale of non-nutritious foods andbeverages in school vending machines. For example,the Texas Commissioner of Agriculture has mandatedthe removal of soft drink vending machines from el-ementary schools.

Lawmakers in 27 States are considering legislationthat would increase requirements for physical activityin schools. The bills address physical education in avariety of ways. Some initiatives require physical edu-cation as part of the school curriculum; others expandthe duration of physical education classes or require year-round or daily physical education courses. Other billspropose to tax school vending machine sales, and to usethe revenue to augment physical education budgets.28

Arkansas has legislative measures aimed at childhoodobesity already in place through “health report cards.”By law, schools there are now required to measure andreport on the BMI of students. The Virginia Legislatureis considering a similar “fitness report card” programthat would be developed by the board of education. TheNew Mexico Legislature has called for a feasibility studyof such a program for that State.29 Also, the West TexasArea Health Education Center (AHEC) has implementeda comprehensive health and fitness program in 30 ruralschools where BMIs are being tracked for third graders.

In Connecticut, current law requires each child toundergo a health assessment prior to public school en-rollment. A piece of legislation under considerationthere would require health care practitioners to includemeasurement of BMI-for-age in the physical examina-tion. The new law also would require local or regionalboards of education to report annually to the local healthdepartment and the Department of Public Health the totalnumber of pupils per school and per school district whohave been diagnosed with obesity based on the BMI-for-age recorded. Iowa, Indiana and Washington alsohave introduced legislation that would require measure-ment and reporting of the BMI of students. 30


The Committee visited a weight loss program inWest Point, Mississippi in September. Thisunique program sprang from the Governor’sCommission, which put together a physical fit-ness report card for Mississippi and found thatthe State was the worst State in the Nation interms of obesity. It was started by the local hos-pital and the county extension service. For the“Weigh To Go” program, teams of 10 partici-pants committed to lose a total of 100 pounds in12 weeks. Ninety-eight teams initially signedup for the weight loss challenge. Each team se-lected a team leader to be their champion andencourager. The team members had to attendweekly seminars on weight loss and nutrition.Seventy-eight teams completed the program re-quirements (attending all the sessions) and at-tended the final weigh-in. Twenty teams lost atleast 100 pounds and completed the programrequirements. A total of 780 people in the cityof West Point lost 5,612.75 pounds. Local busi-nesses donated money for the graduation prizes,which consisted of a $20 VISA card for the mem-bers of the 20 teams who lost 100 pounds and$10 VISA cards for all participants who indi-vidually lost at least 15 pounds or attended allthe seminars. The effects of the program are stillevident. For instance, many local restaurantsbegan offering more nutritious items on the menusuch as whole wheat bread and low fat milk.Some of the local neighborhood residents havealso begun walking together daily. Seven milesof an unused railroad were turned into a walkingtrail. Currently there are plans to take the pro-gram statewide.

Site Visit to West Point, MSeducation campaign with the Ad Council to informAmericans that small, achievable steps can be made toimprove their health and reverse the obesity epidemic.The Secretary advocates “tackling Americans’ weightissues as aggressively as we are addressing smoking andtobacco.”31 Partners in this effort include Lifetime Tele-vision, Sesame Workshop and the United Fresh Fruitand Vegetable Association.

Healthy People 2010, a set of health objectives forthe Nation to achieve over the first decade of the newcentury, is also sponsored by HHS. Healthy People 2010was developed through a consultation process and builton the best scientific knowledge. It is designed to mea-sure programs over time and to be used by individuals,States, communities and professional organizations todevelop programs to improve health. Under the HealthyPeople 2010 initiative, HHS produced Healthy Peoplein Healthy Communities: A Community Planning GuideUsing Healthy People 2010. This document is a guideto developing an action plan through building commu-nity coalitions, creating a vision, measuring results andcreating partnerships.

The Steps to a HealthierUS community grant pro-gram is administered by the CDC. In 2003, a total of$13.7 million was awarded through 12 grants to Statesto fund local efforts to help reduce diabetes, obesity andasthma by addressing three related risk factors—physi-cal inactivity, poor nutrition and tobacco use. Four Statesincluded rural communities in their efforts: Washing-ton, New York, Arizona and Colorado. In Septemberof 2004, 10 new grants were awarded a total of $35.7million.32 While the intent of this program is laudable,there are problems with it when examined from the ru-ral perspective. Of the total $49.4 million (FY 2003and FY 2004), $25.8 million was designated to fundlarge cities; slightly more than $2 million was desig-nated to fund three Tribal applications; and $21.4 mil-lion was designated to fund programs in small cities andrural communities in seven States. The grant requireseach State to choose communities of total residence sizenot to exceed 800,000 persons. In addition, each com-munity must be “geographically contiguous and includea minimum population of 10,000.”33 These stipulationsexclude the smallest rural communities and those re-mote communities in geographically large States.

The CDC administers the Overweight and ObesityState Programs. Twenty States were awarded funding

What Are the Current HHS andGovernmental Roles?

HHS supports the Healthy Lifestyles and Disease Pre-vention Program (http://www.smallstep.gov), a national


in 2004 for programs designed to help States maximizethe effectiveness of their efforts to prevent obesity byimproving nutrition and physical activity. Two of theStates, New York and Texas, incorporate rural commu-nities in their efforts.

The CDC also administers Prevention Research Cen-ters: Preventing Disease through Community Partner-ships. This program funds three extramural researchcenters—the University of Colorado, the University ofIowa and the University of North Carolina at ChapelHill—to support programs that add to the current un-derstanding of preventing and controlling chronic dis-ease.

The National Institutes of Health (NIH) administersthe Strategic Plan for NIH Obesity Research. NIH Di-rector, Dr. Elias A. Zerhouni, announced this strategicplan in the spring of 2004. The plan was created throughthe work of the NIH Task Force on Obesity Researchand coordinates the work of 25 institutes, centers andoffices at NIH that will focus on: behavioral and envi-ronmental approaches to modifying lifestyle; pharma-cological, surgical and other medical approaches to com-bating obesity; and breaking the link between obesityand diseases such as Type 2 diabetes, heart disease andsome forms of cancer. Current NIH funding for obesityresearch is $400.1 million. The budget request for FY2005 is $440.3 million, a 10 percent increase. In addi-tion, the National Heart, Lung, and Blood Institute, oneof the NIH Institutes, launched the Obesity EducationInitiative in January 1991 to help reduce the prevalenceof obesity along with the prevalence of physical inac-tivity in order to reduce the risk of coronary heart dis-ease (CHD) and overall morbidity and mortality fromCHD.

The Food and Drug Administration issued the finalreport of its Obesity Working Group in March 2004.The report includes an action plan that covers six areas:

• Food labeling, especially with respect to giving moreprominence to calories, serving sizes and carbohy-drates

• Enforcement activities against weight loss productshaving false or misleading claims

• Educational efforts aimed especially at youth

• A campaign to urge restaurants to voluntarily pro-vide point-of-sale nutrition information

• A meeting to address therapeutics for treatment ofobesity; and

• Research support for obesity studies

What Are the Shortcomings ofthe Current Response?

Until July of 2004, neither Medicare nor Medicaid re-cipients could benefit from certain health care services,such as nutrition counseling and exercise. Prior to thatdate, providers for these services could not be reimbursedbecause obesity was not recognized as a disease or ill-ness. Local programs spend enormous resources com-bating heart disease, diabetes and other obesity-relatedillnesses. For example, during the site visit to Syra-cuse, Nebraska the Committee was impressed to see asmall hospital working to address obesity by gettingMedicare patients to exercise. Medicare or Medicaidreimbursement for patients with obesity will aid theselocal programs in providing interdisciplinary care to treator prevent their patients’ chronic diseases. However,the Committee also recognizes that focusing on just oneaspect (exercise) within one population subgroup (Medi-care patients) is not enough.

Overall, there is a need for greater emphasis on pre-vention. While the treatment of illnesses, in general, ismuch better supported than prevention efforts, the Com-mittee feels strongly that more focus should be placedon prevention of obesity, especially in the childhoodyears.

In addition, there is not enough support for rural is-sues in relation to obesity. In much of what is proposed,NIH, HHS, the Steps to a HealthierUS program and otherefforts fail to factor in the unique characteristics of ru-ral America. Examples are program guidances that con-sider a “small” community one which has a populationof fewer than 800,000 people; agency strategic plansthat do not break down goals to include rural popula-tions; and a general lack of recognition that many ruralareas do not have the public health infrastructure, re-sources or capacity for program implementation.


Conclusions

The Committee agrees with CDC Director, Dr. JulieGerberding, in her assertion that, “investments in pro-grams to increase physical activity, improve diet andincrease smoking cessation are more important than everbefore and must continue to be high priorities.” Basicpublic health must be promoted across the lifespan, es-pecially in the often-forgotten rural areas of the Nation.Prevention of obesity must be acknowledged as a pub-lic health concern. Current efforts to curb obesity focuson treatment of obesity-related diseases, such as heartdisease, diabetes, etc. Instead, efforts should be aimedat health promotion and disease prevention, which mustinclude issues of nutrition34, and should focus first onthe areas of the country where the problems are the worst.

Unlike tobacco, no windfall from lawsuits aimed atthe fast food industry is anticipated. The U.S. House ofRepresentatives recently voted to ban such obesity law-suits.35 Rather than using legal methods to address theobesity epidemic, support should be given to a massivepublic relations campaign that graphically depicts theperils of obesity.

Recommendations

• The Secretary should encourage the States to reviseMedicaid policy. Medicaid should follow Medicareand remove all references to obesity not being an ill-ness.

The Department should take the lead in working withthe States to classify obesity as an illness and cover pro-cedures related to treatment of obesity. This change iseven more critical in Medicaid than it is in Medicaresince it will allow health care providers to aggressivelytreat those with obesity and it will potentially help pa-tients avoid more serious obesity-related health com-plications in the future.

• The Secretary should make refinements to theHealthierUS community grant program so that ruralconcerns can be more thoroughly represented.

The Committee commends the Secretary for launchingthe Steps to a HealthierUS community grant program,

especially since it includes rural participation. How-ever, the Committee is also hopeful that refinements willbe made to assure that the concerns identified with re-spect to rural representation are addressed. Additionalopportunities for direct granting to rural communitieswould be helpful, as many States did not include ruralcommunities within their grants.

• The Secretary should ensure that the next publica-tion of the CDC Chartbook includes more rural-spe-cific data and that other, future publications includereferences to rural.

The Committee commends the efforts the CDC has madeto conduct studies that include rural areas. These stud-ies have consistently shown that rural areas have higherrates of obesity and are, in general, less healthy thanurban or suburban areas. The Committee would en-courage the publication of a new CDC Chartbook toprovide current, more rural-specific items compared tothe previous 2001 publication, and to continue the in-clusion of rural areas in its other studies. In addition,the Committee encourages NIH and the CDC to includestudies of rural-specific prevention and intervention.

• The Secretary should ensure that rural residents areseen as a separate and unique segment of the popu-lation in funding, research and data collection.

The Committee commends the efforts CDC has madeto conduct studies that include rural areas. These stud-ies have consistently shown that rural areas have higherrates of obesity and are, in general, less healthy thanurban or suburban areas. The Committee would en-courage the publication of a new Rural-Urban Chartbookby no later than 2006 to provide current, more rural-specific items compared to the previous 2001 publica-tion, and to continue the inclusion of rural areas in itsother studies. In addition, the Committee encouragesNIH and the CDC to include studies of rural-specificprevention and intervention.


References

1 Surgeon General’s Call to Action to Prevent and DecreaseOverweight and Obesity. U.S. Department of Health andHuman Services; 2001.

2 “Obesity Trends.” CDC Behavioral Risk Factor Surveil-lance System (BRFSS) and National Health and NutritionExamination Survey (NHANES).

3 Surgeon General’s Call to Action to Prevent and De-crease Overweight and Obesity. U.S. Department of Healthand Human Services; 2001.

4 Sturm R, Wells KB. “Does Obesity Contribute As Muchto Morbidity as Poverty or Smoking?” Public Health; May2001; 115(3).

5 Sturm R. “The Effects of Obesity, Smoking, and Prob-lem Drinking on Chronic Medical Problems and HealthCare Costs.” Health Affairs; 2002; 21(2).

6 Data from the American Obesity Association website,http://www.obesity.org/.

7 “CDC Admits Errors in Obesity Risk Study.” New YorkTimes; November 24, 2004.

8 Mokdad AH, Marks JS, Donna SF, Gerberding JL. “Ac-tual Causes of Death in the United States.” JAMA; March10, 2004.

9 ibid.

10 Surgeon General’s Call to Action to Prevent and De-crease Overweight and Obesity. U.S. Department of Healthand Human Services; 2001.

11 Finkelstein EA, Fiebelkorn IC, Wang G. “State-LevelEstimates of Annual Medical Expenditures Attributable toObesity.” Obes Res. January 2004;12(1).

12 “Obesity Costs States Billions in Medical Expenses.”CDC Press Release; January 21, 2004.

3 “Obesity Trends.” CDC Behavioral Risk Factor Surveil-lance System (BRFSS) and National Health and NutritionExamination Survey (NHANES); 1999-2000.

14 Murray CJL, Michaud CM, McKenna M, Marks J. “U.S.Patterns of Mortality by County and Race: 1965-1994.”Harvard Center for Population and Development Studies;1998. Available at: http://www.hsph.harvard.edu/organi-zations/bdu/images/usbodi/.

15 Kumanyika SK. “Special Issues Regarding Obesity inMinority Populations.” Ann Intern Med. 1993 Oct 1;119(7Pt 2).

16 Food Research Action Center. “A Guide to Food StampProgram Outreach”. Available at: http://www.frac.org/html/federal_food_programs/programs/fsoutreachprg.html

17 Centers for Disease Control and Prevention. Health,United States, 2001.

18 Gamm LD, Hutchison LL, Dabney BJ, Dorsey AM.Rural Healthy People 2010: A Companion Document toHealthy People 2010. College Station, TX: The TexasA&M University System Health Science Center, Schoolof Rural Public Health, Southwest Rural Health ResearchCenter; 2003. Available at: http://www.srph.tamhsc.edu/centers/rhp2010/.

19 National Rural Health Association, 8th Annual RuralMinority Health Conference, “Race, Culture, Technology:Impact on Rural Minority Health.” Conference Program;December 5-6, 2002, San Diego, California.

20 CDC Behavioral Risk Factor Surveillance System(BRFSS) and National Health and Nutrition ExaminationSurvey (NHANES) 1999-2000.

21 Yancey AK, Kumanyika SK, Ponce NA, McCarthy WJ,Fielding JE, Leslie JP, Akbar J. “Population-Based Inter-ventions Engaging Communities of Color in Healthy Eat-ing and Active Living: A Review.” Prev Chronic Dis; Janu-ary, 2004. Available at: http://www.cdc.gov/pcd/issues/2004/jan/03_0012.htm.

22 “Obesity in Minority Populations.” AOA Fact Sheet.American Obesity Association. Available at: http://w w w . o b e s i t y . o r g / s u b s / f a s t f a c t s /Obesity_Minority_Pop.shtml.

23 Paper delivered at 2002 Rural Women’s Health Confer-ence 2002. “Behavioral Risk Factors among Rural NativeAmerican Women in Oklahoma.” Oklahoma REACH 2010by Janice E. Campbell, Ph.D.

24 In the early 1980s, a review of existing data by the Sub-committee on Cardiovascular and Cerebrovascular Diseaseof the Secretary of Health and Human Service’s Task Forceon Black and Minority Health concluded that informationon cardiovascular disease (CVD) in American Indians wasinadequate and strongly recommended epidemiologic stud-ies of this problem. The Strong Heart Study (SHS) wasdesigned to respond to this recommendation.


25 “Obesity in Minority Populations.” AOA Fact Sheet.American Obesity Association. Available at: http://w w w . o b e s i t y . o r g / s u b s / f a s t f a c t s /Obesity_Minority_Pop.shtml.

26 National Rural Health Association, 8th Annual RuralMinority Health Conference, “Race, Culture, Technology:Impact on Rural Minority Health.” Conference Program;December 5-6, 2002, San Diego, California.

27 “Nutrition, Obesity & Physical Education.” NationalConference of State Legislatures; April 2004. Availableat: http://www.ncsl.org/programs/health/hpts/nutrition_obesity.htm.

28 ibid.

29 ibid.

30 ibid.

31 U.S. Department of Health and Human Services. “Cit-ing ‘Dangerous Increase’ in Deaths, HHS Launches NewStrategies Against Overweight Epidemic.” News Release;March 9, 2004. Available at: http://www.hhs.gov/news/press/2004pres/20040309.html.

32 U.S. Department of Health and Human Services. “HHSAwards $35.7 Million to Support Community ProgramsThat Promote Better Health and Prevent Disease.” NewsRelease; September 28, 2004. Available at: http://www.hhs.gov/news/press/2004pres/20040928.html.

33 Tracey Teuber, MPH, CHES, Policy and Communica-tion Specialist, Steps to a HealthierUS, Office of the Di-rector, NCCDPHP, CDC, Atlanta, GA. Email; December7, 2004.

34 Ham RJ. “Best Practices in Service Delivery to the Ru-ral Elderly.” West Virginia University, Center on Aging;March 2003.

35 “House Votes to Ban Obesity Suits.” Trenton Times;March 11, 2004.


Introduction

In 1996, Congress passed the Personal Responsibilityand Work Opportunity Reconciliation Act (PRWORA),dramatically changing the Nation’s welfare system froma program designed to provide income maintenance toone focused on moving families into the workforce.PRWORA replaced a package of entitlement pro-grams—Aid to Families with Dependent Children(AFDC), the Job Opportunities and Basic Skills Train-ing program and the Emergency Assistance program—with a new, $16.5 billion Federal block grant programtitled Temporary Assistance for Needy Families (TANF).

The new program devolved significant programmingauthority to the States, giving the States tremendous flex-ibility in the design and operation of their welfare pro-grams. However, the legislation set forth requirementsfor both States and welfare participants. PRWORAimposed work participation rates on the States, requiredthem to maintain at least the level of their pre-TANFState funding and held them subject to financial penal-ties if they did not comply with certain requirements.For recipients, PRWORA established strong work re-quirements and ended the entitlement to welfare ben-efits. PRWORA mandated a five-year lifetime limit onthe receipt of cash assistance (though up to 20 percentof the caseload could be exempted from the time limitdue to hardship), but allowed States to shorten the timelimit if they chose. All of these requirements were toreinforce the goal of reducing extended welfare depen-dency and promoting self-sufficiency.

In the eight years since the legislation was enacted, awealth of literature has surfaced examining the effectsof the sweeping reforms on America’s low-income fami-lies. From the literature, one conclusion resounds: sincethe creation of TANF, welfare participation has drasti-cally decreased in both urban and rural areas. BetweenAugust 1996 and September 2003, the number of TANFrecipients declined by 60 percent nationally.1 The rateof employment of TANF recipients has increased sig-

nificantly, up from less than one in five adult recipientsin 1991 to one in every three adults in 2002.2 In addi-tion, between 1996 and 2001, the national child povertyrate fell by 20 percent (from 20.5 percent to 16.3 per-cent).3 Based on these national numbers, many pro-nounced welfare reform a success.

Why the Committee ChoseThis Topic

While many agree that welfare reform, backed by therobust economic growth of the 1990s, successfullymoved many recipients into the workforce, the effectsof welfare reform vary across the country. Tremendousvariation between States’ programs often complicatesattempts to get an accurate picture of its effects on ruralAmerica. In addition, in national studies, the stories ofindividual localities are often overshadowed, especiallythe unique struggles faced by some rural communities.

Welfare Reform in Rural Communities

In September 2004, the U.S. Government Ac-countability Office (GAO) issued a report titled“Welfare Reform: Rural TANF Programs HaveDeveloped Many Strategies to Address RuralChallenges.” This report examines the status ofwelfare reform in rural communities and dis-cusses the significant barriers faced by ruralTANF recipients, such as limited transportation,lack of child care services, job shortages and lowwages. The report also highlights the strengthsof rural TANF programs in collaboration andpersonal attention to TANF recipients, and pro-vides examples of innovated strategies for over-coming barriers and moving recipients towardself-sufficiency. The report can be found at http://www.gao.gov/new.items/d04921.pdf.

Welfare Reform Report


Approximately 14 percent of the Nation’s welfarerecipients live in rural communities, although in someStates, rural TANF recipients make up a much largerpercentage of the State’s total number of recipients.4

Rural TANF families are primarily concentrated in ar-eas of high unemployment, causing these recipients tohave a difficult time transitioning into the workforce. Insome States, analyses have found lower caseload de-clines in rural communities, particularly those in areasof persistent poverty.5

When taken as a whole, rural areas have greater ratesof poverty than urban areas. Only poverty rates in cen-tral cities surpass those of rural areas. Areas of persis-tent poverty, such as parts of the Appalachian and Deltaregions, tend to have a disproportionately higher num-ber of “economically at-risk” people, such as singlemothers, high school dropouts and ethnic/racial minori-ties.6 Rural communities often have higher rates of un-employment and underemployment due to more lim-ited economic opportunities and a higher percentage of

low-wage, part-time jobs. All of these factors make itdifficult for rural residents to find jobs that will removethem from the welfare rolls and lift them and their fami-lies out of poverty.7

In addition, a true picture of welfare reform is farmore complex than decreasing caseloads. To more ac-curately judge TANF’s success, one should examine theexperiences of those who have left the welfare system.Although research finds that most “leavers” enter theworkforce, about 25 percent of leavers are not currentlyworking and have no partner working.8 For those whodo find work, the work is often temporary and does notpay enough to meet all financial needs. It has been foundthat approximately 21 percent of TANF recipients wholeave welfare due to employment or higher earningsreturn to the welfare system.9

The Committee has chosen to focus on TANF in thisreport because of TANF’s important implications forrural communities. The Committee recognizes that low-income families often face multiple obstacles to both

Source: Calculated by ERS using data from the 2000 Census of Population.

Nonmetro Poverty Rates, 1999Nonmetro poverty rates are highest in the South and Southwest

20 percent or more15 to 19 percent10 to 14 percentLess than 10 percentMetro counties


finding and keeping a job, such as lack of education orjob experience, drug and alcohol abuse, domestic vio-lence, or disabilities and health problems. Yet rural resi-dents face additional barriers in moving from welfareto work. Rural areas generally lack public transporta-tion systems, ample child care services and diverse em-ployment opportunities, compounding the number ofobstacles already faced by low-income residents andpossibly frustrating the success of welfare reform in ruralcommunities.

The Committee also acknowledges that the TANFprogram interacts with an array of other Department ofHealth and Human Services (HHS) programs, such asMedicaid, State Children’s Health Insurance Program(SCHIP) and the Child Care Block Grant, and has im-portant connections to the overall health and well-beingof rural residents. Such interactions provide HHS witha unique opportunity to foster collaboration and coordi-nation across several programs, which could increaseoutcomes for low-income residents in rural America.

Finally, this topic is especially timely because the

reauthorization of TANF is currently pending in Con-gress. In February of 2003, the House of Representa-tives passed a reauthorization bill that closely mirroredthe President’s reauthorization proposal, which includesan increase in the work requirements for TANF adultrecipients; however, no reauthorization bill passed inthe Senate. In the meantime, the TANF program hasbeen operating under a series of continuing resolutionsand has been extended through March 31, 2005. Reau-thorization will be addressed again in the 109th Con-gress. The Committee believes that any increase in workrequirements is invariably coupled with an increasedneed for jobs and for work support services, and it istherefore vital for any reauthorizing legislation to ac-count for the unique make-up of rural communities andthe employment needs and obstacles of rural TANF re-cipients.

What We KnowStudies have shown that the more barriers a welfare re-

During its site visit to Southeast Nebraska, the Com-mittee met Sondra Germer, of the University of Ne-braska Cooperative Extension and learned aboutSondra’s efforts to construct a stronger community,one family at a time.

As the extension educator of the Building Ne-braska Families program for Gage, Saline andJefferson counties, Sondra works one-on-one withTANF recipients, teaching them skills they need tobetter manage their family resources. Going intotheir homes, Sondra conducts individualized work-shops for her clients on a variety of topics rangingfrom parenting to problem solving to money man-agement. Sondra has found that TANF clients aremore successful at transitioning from welfare to workand maintaining employment if these adults areskilled at managing their personal relationships andlives.

Building Nebraska Families works specificallywith hard-to-employ TANF recipients; yet, in spiteof the multiple obstacles faced by their clients, the

program has assisted 122 (22 percent) of 581 par-ticipants to achieve self-sufficiency since 1999.While research has shown that rural welfare recipi-ents, on average, face a greater number of challengesthan their urban counterparts, it has also shown thatrural clients often receive and benefit from morepersonalized attention and a stronger local supportsystem. Sondra Germer and Building NebraskaFamilies are successfully providing that assistanceand support.

Building Nebraska Families is one of three ruralwelfare-to-work programs from across the countryselected for an evaluative study conducted by theMathematica Policy Research, Inc. with funding fromHHS. The study, which began in 2000 and will con-tinue through 2007, hopes to assess the impact inno-vative service programs have on rural low-incomepeople. The report, to date, can be found at:

http://www.mathematica-mpr.com/welfare/ruralwtw.asp.

Building Nebraska Families


cipient faces the more difficult it is for the recipient tosuccessfully find employment and leave welfare. Un-fortunately, low population density, characteristic of ruralareas, usually leads to three primary barriers: fewermodes of transportation, especially public transporta-tion, fewer child care services, and fewer job openingsand job training opportunities. Therefore, rural TANFparticipants often face these three barriers to employ-ment in addition to any personal challenges, increasingthe difficulty of entering the workforce and becomingpermanently self-sufficient. Yet, regardless of thesebarriers, TANF’s legislation limits cash assistance to alifetime maximum of five years, making it of utmostimportance that rural low-income families receive timelyhelp in overcoming these challenges.

Rural Obstacles to Success

Transportation

Transportation is often cited by welfare recipients asthe number one obstacle to leaving public assistance.Great stretches of open land and small, dispersed popu-lations often make rural public transportation unsupport-able. In fact, 80 percent of rural areas have no publicbus system, compared to only two percent of urban ar-eas.10 While 40 percent of rural communities have nopublic transit system at all, another 28 percent have verylimited services available.11,12

Clearly, the number one means of transportation inrural areas is personal vehicles; however, almost 57 per-cent of the rural poor do not own a car, and a staggering96 percent of all public assistance recipients do not havetheir own vehicles.13,14 In addition, cars owned by low-income families are often unreliable and in need of re-pair, further exacerbating the problem.

Prior to PRWORA, Federal law limited the value ofa vehicle owned by a family receiving AFDC benefitsto not more than $1,500 equity value. Under TANF,States can alter or dismiss this limitation, as well as useFederal and State funds to subsidize car ownership, re-pairs and auto insurance. In response, all States havetaken advantage of this new liberty, and many are see-ing positive results, especially in their rural communi-ties.15 For example, Jump Start, a non-profit organiza-tion in Wisconsin, helps TANF-eligible families pur-chase safe and reliable cars for employment or employ-

ment training. To date, Jump Start has helped more than160 families obtain and maintain a vehicle and thesefamilies report dramatic improvements in work atten-dance and wages. Conclusively, access to employmentincreases when recipients have access to reliable trans-portation, and in rural America, this frequently equateswith an increase in personal vehicle ownership.

Overall, low-income rural residents have less accessto transportation than do their urban counterparts, yetrural residents must travel much greater distances toobtain needed services. This makes it difficult for themto take occasional trips to acquire food or health care,much less to travel to and from an employment site eachday.

Child Care

PRWORA provided States with an increase in Federalfunding for child care in the form of the Child Care andDevelopment Fund (CCDF). CCDF assists low-incomefamilies, including those receiving welfare benefits ortransitioning from TANF, in obtaining child care so thatthey can work or, as an option in some States, attendtraining or educational courses. PRWORA also allowseach State the option of transferring up to 30 percent ofits TANF block grant to CCDF. In addition to the fundsthat each State must provide in order to receive the Fed-eral child care funding, many States spend additionalState funds on child care services. Finally, States mayuse TANF funds to provide child care services directly,without transferring the money to CCDF.

States, recognizing the importance of caring for low-income children as their parents enter the workforce,have taken advantage of the law’s flexibility. In fact,the greatest redirection of TANF funds from 1996 to2001 has been to child care. For Fiscal Year (FY) 2001,$4.6 billion in CCDF was made available through blockgrants to all 50 States, the District of Columbia, fiveTerritories and approximately 500 Indian Tribes. WithState and Federal funds in aggregate, more than $11 bil-lion in CCDF- and TANF-related funds was availablefor child care in FY 2001.16 Yet questions of the avail-ability, reliability and cost of child care in rural areasstill remain, for low-income families continue to iden-tify child care as a significant barrier to employment.

Like transportation, reliable child care has beenproven essential in moving welfare recipients into work,


especially single parents. Most studies on the topic re-port an insufficient amount of child care services. Com-pared to urban areas, rural areas have fewer trained childcare professionals and fewer available slots at child carecenters, often requiring rural parents to rely on friendsand relatives to care for their children. Unfortunately,child care provided by friends and relatives tends to beless reliable.17 Furthermore, many TANF parents findwork in low-paying service or manufacturing positions,and their problems with finding child care are often ex-acerbated by irregular work schedules, such as week-night or weekend hours. One study finds that more thana quarter of former TANF recipients who are employedwork night hours.18

It has also been reported that children in low-incomefamilies have a higher rate of disability, with 18.1 per-cent having difficulties performing everyday activities,compared to 10.9 percent of children in families abovethe poverty line.19 Finding child care is particularlychallenging for these families, especially in rural areasthat are less likely to have specialty child care services.

For many low-income families, the cost of child careis another barrier to face. According to a study by TheUrban Institute, families with incomes below the Fed-eral poverty line spend, on average, 23 percent of theirmonthly earnings on child care.20 This becomes prob-lematic when the cost of child care is too high, becausethe financial incentive to work diminishes, and parents,especially single parents, may not find it beneficial towork. A 1994 GAO study calls the cost of child care adecisive factor in moving low-income single mothersinto the workforce. The study concludes that reducingthe costs of child care through subsidies increases thelikelihood that low-income mothers will work;21 how-ever, only one in seven eligible children in the countryare currently receiving Federal support for child care.22

Clearly, additional child care support is needed for TANFfamilies, especially those in rural areas.

Labor Markets

Even if a rural welfare recipient can access reliable trans-portation and child care, the challenge of finding a jobthat can lift his or her family out of poverty is great.This difficulty exists because, even after a period ofeconomic expansion in the 1990s, rural labor marketsstill have slower job growth, higher unemployment rates

According to the Department of Health and Hu-man Services, in 2000, 2.2 million children in theUnited States were living with a grandparent, aunt,sibling or some other relative because their par-ents were no longer able to care for them. Themajority of these children (69 percent) were caredfor by a grandparent.1

Because many grandparents do not anticipatebecoming primary care-givers for their grandchil-dren, these families often face financial hardshipsand are more likely to be poor and in need of pub-lic assistance than parent-maintained families.2

In 1996, a primary focus of welfare reform wasmoving low-income adults with children into theworkforce and off of public assistance. Over thesubsequent years, as these adults have found workand left welfare, a growing share of the TANFcaseload has become child-only cases, cared forby grandparents. In fact, nine percent of TANFchildren are grandchildren of the head of theirhousehold.3

To ensure the well-being of these families, HHSshould further examine their unique needs andidentify any policy barriers to providing both thechildren and their grandparents with needed ser-vices. In addition, with TANF reauthorization onthe horizon, Congress has an important opportu-nity to institute new policies that will serve thesefamilies as they continue to become more andmore prevalent.

1 Geen R, Holcomb P, Jantz A, Koralek R, Leos-UrbelJ, Malm K. “On Their Own Terms: Supporting KinshipCare Outside of TANF and Foster Care.” The UrbanInstitute; Sept. 2001. Available at: http://aspe.hhs.gov/hsp/kincare01/index.htm.

2 Bryson K, Casper LM. “Coresident Grandparents andGrandchildren.” Current Population Reports. U.S. Cen-sus Bureau; May 1999. Available at: http://www.census.gov/prod/99pubs/p23-198.pdf.

3 Administration for Children and Families. “TANF SixthAnnual Report to Congress.” U.S. Department of Healthand Human Services; November, 2004. Available at:http://www.acf.hhs.gov/programs/ofa/annualreport6/ar6index.htm.

Grandparents As Caregivers


and smaller earnings than the national averages. With agood share of the available positions in low-wage in-dustries, it is slightly harder to get a job, especially agood paying job, in rural areas.23 Additionally, manyrural jobs tend to be temporary, part-time or seasonal,and do not present the opportunity or security of long-term career development.

In a study of job availability in Mississippi, it wasfound that only one job was available for every twoTANF clients.24 In addition, a study by Mathematicacompared the earnings of current and former TANF re-cipients in rural and urban areas of Nebraska and foundthat those working in urban areas had higher earningsthan those with jobs in rural areas.25 Overall, studiesconclude that it is harder to get a job, especially a high-wage job, in rural communities than it is in urban areas.

Although the success of welfare to work depends onthe viability of local labor markets, economic studiesreport that rural areas may be the hardest hit during timesof recession.26 Rural areas are often supported by a fewemployers, and the loss of one major employer maycause increased competition for existing jobs and crippleattempts to successfully transition rural residents fromwelfare to work.27

Another challenge for rural welfare clients lies in thelow number of educational and vocational training op-portunities. A study of Iowa’s communities indicatesthat, in addition to being an individual hardship, “lowwages also depress the tax revenue of communities, af-fecting local public services, such as education, librar-ies, and infrastructure.”28 Problematically, rural adultshave lower levels of educational attainment than urbanadults, hindering their chances of finding work, yet theircommunities are home to fewer educational centers andinstitutions as well as fewer social support centers thatoffer vocational training.29,30

While rural recipients typically have shorter spellson welfare than their urban counterparts, possibly dueto the heightened stigma of public assistance in close-knit communities, some studies show that rural residentsare more likely to cycle off of welfare, only to shortlyreturn to the rolls. Some of this cycling has been attrib-uted to the greater instances of seasonal employment inrural communities.31 For example, in California, oneseventh of all TANF recipients reside in rural or agri-cultural communities. In these areas, TANF use fluctu-ates greatly from the summer to the winter season, and

Head Start, a Federal program created in 1965,provides low-income preschool children withcomprehensive child development and educa-tional services and their families with parentalsupport. Since at least 90 percent of Head Startparticipants must be at or below the Federal pov-erty line, many participants are also TANF re-cipients. In 2003, 21 percent of Head Start fami-lies were in the TANF program.1

Because of the connection between the twoprograms, welfare reform has affected Head Startin several ways. First, Head Start requires pa-rental participation; however, with TANF’s newwork requirements, many low-income parents arefinding it difficult to meet both the demands of afull-time job and the Head Start requirement.Some States have allowed the Head Start require-ment to count toward the TANF requirement aswell. Second, in their move off of welfare andinto the workforce, many parents now have a needfor full-time child care services, yet most HeadStart programs provide part-day, part-year ser-vices. To address this need, HHS has begun fos-tering cooperation between Head Start and childcare services by giving priority of funding to full-day, full-year collaborative programs.2 Such pro-grammatic flexibility and collaboration is vitalto meeting the needs of TANF families in theirmove off of welfare.

1 Hart K, Schumacher R. “Moving Forward: HeadStart Children, Families, and Programs in 2003.”Head Start Policy Brief, No. 5. Center for Law andSocial Policy; June 2004. Available at: http://www.clasp.org/publications/hs_brf_5.pdf.

2 United States General Accounting Office. “Edu-cation and Care: Early Childhood Programs andServices for Low-Income Families.” GAO/HEHS-00-11. Washington. DC: General Accounting Of-fice; Nov. 1999.

Head Start andWelfare Reform


low-income seasonal employees often find it difficultto lift their families out of poverty year-round.32

Current HHS and FederalGovernmental Role

The effects of these unique and challenging barriers arewell documented, as some studies show that rural re-cipients have a harder time transitioning into theworkforce.33 However, studies also have shown thatremoving even one of these barriers for rural communi-ties can drastically improve welfare’s success there. Forexample, the Good News Garage program is tacklingthe transportation barrier in Vermont, supplying TANFrecipients with personal vehicles. This non-profit orga-nization reports that 75 percent of the TANF recipientswho received a car to date have subsequently left wel-fare.34

To address rural TANF recipients’ unique barriers,HHS has taken several measures at the Federal level.

HHS’ Rural Initiative

In July of 2001, Secretary Thompson launched the HHS-wide Rural Initiative by appointing a cross-departmentRural Task Force to explore options and opportunitiesfor strengthening the Department’s commitment to ru-ral America. The Task Force has led to the creation of arural information clearinghouse, the Rural AssistanceCenter (RAC) (http://www.raconline.org), and to un-precedented and targeted technical assistance to ruralareas. The Task Force also has served as a catalyst for astrong rural focus in the Department, which has pro-vided a backdrop of support for the following activitiesaimed at assisting rural TANF recipients.

Administration for Children andFamilies

Within HHS, the Administration for Children and Fami-lies (ACF) is responsible for administering the TANFblock grant program. Although all of the design andimplementation power for the program largely residesin the individual States, various components in ACFhave actively worked to address common issues amongthe States, including the barriers faced by rural commu-nities.

Technical Assistance

ACF’s Office of Family Assistance (OFA) provides tech-nical assistance via the Welfare Peer Technical Assis-tance Network (http://peerta.acf.hhs.gov), which pro-motes best practices and encourages conversation andcollaboration between various organizations, programsand providers. OFA also provides targeted technicalassistance, upon request, to State or local TANF pro-grams. From January to June of 2004, three of the ninetechnical assistance events held by OFA were rural-spe-cific.35

Earned Income Tax Credit Initiative

The Earned Income Tax Credit (EITC), a refundable taxcredit available to low-income employees, began in 1975and was expanded in 1990 and 1993. The EITC canhelp low-income families meet their financial needs,even after their welfare benefits have ended. In 1996,the EITC provided rural areas with an estimated $6 bil-lion; however, the effectiveness of the EITC, on an in-dividual level, requires TANF and former TANF recipi-ents to have heard of the EITC and to take advantage ofit.

In 2003, ACF collaborated with the National Orga-nization of Black County Officials and the InternalRevenue Service (IRS) on the Delta Initiative EarnedIncome Tax Credit Project to increase awareness of theEITC in seven southern States in the Mississippi Deltaregion (Louisiana, Alabama, Tennessee, Mississippi,Arkansas, Missouri and Illinois). Through outreach ef-forts, the initiative met its goal of doubling enrollmentin the EITC in two selected counties of these seven DeltaStates. The initiative hopes to have all eligible TANFand former TANF clients in the Delta region take ad-vantage of the EITC once they are employed. To meetthis larger goal, ACF has met with community leadersand local and State officials for each Delta State anddeveloped strategies to raise awareness of the EITC.

Office of the Assistant Secretary forPlanning and Evaluation

The Office of the Assistant Secretary for Planning andEvaluation has contracted with Mathematica PolicyResearch to establish a foundation for rural human ser-vices research, to facilitate research on human service


conditions in rural areas, and to inform local and Fed-eral policymakers and researchers about the human ser-vices needs of rural communities. The project is sched-uled to be completed by March 2005. A descriptioncan be found at http://aspe.hhs.gov/hsp/ongoing.htm#id-cond-rural-areas.

Inter-agency Collaboration

In 1986, HHS joined with the Department of Transpor-tation to coordinate transportation programs at the Fed-eral level. The two departments created the Coordinat-ing Council on Access and Mobility. In January of 2004,the Department of Education and the Department ofLabor were invited to join the Council and in February,President George W. Bush issued an Executive Ordercalling for expanded membership of the Council to in-clude representatives from other departments as well.The Council has since launched United We Ride, a five-part initiative to break down any barriers to coordina-tion among the 62 Federal programs that fund transpor-tation services; encourage collaboration among localprograms; and better serve elderly, disabled and low-income Americans.

ConclusionThe Committee believes that rural TANF recipients faceunique challenges as they move off of public assistanceand into full-time employment. The very characteris-tics that distinguish rural areas from urban centers, suchas low population density and open landscapes, can cre-ate additional obstacles such as lack of transportation,child care and jobs for TANF families. However, theCommittee recognizes that rural communities possessinherent advantages as well.

Rural communities are often close-knit communities,with active religious or social organizations, providingTANF recipients a strong support system. With fewerpeople, social service caseworkers tend to have fewerTANF clients, affording the caseworker and client anopportunity to build a relationship that will benefit theclient. In addition, rural areas have fewer and limitedresources; yet this limitation frequently results in col-laboration. For example, personal contacts and estab-lished relationships between TANF caseworkers andcommunity employers can yield job placements forTANF clients.

During a meeting in Tupelo, Mississippi in Sep-tember, the Committee visited the MonroeCounty Families Resource Center, operated byLIFT, Inc., and saw first-hand the importance ofstrong leadership in rural TANF programs.

TANF recipients in Monroe County face anuphill battle against the county’s 14.3 percent un-employment rate and the State’s limited finan-cial resources, but Linda Blackwell, ExecutiveDirector of LIFT, and Ann Tackett, ResourceCenter Director, are committed to serving thecommunity’s low-income families, and their com-mitment has led to success.

Blackwell and Tackett’s leadership has re-sulted in collaborations among programs and haslimited duplication of efforts in their community.The new Families First Resource Center is lo-cated in a facility that houses multiple programsand services under one roof, including Head Startand Early Head Start, tutoring for school chil-dren, GED classes, parenting classes, familycounseling, adult literacy programs and “Kids inthe Kitchen,” a nutrition course for children. TheCenter serves as a one-stop resource for low-in-come families in need of assistance.

As natives of the community, Blackwell andTackett have strong ties to their fellow residents.They have recruited dozens of volunteers for theCenter, who gave over 950 volunteer hours lastyear. And most importantly, Blackwell andTackett know each of their clients by name, pro-viding personal attention and helping the fami-lies to receive the assistance they need. WhileBlackwell and Tackett often struggle to find fund-ing for the Center’s programs from year to year,they continue to foster collaborations and forgepublic and private partnerships that have providedgreat opportunities for their clients. The Com-mittee believes the efforts of those like Blackwelland Tackett should be recognized and rewarded.

Monroe County FamiliesResource Center


The Committee would also like to acknowledge thatother issues in relation to welfare reform and rural com-munities—such as health care for TANF recipients—were not addressed at length in this report, but are ofutmost importance. The Commonwealth Fund reportsthat higher-wage workers are more likely than lower-paid workers to have health insurance and health-relatedbenefits. Furthermore, workers without access to thehealth care system are at greater risk of financial ruin inthe event of a serious illness.36 Inadequate health carecoverage can cause former TANF recipients to return tothe welfare rolls if their health worsens. The Commit-tee believes it is tantamount for both health care andsocial service providers to explore the relationship be-tween good health and social well-being for low-incomefamilies.

In March of 2004, the Committee heard testimonyfrom Dr. Wade Horn, Assistant Secretary for Childrenand Families. Dr. Horn explained that in 1996, whenCongress passed welfare reform, $16.5 billion was givenas a block grant to the States while only $1 million wasallocated to the Federal government for conducting tech-nical assistance to the States. Dr. Horn expressed hisdesire for more funds for technical assistance so thatACF may assist States in addressing rural communi-ties’ unique challenges and training rural caseworkersso they may better serve TANF recipients. It is theCommittee’s hope and recommendation that Congress,when reauthorizing the legislation, provides ACF withmore money to help improve rural service delivery andsupport TANF’s success in rural areas.

While the Committee recognizes that most progressis contingent upon TANF’s reauthorization and the al-location of additional funds for technical assistance, italso believes HHS can continue to monitor TANF’s ef-fects on rural low-income families. The Committeesupports HHS’ work, to date, to address the obstaclesto welfare’s success in rural communities and recom-mends the following additional actions to further assistrural TANF recipients.

Recommendations• The Secretary should work with the Administration

for Children and Families (ACF) to provide targetedtechnical assistance that would encourage States toaddress the transportation, child care, and employ-ment and training needs of rural TANF recipients.

• The Secretary should emphasize collaboration andencourage States to utilize best practices, includingthose identified by ACF, particularly in efforts to serverural clients.

• The Secretary should strengthen the Department’sleadership among Federal partnerships and collabo-rations.

As a leader of the Coordinating Council on Access andMobility, which addresses the transportation needs ofelderly, disabled and low-income Americans, the Sec-retary should emphasize the realities of rural transpor-tation and encourage innovative programs that reachrural residents through the United We Ride program.To address rural TANF recipients’ child care needs, theSecretary should encourage coordination and collabo-ration among Head Start, Early Head Start, child careand TANF in serving families in rural areas. Finally,the Secretary should work with the IRS to strengthenoutreach efforts on the Earned Income Tax Credit inrural communities.


References

1 U.S. Department of Health and Human Services. “Wel-fare Rolls Drop Again.” News Release; March 30, 2004.Available at: http://www.acf.hhs.gov/news/press/2004/TanfCaseloads.htm.

2 Administration for Children and Families. “TANF SixthAnnual Report to Congress.” U.S. Department of Healthand Human Services; November, 2004. Available at: http://www.acf.hhs.gov/programs/ofa/annualreport6/ar6index.htm.

3 ibid.

4 United States Government Accountability Office. “Wel-fare Reform: Rural TANF Programs Have Developed ManyStrategies to Address Rural Challenges.” GAO-04-921.Washington. DC: Government Accountability Office; Sept.2004.

5 Whitener L, Gibbs R, Kusmin L. “Rural Welfare ReformLessons Learned.” Economic Research Service; June 2003.

6 Weber B, Duncan G, Whitener L, “Reforming Welfare:Implications for Rural America.” Rural America. 16:3, Fall2001.

7 Findeis JL, Henry M, Hirschl TA, Lewis W. “WelfareReform in Rural America: A Review of Current Research.”Rural Policy Research Institute. P2001-5. Feb. 2, 2001.

8 Loprest P. “Families Who Left Welfare: Who are Theyand How are They Doing?” The Urban Institute; 1999.

9 Loprest P. “Who Returns to Welfare?” The Urban Insti-tute. Series B, No. B-49; Sept. 2002.

10 Federal Highway Administration. 1995 Nationwide Per-sonal Transportation Survey. United States Department ofTransportation.

11 Rucker G. “Status Report on Public Transportation inRural America.” Rural Transit Assistance Program, Fed-eral Transit Administration; 1994.

12 CTAA. “Mobility: Key to Welfare Reform.” Commu-nity Transportation. Community Transportation Associa-tion of America; Winter 1995.

13Federal Transit Administration “Moving Rural Residentsto Work: Lessons Learned from Implementation of Eight

Job Access and Reverse Commute Projects.” Availableat: http://www.fta.dot.gov/14550_ENG_HTML.htm.

14 Miller J. “Welfare Reform in Rural Areas: A SpecialCommunity Transportation Report.” Community Transpor-tation Association of America; Sept. 1997.

15 Waller M, Blumenberg E. “The Long Journey to Work:A Federal Transportation Policy for Working Families.”The Brookings Institute; July 2003.

16 Administration for Children and Families. “Child Careand Development Fund, Report to Congress–FY 2001.”United States Department of Health and Human Services.Available at: http://www.acf.hhs.gov/programs/ccb/policy1/congressreport/index.htm.

17 GAO. “Welfare Reform.” GAO-04-921.

18 Loprest P. “Families Who Left Welfare: Who are Theyand How are They Doing?” The Urban Institute; 1999.

19 Federal Interagency Forum on Child and Family Statis-tics. “America’s Children: Key National Indicators of Well-Being.” 1999. Available at: http://www.childstats.gov/ac1999/ac99.asp.

20 Giannarelli L, Barsimantov J. “Child Care Expenses ofAmerica’s Families.” The Urban Institute; April 2001.

21 United States General Accounting Office. “Child Care:Child Care Subsidies Increase the Likelihood that Low-Income Mothers Will Work.” HEHS-95-20. Washington,DC: General Accounting Office; 1994.

22 United Way of America Public Policy Factsheet. May2004. Available at: http://national.unitedway.org/publicpolicy/docs/TANF_Fact_Sheet.pdf.

23 Gibbs R. “Rural Labor Markets in an Era of WelfareReform.” Economic Research Service, U.S. Departmentof Agriculture. In: Rural Dimensions of Welfare Reform,ed. Weber BA, Duncan G, and Whitener LA. Kalamazoo,Mich.: W. E. Upjohn Institute for Employment Research,2002.

24 Howell, FM. “Will Attainable Jobs Be Available forTANF Recipients in Local Labor Markets?” In: Rural Di-mensions of Welfare Reform, ed. Weber et al., 2002.

25 Ponza M, Meckstroth A, Faerber J. "Employment Ex-periences and Challenges among Urban and Rural Wel-fare Clients in Nebraska." Mathematica, Aug. 2002.


26 Hamrick, Karen. “Rural Labor Markets Often Lead Ur-ban Markets in Recessions and Expansions.” Rural Devel-opment Perspectives 12(3); 1997.

27 Marks E, Dewees S, Ouellete T, Koralek R. “Rural Wel-fare to Work Strategies–Research Synthesis.” June 10,1999.

28 RUPRI. “Rural American and Welfare Reform: AnOverview Assessment.” Feb. 10, 1999.

29 Economic Research Service, U.S. Department of Agri-culture. “Rural Labor and Education: Rural Education.”Briefing room. Available at: http://www.ers.usda.gov/Brief-ing/LaborAndEducation/ruraleducation/.

30 Pindus N. “Implementing Welfare Reform in Rural Com-munities.” The Urban Institute; Feb. 2001.

31 Henry M, Reinschmiedt L, Lewis W, Hudson D. “Re-ducing Food Stamp and Welfare Caseloads in the South.”In: Rural Dimensions of Welfare Reform, ed. Weber et al.,2002.

32 Brady H, Sprague M, Gey F, Wiseman M. “SeasonalEmployment Dynamics and Welfare Use in Agriculturaland Rural California Counties.” In: Rural Dimensions ofWelfare Reform, ed. Weber et al., 2002.

33 Whitener L, Gibbs R, Kusmin L. “Rural Welfare Re-form Lessons Learned.” Economic Research Service, U.S.Department of Agriculture; June 2003.

34 GAO. “Welfare Reform.” GAO-04-921.

35 ibid.

36 Collins SR, Davis K, Doty MM, Ho A. “Wages, HealthBenefits, and Workers’ Health.” Issue Brief. The Com-monwealth Fund; Oct. 2004. Available at: http://w w w . c m w f . o r g / p u b l i c a t i o n s /publications_show.htm?doc_id=241931.


Acronyms UsedACF - Administration for Children and Families

AFDC – Aid to Families with Dependent Children

AHEC - Area Health Education Center

AoA - Administration on Aging

BMI – body mass index

BVCA – Blue Valley Community Action

CAH - Critical Access Hospital

CCDF – Child Care and Development Fund

CDC - Centers for Disease Control and Prevention

CHC – Community Health Center

CHD – coronary heart disease

CNM – Certified Nurse Midwife

DHSPS – Division of Healthy Start and Perinatal Sys-tems

DRTE - Division of Research, Training and Education

EITC - Earned Income Tax Credit

EMTC - Eastern Maine Transportation Collaborative

GAO - Government Accountability Office (formerlyGeneral Accounting Office)

HHS - Department of Health and Human Services

HPSA - Health Professional Shortage Area

HRSA - Health Resources and Services Administration

HTC - Home Town Competitiveness

IOM – Institute of Medicine

JAMA – Journal of the American Medical Association

MCH – Maternal and Child Health

MCHB - Maternal and Child Health Bureau

NACRHHS - National Advisory Committee on RuralHealth and Human Services (also known as NAC)

NIH - National Institutes of Health

NHSC – National Health Service Corps

OB – obstetric, obstetrical, obstetrician

OB/GYN – obstetrician/gynecologist

OFA – Office of Family Assistance

OMB - Office of Management and Budget

ORHP - Office of Rural Health Policy

PRWORA – Personal Responsibility and Work Oppor-tunity Reconciliation Act of 1996

RAC - Rural Assistance Center

RUPRI – Rural Policy Research Institute

SOHSN – Southern Ohio Services Network

TANF - Temporary Assistance for Needy Families

The 2005 Report to the Secretary: Rural Health and …s_report.pdfThe 2005 Report to the Secretary:...

Documents

Transcript of The 2005 Report to the Secretary: Rural Health and …s_report.pdfThe 2005 Report to the Secretary:...