Monday, November 19, 2012

The Rural Differential: Drilling down into the data

By Kathy Miller, RUPRI Program Director

We are introducing a new monthly blog post that will focus on "the rural differential". Each month, we will focus on a particular social, economic, or demographic indicator and examine what the data shows us about rural America.

For this very first edition of The Rural Differential, I thought we should talk about data in general. Where do we get data for rural America?

While most national data sets do include some geographic comparison level (mostly metropolitan and nonmetropolitan), we often need to drill down to small area data, usually county level, to really understand the conditions and trends in rural America. This allows us to not only see national level trends, but also differences across regions and states. Plus, small area data lets us create maps. Maps often tell the story better than any table, chart or graph.

So where do we go for small area data? Mostly, we use the American Community Survey (ACS) from the U.S. Census Bureau.

American Community Survey, you ask? Haven’t heard of it? This is the way the Census Bureau collects all the detailed information – everything from housing conditions to ancestry.

That information used to be collected in the once-a-decade long form, but we needed more timely data to understand conditions and trends, and to make decisions about how to spend federal dollars. A study by the Brookings Institution found that over $400 billion in federal dollars is allocated based on ACS data. Instead of collecting this information once every 10 years, the Census Bureau is now collecting the data continuously, and then aggregating over time for accurate estimates that are much more frequent.

Sounds great, no?

Well… there’s a bit of a catch to “frequent.” In lots of rural places, data has to be collected over a lot longer period than in more populated places in order to obtain a reliable estimate.. In most counties, in fact, it takes five years to get a reliable estimate.

So, think about a large county in the West. We’re already averaging data over a large geographic space, but now we’re averaging it over time as well. And think about what a five year span can represent: 2005 to 2009 had some good years and some really bad years in it.

Frequency of ACS estimates by county (click to see an enlarged map)
So, while it’s true that there is absolutely an inequity between rural and urban places. Urban areas have more timely data, let’s be clear that this doesn’t outweigh the overall benefits of the ACS. The bottom line is that this data is indeed more timely. Even if we can’t get annual estimates for all places, at least we’re seeing more current and more accurate data.

It’s not perfect data – there’s no such thing as perfect data – but for understanding rural America, this data is absolutely essential.

Monday, November 12, 2012

The Youngest Guy in the Room

By Warren Vaughan, Senior Planner for a county development district in SW Montana
I am in my mid-30s, and have worked in local government for the past eight and a half years. For the first two years, I made the rounds - the daily grind of permitting, the phone calls with people asking about zoning, the front counter work with the public. I enjoyed it, but I also struggled: I had gotten a degree in land use planning because I loved the idea of building community, not processing permits as a low-level bureaucrat.
Then I got lucky. A convergence of events led me to suddenly being the primary facilitator of three separate community planning processes across our large and rapidly growing county in Montana. I have spent the past six years working directly with citizens groups and local nonprofits on first-ever community plans, new sidewalks, sewer infrastructure, and a two-county economic development district.
A community meeting in SW Montana
And through all of it, one very personal fact is always apparent to me: I am the youngest guy in the room.

I often wonder where everyone else is - out starting businesses, out raising families? Certainly, the challenges of becoming civically engaged in my mid-30s are very apparent to me. I work full time, am raising my own family, and am enrolled in a doctoral program. Juggling it all is a complicated experience.
The author and his daughter
As someone who is directly involved in day-to-day activities of civic engagement, I think about how community work best gets done in today’s world. Sure, we have our share of Rotary Clubs and American Legions, but most of those organizations are aging and being replaced by local professional organizations.

Rather than focusing on community work, the local associations I see are often not tied to civic service but rather provide venues for people making business and professional connections. Because a significant part of my job involves economic development, I heartily support these sorts of associations...but I also recognize that something is lost. And it isn’t just my own experience: civic engagement, nationally, looks very different than it used to.

Civic engagement in America

Historically, Americans have been civically engaged on multiple levels. Alexis de Toqueville, the most well known early commentator on democracy in the U.S., famously described Americans as constantly forming, dissolving, and reforming local groups to deal with local issues [1]. One of the consequences of all this association, argued Toqueville, was that we were literally practicing democracy at all levels of society. Importantly, the practice of democracy was scalable. Learning how to take part in civil dialogue at the dinner table allowed for a healthy exchange of ideas over a game of cards. The skills that allowed friends to discuss the local politics of the day could work during one’s tenure on the school board; then, what worked on the school board or Lion’s Club could work as a city council member. Moving up, those skills, in turn, would also work in state legislatures and even on a national scale.

Photograph by Kestral Aerial
Toqueville’s work has cast a long shadow. In 2000, Robert Putnam put him back on the map with Bowling Alone, Putnam's account of the decline of social capital in America [2]. Putnam argued that that strong ties and face-to-face interaction in groups created democracy from the ground up. Putnam warned that civic engagement had been on the decline since the 1960s and suggested that any discussion of democracy needed to get serious about social capital and civic engagement.

So what changed since the 1960s? Theda Skocpol, a sociologist from Harvard, provides an historic view [3]. For one, the types of groups Americans join today are different than the ones they joined 50 years ago. Membership in volunteer-driven organizations like the Rotary Club is on the decline, while professionally run organizations with centralized headquarters are up. Single-issue groups are replacing broad associations based on socializing. Vietnam caused a generational rift in community organizations based on military service.

 The upshot of it all is that the character of our civic engagement began looking a lot different. The result, according to Skocpol, is a “diminished democracy”. 

Moving forward

So what’s to be done about this? If we take seriously the idea that a thriving civic life is key to our success as a democracy, then what do those of us working on rural policy issues do about it? How do we encourage a new kind of civic engagement, one that takes into account the realities of striking political polarization, digital communities, and a modern life that leaves little time to get involved in issues larger than oneself?

Public trails in the author's home county

One thing I do know is that civic engagement in politics in my own community looks very different than it did just four years ago. Our local and state tea party group has largely come to dominate my county’s politics, and the process by which they’ve done so is worth understanding. In contrast to many of the political groups involved statewide and locally who depend on professional staff, mailers, and requests to contact legislators at key times, our local tea party group consists of ordinary people who track political issues, are placed on planning commissions, and have been elected to local office.

Regardless of how one feels about the politics involved, the fact remains that this is civic engagement happening on a capacity not seen in 50 years. The process is worth our attention as professionals involved in rural policy and development.

On a professional level, I swing between valuing civic engagement as an end in itself and just wanting to get things done as a professional. The challenge is that local work is inextricably bound up with the national conversation. Sitting down with someone week after week at meetings to try and hammer out local solutions for and by local people simply isn’t going to work if the larger public sphere has been taken over by a divided national conversation, and I often question whether the endless night meetings build social capital or simply entrench positions.

A personal choice to participate

In the end, I find the question of civic engagement a deeply personal one. What does it mean for me to engage in the larger questions of today’s society? How can I effectively move beyond my own self and my private concerns to connect with larger values of community and hope and faith? How do I, as an employee of local government, conduct myself at a time when much of the public sphere is dominated by debates over the value of government?

These questions extend to larger ones about youth engagement. How do we engage people younger than me in questions about the common cause? Youth turnout in the past couple of election cycles has been encouraging, but civic engagement goes beyond casting a vote at the ballot box. 

To quote Robert Bellah, “democracy means paying attention” [4]. In my mind, that means understanding that every one of us is embedded in layer upon layer of relationships, and recognizing that how we engage in these relationships has systemic impact on our civic life and democracy. As challenging as it is in these days of hostile political discourse, we’re all going to have to start paying a lot more attention. I don’t want to be the youngest guy in the room anymore.

I don’t have ready answers, but on a personal level, I put myself firmly in Toqueville’s shadow: I believe civic engagement is the practice of democracy. As I survey my own life as a father, a husband, a brother, a son, a friend, and a professional who deeply cares about the future of my own community, I am moved by the idea that my relationships are part of the practice of democracy. That, indeed, is a powerful idea.


[1] Toqueville, A. de. (2003). Democracy in America. In V. Hodgkinson & M. Foley (Eds.), The Civil Society Reader. Hanover: University Press of New England.

[2] Putnam, R. (2000). Bowling Alone: The Collapse and Revival of American Community. New York: Simon and Schuster.

[3] Skocpol, T. (2003). Diminished Democracy: From Membership to Management in American Civic Life. Norman: University of Oklahoma Press.

[4] Bellah, R., Madsen, R., Tipton, S., Sullivan, W., & Swidler, A. (1991). The Good Society. New York: Knopf.

Warren Vaughan works in community and economic development for local government in Montana. When he finds the time, he squeezes in work on a PhD in collaboration and community at Fielding Graduate University. His favorite thing in the world is getting distracted by his wife and three year old daughter. He can be reached wvaughan [at]

Photo credits: Landscape photographs (including Kestral Aerial photo) courtesy of Gallatin Valley Land Trust. All other images provided by the author.

Visit RUPRI here or the Rural Futures Lab here.

Wednesday, November 7, 2012

RUPRI Policy News: Rural Health Care

By Jocelyn Richgels, RUPRI Associate Director, Policy Programs

Rural health care policy is getting a rare surge of national attention. Two leading health care policy institutions, the Medicare Payment Advisory Commission (MedPac) and the Institute of Medicine (IOM), have released major reports that touch on rural health policy from two important angles. MedPac examines health-care policy that influences rural providers’ decisions and beneficiaries’ access to care, while IOM studies payment policies that are affected by the differences in cost of providing care across the geographic spectrum.

These reports are likely to have an influence on rural health payment considerations well into the future. Major health care organizations with an interest in rural health care policy, such as the National Rural Health Association, have weighed in with numerous studied reactions to the reports’ findings. Both Houses of Congress have reviewed the reports, staff have questioned the authors and will ponder how, if at all, report findings will factor into future health care policy legislation. 

Each report was undertaken to respond to different charges from policymaking bodies. However, both reports addressed geographic variability in health care across this country, albeit for different purposes.  

Medicare Payment Advisory Commission (MedPac)
MedPac is the independent Congressional agency that advises Congress on issues affecting the Medicare program. It released its biannual report in June, with Chapter 5 devoted to “Serving rural Medicare beneficiaries.”  MedPac last included a rural-focused chapter in its 2001 report and has released reports on rural-specific policies in the intervening years. Congress required that the Commission report on rural access to care, quality of care, rural-specific payments to hospitals and the adequacy of Medicare payments to rural providers.

The factors that affect access to care and the quality of care across the rural-urban continuum has a large research base and is better understood with each new study. This report, however, highlights variations across regions in the country.

Click on the image to see a larger version.
Source: MedPac Report, chapter 5, page 132
MedPac finds less variation across rural-urban places within regions than across different regions (see Table 5-7 above), particularly in access to and volume of care. The geographic variations across regions are noticeable in rural physician-to-population ratios, in the volume and utilization of care across regions, and the use of post-acute care, such as skilled nursing facilities and home health care. For people familiar with the variations in poverty, wealth, and health care status across different rural regions of the country, this finding from MedPac may not come as a surprise. The question now is whether there is enough research to understand why these variations exist, and whether and how much influence policy can have on evening them out. 

One area that federal Medicare policy already tries to address is geographic differences in the cost of providing care, through geographic adjustments to fee-for-service Medicare payments. Payments in high-cost and low-cost areas are increased and decreased respectively, relative to the national average.

Institute of Medicine (IOM)
The IOM is the independent health division of the National Academy of Sciences. IOM was charged through the Affordable Care Act to produce two reports on improving the accuracy of the data sources and methods used for making geographic adjustments to Medicare payments for both hospitals and physicians.

IOM’s major recommendation is that physician payment areas be transitioned to the same current payments areas as hospitals, which are divided into 441 metropolitan statistical areas (MSAs) and statewide non-metropolitan statistical areas. Given that MSAs are established based on resident populations and employment commuting patterns, payment rates based on existing known labor markets is the rationale for moving physician payment rates to the same structure as hospitals. The report also argues that using the same labor market definition for both hospitals and payments is in line with increasing integration of hospital and physician care settings and movement toward Accountable Care Organizations, where hospitals, physicians and other providers are jointly responsible for care delivery. 

The effect of payment changes on rural providers was an explicit consideration of the IOM, because as the report points out, the current physician payment areas were partly designed to attract providers in nonmetropolitan areas through payment calculations. Under this MSA/non-MSA approach, nonmetropolitan provider payment areas would see a decrease between 2 and 3 percent, under slightly different payment structures, while large metropolitan areas would increase payments by less than 1 percent to about 1 percent. IOM also found that “geographic areas used for payment adjustment are large relative to the locations of specific underserved populations. Thus, geographic payment adjustment is a blunt instrument for resolving these more localized disparities and is not sufficiently targeted to be an appropriate use of resources.”

As the federal government continues to consider unprecedented actions to address the country’s deficit, while at the same time new policies of the Affordable Care Act continue to be implemented, these reports from two respected institutions are well-timed to add to the policy considerations. Expect to see continued analysis and counter-analysis of both reports by rural health research and policy analysis institutions to add to this growing body of knowledge.

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