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MY VISION FOR RURAL HEALTH IN THE 1990S
BY

C. EVERETT KOOP, M.D., Sc.D.
PRESENTED TO
THE NATIONAL RURAL HEALTH ASSOCIATION

13TH NATIONAL ANNUAL CONFERENCE

MAY 17, 1990

NEW ORLEANS, LOUISIANA
| AM PLEASED TO HAVE THE OPPORTUNITY TO BE A PART OF THE

NATIONAL RURAL HEALTH ASSOCIATION’S ANNUAL CONFERENCE.

| AM SORRY |! WAS NOT ABLE TO ACCEPT YOUR INVITATION TO
SPEAK TO THE CONFERENCE IN WASHINGTON TWO YEARS AGO.

ACTUALLY I WOULD PREFER TO BE IN NEW ORLEANS.
WHEN | ACCEPTED YOUR INVITATION LAST FALL I FELT AN
INTELLECTUAL BOND TO YOUR CAUSE, BUT DID NOT KNOW A LOT

ABOUT IT.

SINCE THAT TIME | HAVE WALKED THE LONELY ROADS OF
APPALACHIA, | HAVE VISITED SICK CHILDREN, VISITED WITH RURAL
ADULTS, AND TALKED TO WORRIED AND OVERWHELMED HEALTH

CARE PROVIDERS.
| HAVE SEEN THE FACE OF RURAL POVERTY, | HAVE SEEN THE
S
GROWING LOSE OF THE CAPACITY AND LOSS OF PUBLIC

CONFIDENCE IN LOCAL HEALTH CARE ¥%@ DELIVERY.

MY INTELLECTUAL BOND WITH YOU AND YOUR RURAL

CONSTITUENCY IS NOW AN EMOTIONAL BOND, AS WELL.
| NOW FEEL AN EMOTIONAL BOND WITH YOU AND YOUR RURAL
CONSTITUENCY. WHILE | AM APPALLED AT THE LEVEL OF NEED FOR
ALL HUMAN SERVICES IN OUR RURAL AREAS, MY HEART IS WARMED

AT THE STRENGTH, COURAGE, AND HOPE OF OUR RURAL CITIZENS.

| HAVE KNOWN WHAT NRHA DOES FOR SOME TIME. NOW I KNOW

WHY IN A VERY PERSONAL WAY.
IN THE LAST YEAR NRHA HAS BLOOMED INTO MATURITY.

YOU HAVE BECOME A FORCE TO BE RECKONED WITH AS AN
INTEREST GROUP PROMOTING THE HEALTH AND WELL BEING OF

RURAL PEOPLE.
YOU HAVE COME A LONG WAY FROM THE LITTLE BAND OF

FEDERALLY ASSISTED RURAL PROJECTS OF THE MID-1970’S.

YOU HAVE ALL THE ELEMENTS OF A MATURE ORGANIZATION. YoU
Have FOUNDING FATHERS: DAVID FENTON, MIKE SAMUELS, JOHN CLARK,

JOHN LACASE.
YOU EVEN HAVE YOUR MARTYRS: LOU GORIN, FOR WHOM YOUR
HIGHEST AWARD IS NAMED, TERRY REILLY, FOR WHOM THE

MEMORIAL LECTURE IS NAMED.

A VERY RICH HISTORY INDEED WITH A CLEAR TREND OF

DIVERSIFICATION TO INCLUDE ALL CONCERNED GROUPS.
YOU MERGED WITH THE AMERICAN RURAL HEALTH ASSOCIATION TO
ADD AN ACADEMIC AND RESEARCH COMPONENT AND THE JOURNAL

OF RURAL HEALTH, TO SHARE KNOWLEDGE.

| COULD CONTINUE,
BUT THE POINT IS THAT YOU HAVE ACHIEVED A DIVERSITY THAT

MIRRORS THE RURAL AMERICA FOR WHICH YOU ARE ADVOCATES.

THE COALITION YOU HAVE BUILT CUTS ACROSS MORE NARROWLY

FOCUSED INSTITUTIONAL AND PROFESSIONAL INTERESTS.
MUCH OF THE CREDIT FOR YOUR SUCCESS MUST GO TO YOUR

EXECUTIVE DIRECTOR BOB VAN HOOK.

WHEN HE ASSUMED HIS POSITION AS EXECUTIVE DIRECTOR THIS
ORGANIZATION WAS ON THE CRITICAL LIST. HE BROUGHT YOU OUT
OF THE ICU, YOU HAVE RECOVERED AND ARE POST

REHABILITATION.

10
ON YOUR BEHALF HE HAS BUILT NRHA INTO A STABLE
BROAD-BASED ORGANIZATION OF NEARLY 2000 INDIVIDUAL AND
INSTITUTIONAL MEMBERS AND A WELL DIVERSIFIED BUDGET OF

OVER $1.5 MILLION .

11
THIS STRONG COALITION OF PRIMARY CARE CENTERS, HOSPITALS,
CLINICIANS, ACADEMICS, RESEARCHERS, AND COMMUNITY PEOPLE

HAS SUCCESSFULLY ENGAGED THE POLITICAL PROCESS.

12
YOUR FRIENDS INCLUDE, AMONG OTHERS, SENATORS HARKEN,
AiD> = Abwitc As
BYRD, HOLLINGS, DURENBEGER, DOLE, PRESIDENT CARTER, AND

VICE PRESIDENT MONDALE.

13
YOUR ALLIES INCLUDE THE ACADEMY OF FAMILY PHYSICIANS, THE
AMERICAN ACADEMY OF NURSE PRACTITIONERS, AND THE

AMERICAN HOSPITAL ASSOCIATION, AND NOW ME.

14
YOUR CONFERENCE THEME ”EMPOWERED TO MAKE A DIFFERENCE
” REFLECTS THE CAPACITY YOU AS THE NATIONAL RURAL HEALTH

ASSOCIATION HAVE BUILT OVER THE LAST THIRTEEN YEARS.

YOU ARE EMPOWERED IWDEED §

15
LAST YEARS SENATE APPROPRIATION LABOR, HEALTH AND HUMAN
SERVICES SUB-COMMITTEE REPORT WAS CALLED ” THE RURAL

CHRISTMAS TREE ”.

AND YOU HAVE CONSISTENTLY SCORED WELL FOR RURAL HEALTH

INTERESTS IN THE PAST THREE BUDGET RECONCILIATION BILLS.

16
YOU HAVE INFLUENCED THE ESTABLISHMENT OF A FEDERAL OFFICE
OF RURAL HEALTH POLICY AND ARE FORTUNATE TO NOW HAVE
JEFF HUMAN AS A STRONG VOICE FOR RURAL HEALTH INSIDE THE

BUREAUCRACY.

WITH EMPOWERMENT COMES THE STEWARDSHIP AND ALL THE

RESPONSIBILITIES THAT GO WITH IT.

17
HOW CAN YOU BEST SERVE RURAL AMERICA ?
SO OFTEN MATURE MOVEMENTS PERPETUATE SELF SERVING
POLICIES AND FORGET THAT IT IS NOT THEMSELVES BUT A

CONSTITUENCY THAT MUST BE SERVED.

CLEARLY YOU HAVE DONE A GREAT DEAL TO FOCUS ATTENTION ON

THE HEALTH NEEDS OF THE RURAL POPULATION.

18
YOUR CONTINUING LEADERSHIP TASK IS TO FORMULATE AND
REFORMULATE A COLLECTIVE VISION FOR THE HEALTH OF RURAL

AMERICA.

MY ASSIGNMENT FOR TODAY IS TO THINK ALOUD WHAT THAT

VISION LOOKS LIKE FOR THE 1990'S.

prpofies)
IN THINKING ABOUT THIS G®&=6R | WONDERED, WHAT CAN |

CONTRIBUTE ?

19
BouxLyvV
| WAS BORN AND GREW UP IN NEW-CYSRE-CEFY AND LIVED MOST OF

MY ADULT LIFE IN URBAN PHILADELPHIA.
AS YOU KNOW, HOWEVER, RURAL IS A STATE OF MIND AND BESIDES

MY HEART WAS ALWAYS IN RURAL #&@@5He NEW HAMPSHIRE.

AMERICAS’ SOUL HAS DEEP RURAL ROOTS.

20
LIKE JEFFERSONS’ DREAM OF A NATION OF SMALL FARMERS, AND
THE LURE OF THE 1/4 SECTION OF LAND (160 ACRES) THAT

BROUGHT OUR LANDLESS PEASANT ANCESTORS FROM EUROPE

OR THE DREAM OF ”40 ACRES AND A MULE ” THAT ENTICED SLAVES

RECENTLY FREED TO HOMESTEAD AFTER THE CIVIL wary

21
RURAL AMERICA PROVIDES THE BREAD FOR OUR TABLES, THE FUEL
FOR OUR CARS, AND THE WOOD FOR OUR HOMES, AND
INCREASINGLY, THE SMALL MANUFACTURED PARTS THAT MAKE

MOST THINGS GO.

PERHAPS THE MOST IMPORTANT CONTRIBUTION OF RURAL
Fel
AMERICA, HOWEVER, IS ITS VALUES OF RESPECT @F OUR PRECIOUS

FARMLAND, AND AN UNQUESTIONED BELIEF IN THE FUTURE.

22
THE AMERICAN DREAM AND THESE HEADY, SOMEWHAT ROMANTIC
THOUGHTS DON’T SQUARE WITH MUCH OF WHAT | SEE AS THE

REALITY OF MODERN RURAL AMERICA.

BUT THERE IS NO DOUBT THAT THESE THOUGHTS DO BIND

TOGETHER THOSE WHO COULD HELP CHANGE IT FOR THE BETTER.

23
| WILL FIRST PREACH TO THE CHOIR AND OUTLINE WHAT | BELIEVE

ARE SOME MAJOR RURAL ISSUES, SOME IMMEDIATE ACTION STEPS

THAT COULD BE TAKEN.

AND THEN CONCLUDE WITH SOME BROADER VISIONS OF DESIRABLE

CHANGE.

24
A MAJOR ISSUE AND THE DRIVING FORCE BEHIND THE CURRENT
SUPPORT FOR RURAL HEALTH IS THE THREAT TO THE CONTINUED

EXISTENCE OF SMALL RURAL HOSPITALS.

THE CLOSURE OF A RURAL HOSPITAL MARKS MORE THAN A LOSS

OF HEALTH CARE CAPACITY FOR THE COMMUNITY.

25
AS A MAJOR ECONOMIC PILLAR IT OFTEN TOLLS THE DEATH KNELL

OF A SEs COMMUNITY.
BUT DATA ON HOSPITAL CLOSURES ARE LIKE MORTALITY
STATISTICS, THEY REFLECT DEATH ONLY, NOT SICKNESS AND

SUFFERING.

MANY RURAL HOSPITALS ARE BEING STRANGLED. |

26
THIS MAY RESULT, NOT IN THEIR DEATH, BUT IN THEIR RELATIVE
FINANCIAL AND ORGANIZATIONAL SICKNESS.

ITS
DHHS SHOULD MOVE ON TeEFR PLAN TO ELIMINATE THE
URBAN/RURAL DIFFERENTIAL IN STANDARDIZED MEDICARE
HOSPITAL PAYMENTS AS SOON AS POSSIBLE. MANY RURAL
HOSPITALS WILL NOT MAKE IT UNTIL 1995 WHEN THE CURRENT

PLAN IS TO GO INTO EFFECT.

27
| SEE NO REASON WHY THIS COULD NOT BE ACCOMPLISHED IN FY

91.
CONCURRENTLY DHHS SHOULD REFINE THE AREA WAGE INDEX

UNDER MEDICARE TO REFLECT THE REALITY OF A SINGLE NATIONAL

MARKET FOR HEALTH PROFESSIONALS.

28
HEAL
| CONTINUE TO KAERE STORIES OF AGED VETERANS WHO MUST

TRAVEL A HUNDRED MILES TO A VETERANS ADMINISTRATION

HOSPITAL AND EVEN THEN MAY NOT BE SEEN THAT DAY.

LETS HELP THE VETERAN, DECREASE THE OVER°CROWDING OF V.A.
HOSPITALS, AND INCREASE UTILIZATION OF RURAL HOSPITALS BY

ALLOWING OUR RURAL VETERANS TO RECEIVE THE CARE THEY ARE

ELIGIBLE FOR AT THEIR LOCAL HOSPITAL.

a )

29
INE oF

FARMING IS OUR NATION’S MOST DANGEROUS OCCUPATIONS, AND
Artnover! Ave
FARM ACCIDENTS 8 A MAJOR PROBLEM BE UNDER - REPORTED.

GOOD FARM SAFETY PROGRAMS COULD DECREASE NEEDLESS

SUFFERING AND THE NEED FOR COSTLY MEDICAL CARE.

30
THERE ARE MANY NEW INITIATIVES UNDERWAY.

BUT ! AM ESPECIALLY EXCITED ABOUT THE UNIVERSITY OF NORTH

DAKOTAS’ RURAL RESEARCH CENTER.

THERE THEY ARE DEVELOPING GUIDANCE IN ORDERING ROLL BARS

FOR TRACTORS AND FOR ADAPTING ROLL BARS FOR DISCONTINUED

TRACTOR MODELS.

31
THIS COULD PROVIDE A SOLUTION TO A MAJOR SOURCE OF FARM

ACCIDENTS.

FARM SAFETY IS ALSO AN AREA WHERE THE EXTENSION SERVICE

OF USDA COULD BE OF TREMENDOUS ASSISTANCE.

| ENCOURAGE DHHS AND USDA TO WORK CLOSELY TOGETHER IN

THE AREA OF FARM SAFETY.

32
MENTAL HEALTH CARE SERVICES IN THE UNITED STATES ARE INA

ee

SAD STATE OF AFFAIRS.

THE MENTAL HEALTH BLOCK GRANT PROGRAM, WITH ITS UNDER -

FUNDING, IS A FAILURE.

MOST STATES HAVE ONLY SUFFICIENT RESOURCES TO TREAT THE

CHRONICALLY MENTALLY ILL.

33
COMMUNITY MENTAL HEALTH CENTERS HAVE ABANDONED

OUTREACH AND COMMUNITY S@& PREVENTION PROGRAMS.

THEY LOOK INSTEAD TO MEDICAID AND PRIVATE INSURANCE TO

COVER PATIENTS AND INSURE SURVIVAL.

LET ME REMIND YOU THAT MOST MENTAL DISORDERS ARE TREATED

BY FAMILY PHYSICIANS AND THE CLERGY.

34
WE MUST RECOGNIZE THE INTERDEPENENT RELATIONSHIP
BETWEEN PHYSICAL AND MENTAL HEALTH AND FIND WAYS TO

BRING THE TWO TOGETHER.
IN THE LATE 1970'S THERE WAS AN INNOVATIVE PROGRAM

BETWEEN COMMUNITY HEALTH CENTERS AND COMMUNITY MENTAL

HEALTH CENTERS CALLED ”MENTAL HEALTH LINKAGES”.

35
MENTAL HEALTH LINKAGE WORKERS 3 USUALLY SOCIAL WORKERS,
CARRIED A CLIENT CASE LOAD, ACTED AS A LIASON, AND
EDUCATED AND SENSITIZED THOSE PROVIDING PHYSICAL HEALTH-

CARE.

THE PROGRAM WAS AS SUCCESS, BUT FELL TO THE BUDGET CUTS

OF THE EARLY 1980’S. RENCOURAGE ITS REDISCOVERY”? 4 ©
Ze off CoMSIDERATLE FEWELTT.

36
ON A MORE POSITIVE NOTE I APPLAUD THE RECENT
ESTABLISHMENT OF A RURAL MENTAL HEALTH RESEARCH
PROGRAM AT THE NATIONAL INSTITUTE OF MENTAL HEALTH UNDER

DR. DELORES PARRONE.

| HOPE THEY WILL FUND RESEARCH AND DEMONSTRATION
PROJECTS THAT UTILIZE THE RESOURCES OF PRIMARY CARE
PHYSICIANS AND CLERGY TO HELP THOSE WITH MENTAL HEALTH

PROBLEMS.

WE NEED MORE RESEARCH, BUT WE ALSO NEED PROGRAMS THAT
WILL ADDRESS UNMET LOCAL NEEDS FOR INTEGRATED MENTAL

HEALTH SERVICES.

37
THERE ARE MAJOR SHORTAGES OF HEALTH PROFESSIONALS IN THE

RURAL AREAS.

WHILE | ADVOCATE RURAL HEALTH SYSTEMS THAT UTILIZE

RELATIVELY SMALL NUMBERS OF PHYSICIANS; THERE MUST BE

PHYSICIANS AVAILABLE TO SERVE IN RURAL AMERICA.

38
WE MUST MAKE RURAL PRACTICE ATTRACTIVE TO THEM AND TO

OTHER HEALTH PROFESSIONALS.

| FAVOR REAUTHORIZATION OF THE NHSC, BUT WITH SOME MAJOR
CHANGES. SCHOLARSHIP FUNDING PREFERENCE SHOULD GO TO
MEDICAL SCHOOLS, LIKE THE KIRKSVILLE COLLEGE OF
OSTEOPATHIC MEDICINE, WITH A LONG TRACK RECORD OF

PRODUCING RURAL FAMILY PHYSICIANS.

39
WE DON’T NEED MORE EXPENSIVE URBAN ORIENTED PROGRAMS |
LIKE GEORGETOWN AND GEORGE WASHINGTON UNIVERSITY WITH

EXPECTATIONS THAT THEY WILL PROVIDE RURAL PHYSICIANS.

PAY BACK

WE SHOULD SUPPORT, DEFERMENT FOR PRIMARY CARE PHYSICIAN

RESIDENCIES ONLY IN AHEC OR AHEC-TYPE MULTI DISCIPLINARY

PROGRAMS PHYSICALLY LOCATED IN RURAL AREAS.

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40
RURAL PRACTICE IS DIFFERENT.
F

WE DON’T NEED HUGE NUMBERS OF RURAL FAMILY PHYSICIANS
AND WE DON’T NEED TO SPEND A LOT OF MONEY IF WE SPEND IT

IN THE RIGHT PLACES.

THE N.H.S.C .SHOULD NOT BE A PHYSICIAN - ONLY ACTIVITY.

41
WE HAVE JUST AS GREAT A NEED FOR NURSE PRACTITIONERS,
PHYSICIANS ASSISTANTS, NURSES, AND ALLIED HEALTH
PERSONNEL.

Als 0
WE SHOULD ENCOURAGE STATES TO LICENSE MORE INDEPENDENT

NURSE = PRACTITIONERS FOR RURAL

 
 
    

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AREAS | WOULD ALSO ENCOURAGE MORE FLEXIBILITY IN NHSC
ASSIGNMENTS TO ALLOW FOR EXPERIMENTATION IN NEW MODELS

ee,
OF CARE. (E.G. ALLOW COMMUTING, ALLOW COMBINATION CH

HEALTH DEPT./ PRIVATE COMBINATIONS.

42
| WOULD LIKE TO SEE STRONGER STATE ROLES IN ESTABLISHING
HEALTH MANPOWER SHORTAGE AREAS THAT ARE MEDICAL

SERVICE AREA BASED RATHER THAN COUNTY BASED.
STATES SHOULD BE GIVEN AN OPPORTUNITY TO SET THEIR OWN

PRIORITIES, WITH APPROPRIATE SAFEGUARDS) FOR COMMUNITY

HEALTH CENTER’S / COMMUNITY MENTAL HEALTH CENTER’S.

43
Wauow'T 17 BE 6909
AQUGEED*REE TO SEE STATE OFFICES OF RURAL HEALTH AS A
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MECHANISM FOR THIS AND #6?2=7R@ Wel TAKE THE BROAD
APPROACH OF WORKING WITH PRIVATE AND PUBLIC PROVIDERS Sve
AS #gps@ JIM BERNSTEIN, HAS PIONEERED IN NORTH CAROLINA FOR

ALMOST 20 YEARS.

44
| REFERRED EARLIER TO THE "RURAL CHRISTMAS TREE” IN THE

SENATE APPROPRIATIONS REPORT.

IT CONTAINED SOME VERY ENCOURAGING THINGS : EQUITABLE
FUNDING ALLOCATES TO RURAL / URBAN COMMUNITY HEALTH
CENTERS, RURAL MENTAL HEALTH RESEARCH, INCLUDING
RESEARCH & DEVELOPMENT 38@®8 CENTERS, TWO ADDITIONAL
RURAL HEALTH RESEARCH CENTERS ( ONE MINORITY ), ACADEMIC
/ PRACTITIONER LINKAGE GRANTS, AND A COMPREHENSIVE RURAL

POLICY RESEARCH STUDY.

45
| CONTINUE TO WORRY ABOUT ”SPECIAL POPULATIONS” : BLACK,
HISPANIC, ELDERLY, ETC. AS COMMUNITY HEALTH CENTER’S /
COMMUNITY MENTAL HEALTH CENTER’S, HEALTH DEPARTMENTS

HAVE CUT BACK OUTREACH, THESE ARE FORGOTTEN PEOPLE,

| HOPE THERE ARE RESEARCHERS IN THIS AUDIENCE WHO WILL GO

OUT AND SURVEY THESE renews)

 

SO WE CAN RE - INVENT OUTREACH WORKERS AND COMMUNITY

CASE WORKERS.

46
—

THESE SPECIAL POPULATIONS ARE DIVERSE AND WILL REQUIRE
NEW APPROACHES SUCH AS WORKING THROUGH THE BLACK

OLDER.
CHURCHES, AS WELL AS, METHODS TRIED AND TRUE.

47
ALSO IN THAT REPORT WAS THE REQUIREMENT FOR SOME PILOT
PLANNING GRANTS TO COALITIONS OF STATE HEALTH
DEPARTMENTS, STATE PRIMARY CARE ORGANIZATIONS, AND
UNIVERSITIES TO DEVELOPE STATE MIGRANT HEALTH AND SOCIAL

SERVICES PLANS.

48
THE MIGRANTS ARE TRULY ”THE WORKING POOR”.

THEY DO SO MUCH; THEY ASK FOR SO LITTLE, 7~

JUST A SHOT AT THAT AMERICAN DREAM | MENTIONED EARLIER.

MIGRANTS HAVE NO POLITICAL POWER.

 

 

THEY CAN’T TAKE PART IN OUR ” INTEREST GROUP” STYLE OF

POLITICS.

49
AT THE MOMENT THEY HAVE ONLY A FEW STRONG ADVOCATES LIKE
SONIA REIG, DIRECTOR OF THE FEDERAL MIGRANT HEALTH

PROGRAM, THERE MUST BE MORE.

HUMAN COMPASSION ASIDE, WE MUST REALIZE THAT WE ARE
BECOMING PART OF A WORLD ECONOMY AND FOR MODERN
AGRICULTURE TO SURVIVE AND COMPETE WE NEED A HEALTHY AND

PRODUCTIVE MIGRANT AGRICULTURAL WORK FORCE.

50
| URGE STATE HEALTH DEPARTMENTS, STATE ECONOMIC
DEVELOPMENT BOARDS, CONCERNED STATE AND FEDERAL
AGENCIES, STATE PRIMARY CARE ORGANIZATIONS AND THE
PRIVATE SECTOR TO COME TOGETHER AND SUPPORT THE
DEVELOPMENT OF A SYSTEM OF AGRICULTURAL LABOR WE CAN BE
PROUD OF; ” HEALTHY HARVESTERS ”.

co

51
AS A PEDIATRIC SURGEON, CARE OF CHILDREN HAS BEEN MG@63-QF
Pho FStownL

- MY CAREER.

| WORRY ABOUT THEM AT ALL LEVELS AND AM ESPECIALLY

CONCERNED ABOUT THE FIVE MILLION WHO LIVE IN POVERTY.

52
1 HAVE A CONCERN THAT WE MAKE OUR SYSTEM WORK IN SUCH A
WAY THAT CHILDREN RECEIVE THEIR BASIC NEEDS IN THEIR OWN
COMMUNITY, BUT WHEN NEEDED, THE KNOWLEDGE AND SYSTEM
MUST EXIST TO SEE THAT THOSE WHO NEED IT FIND THEIR WAY TO

      
  

SPECIALIZED PEDIATRIC CARE.

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53
| AM EQUALLY CONCERNED ABOUT HOW FAMILY PHYSICIANS CAN
BURG Eo Mae |
ACQUIRE THE GCONTINGING KNOWLEDGE THEY NEED TO OPERATE

IN TODAYS ENVIRONMENT.

| KNOW THIS ANSWER IS NOT JUST OUR LEARNED JOURNALS. |
THINK IT IS PROBABLY SOME SORT OF INTERDISCIPLINARY HEALTH
EDUCATION PROGRAM RELYING HEAVILY ON AUDIO & VIDEO

TECHNOLOGY.

54
| ENCOURAGE THE AGENCY FOR HEALTH SERVICES RESEARCH AND
Veveror?
POLICY TO DO THE NECESSARY RESEARCH TO -S@ THE
KNOWLEDGE BASE FOR PROGRAMS TO MEET THE SPECIAL
INFORMATION AND CONTINUING LEARNING NEEDS OF RURAL

FAMILY PHYSICIANS.

ao”

55
THERE IS A GROWING CONCERN ABOUT THE SPREAD OF AIDS AND

SUBSTANCE ABUSE IN RURAL AREAS.
DR. JUNE OSBORNE, CHAIR PERSON OF THE NATIONAL AIDS

COMMISSION, SHARES THIS CONCERN AND HAS HELD HEARINGS IN

RURAL GEORGIA.

56
1 CAN’T PREDICT THE SPREAD OF AIDS IN THE RURAL AREAS, BUT
| KNOW WITH CERTAINTY THAT THE FRAGILE RURAL HEALTH CARE

SYSTEM HAS ALMOST NO TOLERANCE FOR ADDITIONAL PATIENTS.

HOW MANY CASES OF AIDS WILL IT TAKE TO BANKRUPT A

MARGINAL SMALL RURAL HOSPITAL ?

57
THE ANSWERS LIE IN AIDS AND SUBSTANCE ABUSE PREVENTION
EFFORTS, MORE DRUG TREATMENT SLOTS, AND SYSTEMS BUILDING
FOR HEALTH AND HUMAN SERVICES LIKE THOSE SPONSORED BY
HRSA’S PLANNING GRANTS FOR LOW PREVALENCE HIV STATES AND

COMMUNITIES.

58
| CAN’T LEAVE WITHOUT MENTIONING THE ADDICTIVE AND DEADLY

SCOURGE OF TOBACCO.

WE HAVE TURNED THE TIDE, BUT THERE ARE STILL AREAS OF

CONCERN: TEENAGE GIRLS IN GENERAL, RURAL MALE

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ADOLESCENTS AND SMOKELESS PRODUCTS.

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59
THESE ARE PUBLIC HEALTH ISSUES ALL OF US HAVE TO BELIEVE IN.

STROM ER
THERE MUST BE A PEW COMMITMENT TO PUBLIC HEALTH.

THE HEALTH SYSTEM WILL COLLAPSE IF WE DO NOT SUPPORT

DISEASE PREVENTION AND HEALTH PROMOTION.

60
| WOULD LIKE TO SEE A REVITALIZATION OF THE LOCAL HEALTH
DEPARTMENT, PERHAPS IN THE KIND OF FLEXIBLE AND

COOPERATIVE MODEL I PROPOSED FOR THE NHSC.

THE NEW LEADERSHIP IN HRSA (DR. BOB HARMON ) COULD BRING
THAT BACK AND REVITALIZE THE MORALE OF FEDERAL EMPLOYEES
AS WELL. WE NEED NEW DIRECTION AND POSITIVE PROGRAM

ACTION. lt HAVewT SESW oR stEAeO OF (7

YET!

61
IN MY VISION FOR THE 1990’S WE MUST ALSO HAVE SYSTEMS OF
HEALTH CARE THAT MEET NEEDS WITHIN THE CONSTRAINTS OF

EXISTING RESOURCES.

CONCURRENTLY THEIR MUST BE BETTER EDUCATION SYSTEMS,

ECONOMIC DEVELOPMENT, AND SUPPORTING INFRASTRUCTURE.

62
THESE ELEMENTS ARE INTERDEPENDENT AND THEIR LACK
CONTRIBUTES TO A CONTINUING CYCLE OF POVERTY. BUT THERE

IS HOPE.

KENTUCKY’S RECENT DECISION FOR STATE - WIDE EQUAL FUNDING

FOR EDUCATION IS A STEP IN THE RIGHT DIRECTION.

63
LONG TERM CARE FACILITIES DEVELOPED IN RURAL AREAS MEAN

MORE JOBS AND DOLLARS FLOWING TO THE COMMUNITY.

THAT’S ECONOMIC DEVELOPMENT COUPLED WITH HEALTH CARE.

64
PERHAPS STATES SHOULD GIVE PREFERENCE TO CERTIFICATES OF
AS
NEED FOR LONG TERM CARE BEDS IN RURAL AREAS 6&F ONE WAY

TO MEET THESE PROBLEMS.

pbs? OUR MODELS OF CARE MUST START WITH REALISTIC NEEDS
ASSESSMENT THAT RECOGNIZES THE UNIQUENESS OF EACH RURAL

COMMUNITY.

eid THERE MUST BE A PLANNING PROCESS THAT INVOLVES AND

EMPOWERS ALL OF THE COMMUNITY.

65
SUCH A PLAN MUST MAKE PROVISION FOR AT LEAST THE

FOLLOWING:

* MECHANISMS FOR COORDINATION BETWEEN HEALTH AND

SOCIAL SERVICES INSTITUTIONS.

* TRAINING OF COMMUNITY PEOPLE FOR EXPANDED AND
PARAPROFESSIONAL HEALTH ROLES.

* OFF - SITE PHYSICIAN surenvision/A GREATER USE OF
NURSE PRACTITIONERS, PHYSICIANS ASSISTANTS, MID — LEVEL
MENTAL HEALTH WORKERS, MULTI - COMPETENT TECHNICIANS

* GREATER USE OF LOW COST TECHNOLOGY ( E.G. FAX
MACHINES, P.C.’S )

* REGIONAL AND STATE - WIDE SYSTEMS OF COMMUNICATION,

REFERRAL, AND CARE.

66
ud (GLEVIDIOW SD MTOOT IY eR Tem En Ge
THE Basic HEaiTe CANE Prastsur Fate wor Mee
Oy enews th VEBRW S1E772 0d AHaw (hl CAME Gy,

WE’VE ALWAYS SAID WE NEVER WANTED EVEN A TWO-TIER SYSTEM, 4
OF FEALTH Ce RE pW AMERICH,

BUT WE HAVE IT ... AND A THIRD TIER, ALSO.

67
IN THE FIRST TIER .. THE BOTTOM TIER ... ARE UPWARDS OF
PERHAPS 30 MILLION AMERICANS -- ABOUT 13 PERCENT OF THE
POPULATION -- WHO FALL THROUGH THE CRACKS AND HAVE NO
HEALTH INSURANCE COVERAGE ... NO HIGH OPTIONS ... NO LOW

OPTIONS ... NO OPTIONS AT ALL.

THEY’RE NOT OLD ENOUGH FOR MEDICARE AND NOT POOR

ENOUGH FOR MEDICAID.

68
RECENTLY RELEASED FIGURES INDICATE THAT ONE OUT OF EVERY
EIGHT AMERICANS FALLS INTO THIS CATEGORY OF THE
UNINSURED. FOR BLACKS, THE FIGURES ARE WORSE, WITH ONE
OUT OF FIVE BLACKS UNINSURED. AND IN THE HISPANIC
POPULATION, ONE OUT OF EVERY FOUR PERSONS HAS NO HEALTH

INSURANCE

69
WHAT, THEN, DOES THIS "HEALTH CARE SYSTEM" OF OURS DO FOR
THE UNINSURED?

AS YOU KNOW, IN THE VAST MAJORITY OF CASES THE ANSWER IS
.. VERY LITTLE «- OR NOTHING. AND THEY ARE SUFFERING THE

CONSEQUENCES.
STUDY AFTER STUDY INDICATES THE CORRELATION BETWEEN NO

MEDICAL INSURANCE AND INCREASING HEALTH PROBLEMS.

THE HEALTH PROBLEMS OF THE LOWEST TIER, IF IGNORED BY

SOCIETY NOW, WILL BE BORNE BY SOCIETY LATER.

70
THEN WE HAVE A SECOND TIER.

THIS TIER RECEIVES A NARROW RANGE OF BASIC MEDICAL AND
HEALTH SERVICES WITH MORE OR LESS FIXED LEVELS OF
REIMBURSEMENT.

THIS IS LOW-OPTION COVERAGE ... MEDICARE AND MEDICAID
COVERAGE ... WITH THE PATIENT PAYING MANY COSTS OUT-OF-
POCKET OR WITH THE HELP OF SOME FORM OF SUPPLEMENTAL
INSURANCE, WHICH IS -- IN MY BOOK -- JUST ANOTHER KIND OF

OUT-OF-POCKET EXPENSE.

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FINALLY, WE HAVE THE THIRD TIER, THE TOP TIER.

THE PEOPLE IN THIS TIER RECEIVE A FULL RANGE OF MEDICAL
AND HEALTH SERVICES. THEY ARE COVERED BY HIGH-OPTION
HEALTH INSURANCE AND ALSO HAVE A FEW DOLLARS LEFT OVER
TO PAY THE 15 OR 20 PERCENT DIFFERENCE BETWEEN THE ACTUAL
BILL FROM THE DOCTOR AND THE CHECK FROM THE INSURANCE

COMPANY.

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FOR THOSE WITHOUT ACCESS, THE GOAL IS UNIVERSAL COVERAGE
TO BE ACHIEVED THROUGH COMPREHENSIVE REFORMS OF
GOVERNMENT PROGRAMS FOR THE POOR AND UNINSURED

COMBINED WITH RISK POOLING.

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MEANWHILE INTERIM STEPS INCLUDE MEDICAID EXPANSION,
UNDER EXISTING LAW, AND TAX INCENTIVES TO ENCOURAGE

SMALL BUSINESS INSURANCE COVERAGE. FHESE—EAFFER—

el ls meee Dold eed et Brel a ed .

 

reronas WE WEED SOME (~MMITATVE vee
LerolMs ESVEAHCLY D E5¢6 WED fo ke fe

OMe ce

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THE TIME IS RIGHT FOR CHANGE AND THE ELEMENTS EXIST:
- A MATURING RURAL HEALTH MOVEMENT
- A HEIGHTENED CONGRESSIONAL INTEREST

- STRENGTHENED STATE HEALTH DEPARTMENTS

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«# STABLE COMMUNITY AND MIGRANT HEALTH CENTERS
- GROWING NUMBERS OF STATE OFFICES OF PRIMARY CARE
-COMMUNITY MOBILIZATION AROUND POTENTIAL RURAL HOSPITAL

CLOSINGS

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| THE TIME IS NOW AND YOU HOLD THE KEYS *
GY IN CLOSING, | PLAN TO SPEND THE CURRENT PHASE OF MY CAREER
MAKING AMERICA AWARE OF ITS HEALTH PROBLEMS SUGGESTING
APPROACHES TO CONFRONTING THEM, AND GOADING THE

COUNTRY TO ACTION. YOUR GOALS ARE SIMILAR.

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[| WILL NEVER BE A ”COUNTRY BOY”, BUT | WILL SUPPORT THE
EFFORTS OF MY "COUNTRY COUSINS”S IN THE NRHA AND BE

PROUD TO BE THEIR FRIEND.

——_

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