Friday, July 31, 2015

Rural America in the 2000s: Age


Roberto Gallardo This map shows whether the proportion of young people (under 25) increased or decreased in rural counties between 2000 and 2009. Red counties saw a decrease in the percentage of their populations under 25. Green counties saw the proportion of that population get bigger. Click the map to see a bigger version.

America has gotten older since 2000 — and rural America has gotten older than its city and exurban neighbors.

As with other demographic changes in the nation’s 2,038 rural counties between 2000 and 2009, place still matters. Some regions saw their share of the young increase while other parts of the country had the percentage of their populations under 25 go down.

The map above shows whether a rural county gained or lost its share of those under 25 years of age. Red means the percentage of those under 25 decreased in that county between 2000 and 2009. Green means the percentage of the county’s under 25 population increased.

(Figures used in this story are projections from EMSI, Inc., an economic modeling company, based on Census Bureau data. To see a larger version of the maps in this story, click on ‘em.)

Most of rural America is red. For that matter, most of America should be red. The percentage of the population that was under 25 dropped in urban, rural and exurban America. (See chart on the next page.)

The map above does have some striking exceptions to the rural-is-getting-older story. Counties in West Texas, the Panhandle and Oklahoma showed patches of green, indicating an increasing percentage of the population being young. So did isolated counties in the Mountain West.

Urban, rural and exurban counties all got older this decade. The chart below shows the shift in the population under 45 this decade. Rural counties had the lowest percentage of young people in 2000, and that continues to be the case in 2009.

Urban counties have the largest share of population under 45 — and urban counties saw a smaller shift in their young population than either rural or exurban counties.

Roberto Gallardo This map shows the change in the share of over 65 population in each rural county between 2000 and 2009. Red counties had a smaller percentage of residents in this age category. Green counties had a larger share. Click on the map to see a larger version.

The map above shows the change in each rural county’s share of the old, those over 65. Green means the percentage of those over 65 increased since 2000. Red means the share of older folks decreased.

Most of rural America is green. The exceptions can be found in the Great Plains and parts of Central Texas, both of which have a large number of counties that reported decreasing percentages of older residents.

Rural America has a larger percentage of its population over 45 than either urban or exurban counties. Urban counties show the smallest increase in this population. See chart below.

Here are the fifty rural counties with the greatest decline in their share of residents under 25 years of age from 2000 to 2009, according to these projections from Census data.

And here are the fifty rural counties with the greatest increases in their share of residents older than 65 years of age from 2000 to 2009.


Physician Workforce from and For Top Aging Counties

The 50 counties ranked in greatest percentage increase are approaching 700,000 people with about 6 people per square mile. Over half of the counties were whole county primary care shortage areas. The counties had average high school graduate rates and slightly less than average college graduate rates.

Physician workforce has been a major problem for these counties and deficits in physicians also result in fewer dollars and jobs flowing to these areas via health care. As the elderly increase and get older, their greatest increased need is primary care (double to triple). Current workforce design will make this problem worse.

There is not a plan to address deficits in workforce that impact most locations and most of the nation most of the years of their lives. The current design addresses the needs of some of the population in some locations some of the years of their lives.

Studies consistently demonstrate that the physicians found serving counties with the most need of physicians are those with

  • Origins in the Counties in Need of Physicians
  • Older Age at Medical School Graduation
  • Family Practice Career Choice
  • More normal medical education (not the most exclusive)

Origin Factors Changes

Those most likely to distribute are decreasing in admission to medical school. The children in these 50 counties face many barriers to admission resulting in less than 3 admitted per 100,000 people per class year from these 50 counties or about 118 in total numbers for the 1987 to 1996 class years of US medical schools. This is about 40% of the average probability of admission. This compares to highest income and most urban students that dominate admission (and are increasing) with 2 to 4 times greater probability of admission and lowest probability of serving basic health access needs.

The US has progressively admitted highest income, most urban, children of professionals at higher levels for all races and ethnicities - a steady move away from the origins that are most associated with needed health access. Even rural origin medical students are changing in ways less likely to result in rural distribution (near metro origins, higher income parents).

About 20% of the 118 born in these 50 counties became family physicians. Highest family medicine choice is consistently found in medical student origins shared with locations with the lowest concentrations of physicians. Also rates of rural practice and underserved practice are the highest at about 15 - 20% or 2 to 3 times the national average. The opposite is true of highest income most urban origin children who are found in family medicine, rural, or underserved locations as physicians at rates all less than 5%.

Physicians who are themselves older at medical school graduation are also 40% more likely to be found serving counties with higher concentrations of elderly.


Family Medicine and Changes

Family physicians are the dominant workforce in the 50 rapidly aging counties claiming 24% of the local county workforce. No other source reached half this level. Family physicians are 4 times more likely to be found serving such counties controlling for physician origins, ages, and career choices. Nurse pracititioners and physician assistants have been a help when they remained working with family physicians but with progressive declines from 50% to 25% working in the family practice mode in the past 25 years, the primary care and rural and underserved workforce contributions of NP and PA have decreased as well. Only family practice MD, DO, NP, and PA forms distribute where most needed in the United States and only when they stay in family practice.

Medical Education Changes

Medical school training also plays a role. The top schools ranked by prestige, by research, by MCAT scores, or by funding produce graduates that are half as likely to be found in these counties. Schools admitting more normal students, schools with training in more normal and less exclusive locations, and schools focusing on primary care and health access multiply rural practice location by 2 to 3 times. Schools that focus preparation, admission, training, and family medicine have the top rural workforce production (West Virginia School of Osteopathic Medicine, Duluth).

The states depending upon a single public school for much of their rural workforce also face greater workforce problems as family medicine choice has been cut in half in these schools in the past 12 years. Loss of the one career choice that triples rural distribution for any type of school or for any type of origin is a serious loss for rural America.


Solutions That Work

The United States could have increased the physician workforce specific to these 50 counties and specific to Rural America, if it had a plan. Such a plan should have been implemented about 30 years ago as it takes about 30 - 35 class years of graduates to fulfill any workforce plan. This is also why current crash efforts to produce more primary care are doomed to failure. Real workforce change requires consistent steady effort, dedicated leadership, and a real plan of action that will deliver.

National policies over the past 30 years have moved physician workforce in the opposite direction - away from generalists (primary care and specialty care) and away from rural workforce and away from underserved workforce. Studies of rural workforce needs have not changed in their recommendations, but they have been ignored.

Two areas could have addressed this workforce need - health access medical schools and expansions of family medicine graduates.

  • Family medicine is the only source of primary care to remain consistent in primary care workforce as well as care of rural, elderly, poor, near poor, CHC, and underserved populations. Family medicine is the only source of primary care with zero annual graduate growth since 1980 - no increase at all - still 3000 per year. Even a 1 or 2% annual growth of family medicine graduates over 30 years would have addressed substantial needed workforce - as long as the US also planned to support this workforce in rural areas.
  • Despite family medicine, a second intervention would still be required. The US could have established a rural medical school such as Jichi in Japan (Matsumoto, Inoue). Graduates of Jichi train for rural practice and owe 7 years of most needed rural practice in the prefecture (state) that sponsors them. After the first 3 years of this obligation, Jichi graduates have served more years of instate most needed workforce than any US school, including the best US pipeline programs. This is just the beginning as Jichi graduates over their 35 or more year careers go on to spend another 10 years where needed most. Jichi graduates are selected, trained, and obligated for rural health access and have delivered. This federal-state-local collaborative really works - in contrast to other health professional schools and government programs.
  • The best option is A and B - both of the above combined with training that has a beginning, a middle, and an ending where most needed. Selection, training, family medicine, and graduate support are focused together with a choice of the long term instate rural obligation.

After 35 years of focus on most needed health access, Japan has realized the success of this model. Not surprisingly Japan is expanding this model. Of note to health reform buffs - Japan still needed a specific health access medical school, despite expansions of graduates, despite universal health care coverage for decades, and despite better pay for front line physicians and rural physicians.

Japan has projected a need for 600 annual graduates for a nation of 127 million people with very little population growth. The comparable US need would be 2000 annual graduates (12 medical schools) with long term obligations to address the US populations left behind. The US mainly has loan repayment that impacts mainly family physicians that distribute already at the highest levels where most needed anyway. Japan has an upfront model that invests in the right medical students that become the right physicians that are trained specifically for rural needs.

Jichi is a school that guarantees most needed health access workforce and this has been confirmed in the past 30 years of graduates. The US health care education and health care policy design over the past 30 years has driven nurses, hospitals, physicians, non-physician clinicians, health care services, and health care funding away from rural locations. Also driven away are young Americans, which is why many rural counties are aging.

Robert C. Bowman, M.D.