Tuesday, July 28, 2015

The Great Plains Since 1950


The geographic boundaries of the American Great Plains.

The Great Plains run from Canada to Mexico, containing 18 percent of the nation’s landmass but only 3 percent of its people.

No wonder it’s so cool!

The U.S. Census Bureau has released a new report on the Great Plains, a study of the region’s population from 1950 to 2007 by demographer Steven Wilson. You can see the general borders of the Plains in the map to the right, boundaries devised in 1946. 

There are 376 counties in the Great Plains. (In 1950 there were only 375. Broomfield County, Colorado, was added in 2001.) Most counties (261) have fewer than 10,000 people. Only 34 have more than 50,000 residents.

Wilson’s paper is largely about population change. Yes, the Plains overall have continued to add people since 1950. But most of that growth is limited to two states. Colorado and Texas have only a third of the Great Plains counties but account for 96% of the region’s growth. Great Plains counties in four states have had total population declines since 1950. South Dakota was the only state where Great Plains counties accounted for an increased share of a state’s population.

We’ve pulled maps from the Census report. (The full report can be found here.) We’ve interspersed those maps with excerpts from Wilson’s report:

This shows the current population of Great Plains counties. Most counties have fewer than 10,000 people, in the light blue.

Wilson: Almost two-thirds (244 of 376) of the counties in the Great Plains lost population between 1950 and 2007. The total loss for those 244 counties was roughly 600,000 people. In addition, 69 Great Plains counties lost over 50 percent of their population. The largest decline occurred in Harding County, New Mexico, which lost 76 percent of its population between 1950 and 2007.

County-level population loss was the norm in the Great Plains portions of most states. Twenty of the 25 Great Plains counties in North Dakota lost population, as did 46 of the 58 Great Plains counties in Kansas. In addition, around half of the Great Plains counties in Colorado and Texas, the states that contributed the most to the region’s overall population gain, lost population.

The map at the top shows the percentage loss of population in Great Plains counties from 1950 to 2007. The bottom map shows the numeric change in population.

For most Great Plains counties, population loss started before 1950. For a majority of counties in and just outside the eastern border of the Great Plains, the census year of maximum population occurred before 1950 and in some cases, before 1900. Almost 60 percent (217 of 376) of Great Plains counties reached their maximum population before 1950, with most of those peaking between 1900 and 1920. The most frequent year of maximum population, for just under 25 percent of Great Plains counties, was 1930.

This map shows the year when each county had its largest population. The darker the blue, the longer ago the county reached its maximum.

In 2007, just over 68 percent of the Great Plains population resided in metro area counties. While this figure is lower than the 83 percent share for the United States, it is a higher percentage than in 1950, when 39 percent of the Great Plains population was metropolitan.

While the total natural increase in the Great Plains was similar in 1949–1950 and 2006–2007, growth in the natural increase in the Great Plains portions of Colorado and Texas was more than off set by a decline of over 27,000 in the natural increase in the Great Plains portions of the other eight states. Nebraska (–7,000), Kansas (–5,900), and North Dakota (–4,000) had the largest declines in natural increase. For North Dakota’s Great Plains counties, natural increase dropped from 4,800 in 1949–1950 to 800 in 2006–2007, a decline of 84 percent.

Examination of Great Plains counties by population size revealed strong patterns in the relative contributions of natural increase and net migration to overall population change. Among the smallest counties (those with fewer than 10,000 people), most (239 of 261) had negative net migration, and over 51 percent (133 of 261) had negative net migration and natural decrease. Of the 261 counties, only 9 had both natural increase and positive net migration.

Of the 81 midsized counties (those with 10,000 to 49,999 people), most (59 of 81) had negative net migration and 7 had both natural decrease and negative net migration. Of the 81 counties, 18 had both natural increase and positive net migration. All 34 Great Plains counties with populations of 50,000 or more had natural increase, and 23 of the 34 had positive net migration.

The age structure of the U.S. population changed between 1950 and 2007, with the median age climbing from 30.2 years to 36.6 years, an increase of more than 6 years. The median age in the Great Plains increased in a similar manner, from 28.5 years in 1950 to 34.9 years in 2007.

This map compares the median age of each county's population in 1950 (top map) and 2007 (bottom map). The lighter the purple, the younger the median population.

In 1950, the median age in most U.S. counties was under 30 years. By 2007, the median age of the population in most U.S. counties was 35 years or more. In 1950, almost three-quarters of Great Plains counties had a median age below that of the U.S. median age of 30.2 years. In 2007, in comparison, just over 20 percent of Great Plains counties had median ages below the U.S. median age of 36.6 years, a decline of over 50 percentage points since 1950. Furthermore, in 1950, no Great Plains county had a median age above 37.1 years. By 2007, almost 55 percent of Great Plains counties had a median age of at least 40 years. Of these counties, over 80 percent are located outside (cities). One Great Plains county, Sheridan County, North Dakota, had the highest median age in the United States in 2007 at 54.5 years.



Great Plains and Health Care

Nebraska's situation in the 1980s: about half of 93 counties with less than 10,000 people, at least one physician, and a rural hospital. Half of the population was rural and half was urban. The US design for health care did not fit Nebraska as rural hospitals were closing and the federal programs were a poor fit (the National Health Service Corps and Community Health Centers). Most of all, Nebraska needed physicians that would meet the needs of rural Nebraska.

Jim Stageman and Mike Sitorius converted Nebraska's family medicine effort to rural focus with rural family medicine residency training and accelerated family medicine training. These two programs have graduated about 8 - 12 per year with 75% remaining in rural Nebraska practice locations. The graduates have replaced retiring rural physicians, restored health care to communities that lost all physicians, and solidified health care into sustainable call systems.

The effort was comprehensive cradle to grave developed in partnership with the state and the state's rural communities and hospitals. Rural oriented admission, rural rotations for medical students, rural rotations for family practice residents, and numerous opportunities were developed to keep rural communities in contact with the state's efforts. Some of these have continued although some efforts have been cut or changed.

The primary care that Nebraska built over decades was not only specific to Nebraska rural needs, it remained steady in the past decade as primary care has melted away across the nation. Again this was because Nebraska rural primary care was built on the solid foundation of family physicians specifically trained for rural locations. In addition geriatric family medicine faculty such as Tim Malloy in the UNMC Department of Family Medicine did a superior job of preparing family physicians to care for those over age 65 that are 20 - 25% of the population in many counties.

Nebraska's family medicine department received much deserved recognition in a national award from the National Rural Health Association as program of the year.

Nebraska also helps out with the top high school graduation rate in the nation and this is aided by the top rural high school graduation rate. Nebraskans who attend college have top college completion rates, also an advantage of a state with better distributions of education and income. Nebraska also had a top medical school admission rate for any state, but there are changes in economics and education, and these impact admission to higher education.

Nebraska has broad distributions and Nebraskans are broad in their education and training. They have good standardized test scores, but not the exclusive scores.

This translates to changes in medical school admission. More children have been admitted with top scores, higher parent income levels, and most urban origins. Some have spent little time in the state prior to admission.

The beginning of health access for rural Nebraska is about those gaining admission to the University of Nebraska Medical Center as well as national policies regarding health access. With Nebraskan's gaining admission that are most connected to a state and most likely to stay instate and with policies supportive for Nebraskans, health access is possible. The current changes make health access difficult.

The medical students born and raised in Omaha and Lincoln (and other most metro areas) that increasinly dominate admissions have only 3% choice of family medicine. This means that they not only are unlikely to deliver rural practice, they are also most likely to leave the state. Those from the large rural towns such as Grand Island and Kearney only have 10% family medicine choice as noted in the 2009 UNMC match. The rural Nebraskans maintain 20 - 30% family medicine choice. A decade ago family medicine choice was over 10% for Omaha and Lincoln origins, 20% for large rural towns, and 30% and above for smaller rural origins.

The reason for decline in family medicine is primarily a matter of primary care policy in the nation. First, primary care is not a priority and is squeezed constantly by a design that favors hospital and specialty care. Second, lower and middle income and rural people have difficulty with health access from the financial aspects. The rural hospitals and rural physicians depend upon patients that have financial access to care. The design fails them as it fails most Americans. Third, it is difficult for medical students to trust a permanent primary care choice such as family medicine. They cannot trust that a choice of family medicine will support them, their families, their co-workers delivering most needed health access, or the facilities where they will work.

Nebraska had a solution that worked. It worked in outstanding fashion in the 1970s and 1990s under optimal health policy support for primary care and those left out of the health care design. The design favored family medicine and the patients of family physicians in rural, lower income, and middle income populations. The current US design is a super center design favoring those in zip codes with 200 or more physicians.

Great plains states have few such Super Center zip codes with 200 or more physicians. The western states also lack these zip codes other than the west coast metro areas. Southern states also have very few top concentrations. Most states with any significant rural population need the same solution. 1) medical students that represent the populations left behind 2) family practice graduates 3) training focus on health access 4) policy that supports the people left behind and the primary care most likely to serve those left behind.

Nothing seen in Washington DC yet will address any of these long term needs to establish health access and primary care as a priority. There are no coalitions of elderly, rural, or lower and middle income people, or various businesses or the multiple local and state governments left behind.

What is worse is that the Great Plains states are not telling the nation's leaders that the design still is a poor fit for 65% of the nation's population left behind in rural and urban America. What is worse is that Great Plains children with investments by Great Plains parents and states are bailing out California and other states by supplying school teachers, nurses, and public servants (census migration studies). States need to be self-sufficient, especially the states with the most powerful economic engines in the world.

All of this awareness and more is possible for those who have been privileged to practice as a rural physician for 4 years in the Great Plains and have had 15 years to serve the health access needs of the Great Plains state of Nebraska. It was a chance to learn from the best, to understand how the design fails, and to understand the process that must be entered to work toward most needed health access from Alaska to Hawaii to the East Coast.

The great failure of a super center design is the failure of health access. Super centers are built on the fallacy of cure of disease. If we just know enough or get the right specialist or treatment, we will be cured. Health access will never be cured, as with most of the conditions that people face in their health care. But health access must be constantly addressed. The great models of health access have involved Great Plains models - the Duluth medical school, the MN Rural Physician Associate Program (Verby), rural graduate training efforts, the most successful accelerated programs, the lasting rural preceptorships, Oklahoma's support of family medicine residents and communities in need, Iowa's primary care tracking (Roger Tracy), Wisconsin's (Fred Moscol) community recruitment program and then 3RNet recruitment for most needed health access nationwide, top health access osteopathic schools, and leadership for rural medical education nationwide for decades.

The Great Plains has always been about working together and meeting the needs of others as well as one's own needs. This is a reason that Great Plains states lead in health care quality and cost areas. Focus on children results in quality in education and higher education. The Great Plains must continue to remind the nation about what it most needs to remain a viable nation and people.

Robert C. Bowman, M.D.
North America Co-Editor Rural and Remote Health