toward a community based rural policy: implications for ...• a growing understanding of the true...
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Toward a Community Based Rural Policy:
Implications for Rural Health Care
Presented to theNorthwest Regional Rural Health Conference
January MeetingSpokane, Washington
March 27, 2003
Charles W. Fluharty, DirectorRural Policy Research Institute
http://www.rupri.org
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Five Considerations:I. The case for a rural policy “tipping point”
• The Farm Bill process and outcome• A growing understanding of the true rural economy• The new Census and its public policy implications• Rethinking rural governance
II. Building a constituency for a community-based rural policy:
• New political realities• The policy context• Alternatives for consideration
III. The rural / urban dialecticIV. Linking policy and community practice: “Bring in the
bridge builders!”V. Implications for rural health care
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I. The case for a rural policy “tipping point”
• The Farm Bill process and outcome• A growing understanding of the true rural
economy• The new Census and its public policy
implications• Rethinking rural governance
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1. “Rural” is much more than agriculture; and the future success of our nation’s family farms are critically linked to the economies of rural communities.
• Only 6.3% of rural Americans live on farms.• Farming accounts for only 7.6% of rural
employment. • 90% of rural workers have non-farm jobs.• In 1999, 90% of all farm operator’s household
income came from off-farm sources.
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• Only 0.39% of the US population is engaged in farming as a primary occupation; and
• Only 1.78% of the US rural population is engaged in farming as a primary occupation.
But . . . • In ag dependent counties, or rural areas where
agriculture is the dominant sector, as in most of the Great Plains, we are literally in “crisis”!
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17.7%11.6%$23,371$35,572$201,20658,403Very Large Family Farms
40.4%28.0%$24,011$34,598$85,68577,314Large Family Farms
49.9%36.0%$19,194$26,621$53,322175,370Farming-occupation high sales
100.3%56.3%$22,379$39,892$39,764480,441Farming-occupation low sales
104.8%95.5%$79,982$87,796$83,788931,561Residential / lifestyle
103.3%27.7%$11,254$41,991$40,643297,566Retirement
137.5%61.5%$5,862$13,114$9,534126,920Limited Resource
Small Family Farms
Percent of HH
income from
total off-farm
sources
Percent of HH
income from
earnedoff-farm sources
Avg. earnedoff-farm income
Avg. Off-
Farm Income
Avg. HH Income
Number of
HouseholdsERS Farm Typology
Source: ERS, February 2001
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Farm / Farm Policy Structure:• 2 million farms – 2% produce 50% of food / fiber
• 36% of farms participate in support programs (30% of total farm acreage)
• Between 1996 and 1998:
• $22.9 billion in farm subsidies
• 144,000 participants received 61% of money
• (7.2% of America’s farmers received $13.97 billion)
• The more farm dependant an area is, the more its
economic growth lags the rest of America.
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2. The rural economy has strengthened and is slowly growing, but remains fragile and uneven:• Over 2 million more rural Americans are
employed today than at the start of the last decade.
• Until this downturn, rural unemployment had continued to decline -- lowest level since 1990 recession.
• Rural earnings, after a decade of decline, were rising at rates similar to urban, as was per capita income.
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• In 1996, 23% of rural workers in the service sector• Rural workers are nearly twice as likely to earn the
minimum wage (12% - rural, 7%- urban)• Rural workers remain more likely to be underemployed
and are less likely to improve their employment circumstances over time. (40% less likely to move out of low wage jobs than central city residents)
• In 1999, 27% of rural workers over age 25 received wages that if earned full time, full year, would not lift a family of four above the official poverty line (5 million workers).
But . . .Rural employment is still dominated by low wage industries:
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Distribution of Nonmetro Employment, 1969
Construction5%
Manufacturing21%
TCPU4%
Trade17%
FIRE4%
Services15%
Extractive17%Government
17%
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Distribution of Nonmetro Employment, 1979
Construction5%
Manufacturing20%
TCPU4%Trade
18%
FIRE5%
Services17%
Extractive15%Government
16%
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Distribution of Nonmetro Employment, 1989
Construction5%
Manufacturing18%
TCPU4%
Trade19%
FIRE5%
Services20%
Extractive12%Government
17%
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Distribution of Nonmetro Employment, 1999
Manufacturing15%
TCPU4%
Trade20%
FIRE5%
Services24%
Construction6%
Extractive10%Government
16%
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Between 1990-1996 there was a gain of 2,756,000 jobs in rural America – an increase of 11.3%.
However, between 1990-1996 there was only anegligible change in non-metropolitan job earnings – remaining more or less around $22,493 per year per job. (1996)
In fact, the rural/urban earnings gap persisted and widened in the 1990s (from 73.8 to 70 percent).
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Metro and Nonmetro Employment Change:Percent Change from Previous Year
-1.0%
-0.5%
0.0%
0.5%
1.0%
1.5%
2.0%
2.5%
3.0%
3.5%
1991 1992 1993 1994 1995 1996 1997 1998 1999
Metro Nonmetro
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Therefore:
• Rural incomes remain lower than urban (1997 median: $30K+ - Rural, 39K+ - Urban)
• Rural poor families are more likely to be employed and still poor. (In 1998, 2/3 of poor families had at least one member working at some time during the year; 16% had two or more members working; 29% had one or more full time, full year workers -- a 9% rise since 1996).
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Per Capita Income in the U.S. andin Metro and Nonmetro Areas
(all figures adjusted to 2000 dollars)
-
5,000
10,000
15,000
20,000
25,000
30,000
35,000
1969
1971
1973
1975
1977
1979
1981
1983
1985
1987
1989
1991
1993
1995
1997
1999
U.S.
Metro
Nonmetro
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Farm Income as a Percent of Total Incomein Nonmetro Areas
0.0%
2.0%
4.0%
6.0%
8.0%
10.0%
12.0%
14.0%
1969
1971
1973
1975
1977
1979
1981
1983
1985
1987
1989
1991
1993
1995
1997
1999
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Per Capita Income Gap in 1990:Nonmetro Per Capita Income as a Percent of Metro
78.1
70.480.0
72.781.0
77.3
70.7
86.8
69.2 83.6
85.0
79.2 71.5
73.4
87.9
72.6
71.7
79.6
66.2
87.0
84.4
93.0
73.7
65.7
79.0
88.9
82.6
78.5
76.7
81.2
76.7
83.074.6
76.2
86.6 66.1
76.4
78.5
78.4
85.1
NH: 90.5
VT: 88.1MA: 86.5
RI: 109.1
CT: 83.8
NJ: 0.0 DC: 0.0
DE: 76.4 MD: 74.2
Alaska: 77.2%Over 90 percent
Hawaii: 76.4% 80 to 90 percent75 to 80 percentLess than 75 percent
Note: New Jersey and Washington, D.C. do not have nonmetropolitan areas
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Per Capita Income Gap in 2000:Nonmetro Per Capita Income as a Percent of Metro
77.6
67.679.0
67.1
73.9
75.6
68.4
78.6
67.5 83.3
84.7
73.1 71.0
75.9
84.7
69.9
68.5
76.6
67.5
84.6
74.3
92.4
69.8
63.6
77.1
86.5
82.9
78.7
74.2
76.1
74.9
85.472.1
70.6
80.5 62.6
68.5
79.0
76.4
88.1
NH: 83.2
VT: 86.1MA: 79.6
RI: 117.2
CT: 76.7
NJ: 0.0 DC: 0.0
DE: 66.8 MD: 76.1
Alaska: 74.0%Over 90 percent
Hawaii: 74.6% 80 to 90 percent75 to 80 percentLess than 75 percent
Note: New Jersey and Washington, D.C. do not have nonmetropolitan areas
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Change in the Per Capita Income Gap1990 to 2000
Alaska
HawaiiGap Decreased
Gap Increased
Note: New Jersey and Washington, D.C. do not have nonmetropolitan areas
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3. While the economy of rural America, in general, has improved, persistent pockets of intractable rural poverty remain:• In general, poverty rates are higher in rural than urban areas.
(15.7% rural and 12.6% urban, 1997)• While the rural poverty rate declined by 1 ½% between 1997
and 1998 – still 14.3% [urban 12.3%]. • 7.5 million rural residents live in poverty; an additional 11%
live close to poverty (between 100-150% of poverty) [urban 8%].
• Rural poverty is working poverty -- 2/3 of rural poor live in a family with at least one member working.
• Child poverty is higher in rural areas. (22.7% rural and 19.2% urban, 1997)
• Over half of rural children in female-headed households are in poverty. (3.2 million rural children, 1996.)
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Nonmetro Persistent Poverty CountiesPoverty Rates of 20% or more in 1960, 1970, 1980, 1990 and 2000
Nonmetro Persistent Poverty Counties (361)Source: Economic Research Service, USDA and U.S. Census Bureau2000 Update Prepared and Mapped by RUPRI
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Source: U.S. Census BureauMap Prepared by RUPRI
Nonmetro Counties (459)
Metro Counties (41)
500 Poorest Counties in the U.S., 2000
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4. The 1990’s rural population shifts were very significant:• The 1990’s saw a rural population rebound; which totally
reversed the outmigration of the 1980’s.• 70% of rural counties grew in population from 1990 to
1999.• But, this growth is largely concentrated in only 40% of
rural counties. • 7/8 of these growing counties derived some or all of their
increase from in-migration of metro residents.• 61% of rural counties experienced net in-migration between
1990 and 1999.• In fact, between 1990 and 1999, 2.2 million more
Americans moved from the city to the country, than the reverse.
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• However, rural population increases have steadily dropped since momentarily exceeding urban levels in 1994-95.
• And, all rural counties have turned downward in growth rate since 1995, except commuter counties:– Mining and farming dependent counties had the greatest relative fall-off in
pace of growth.
• In 1998-99, the rural population growth rate was less than half of urban.
• And, the number of rural counties with decreasing population rose from 600 in 1990-95 to 855 in 1995-99.
• Significant rural population declines continue in the Great Plains, and other “disadvantaged” rural areas.
• And, numerous growth counties are experiencing expanding diversity in ethnic / racial composition, with attendant challenges.
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Rural Population Growth• 1990-1999 Population Growth
+ 3.9 million people + 7.6% increase from April 1990 to July 1998.
• Compared to 1980-1989 Population Growth+ 1.3 million people + 2.7% increase
• This entire 1990’s increase is a product of migration:• During 1980’s – annual rural outmovement of 269,000• During 1990’s – average annual inmovement of 242,000
• The fastest growth and migration rates occurred in the South and the West.
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Net inmigration over 3.2% (1036 cos.) Net inmigration up to 3.2% (377 cos.) Net outmigration (892) Metro
Nonmetro net migration, 1990-99
Source : P repa red by Ec onomic Re se a rch S ervic e, USDA, using da ta from the Bure a u of the Ce nsus.
The US average for this period was 3.2 percent.The Nonmetro average for this period was 4.4 percent.
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Figure 1Annual population growth rates for metro counties, nonmetro counties, and the Nation, 1990-99The pace of nonmertro population growth in 1998-99 continues the slowdown that began after 1994-95
0.79
0.911.01
0.961.02
0.8
0.68
0.560.48
1.151.2
1.1
0.990.93 0.95
1.03 1.01 1.01
.0
.2
.4
.6
.8
1.0
1.2
1.4
1990-91 91-92 92-93 93-94 94-95 95-96 96-97 97-98 98-99
Percent
NonmetroMetroU.S. total
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Total Population, 1990
Metro, inside central cities
31%
Metro, outside central cities
46%
Nonmetro23%
Source: U.S. Census Bureau
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Total Population, 2000
Metro, inside central cities
30%Nonmetro
20%
Metro, outside central cities
50%
Source: U.S. Census Bureau
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Total Hispanic Population, 1990
Metro, outside central cities
39%
Metro, inside central cities
51%
Nonmetro10%
Source: U.S. Census Bureau
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Total Hispanic Population, 2000
Nonmetro9%
Metro, inside central cities
46%
Metro, outside central cities
45%
Source: U.S. Census Bureau
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Total Population, 1990 and 2000
-
20,000,000
40,000,000
60,000,000
80,000,000
100,000,000
120,000,000
140,000,000
160,000,000
Metroinside central cities
Metrooutside central cities
Nonmetro
1990
2000
Source: U.S. Census Bureau
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Total Hispanic Population, 1990 and 2000
-
2,000,000
4,000,000
6,000,000
8,000,000
10,000,000
12,000,000
14,000,000
16,000,000
18,000,000
Metroinside central cities
Metrooutside central cities
Nonmetro
1990
2000
Source: U.S. Census Bureau
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Total Population
1990
Hispanic Population
1990
Hispanic Percent
1990U.S. Total 248,709,873 22,354,059 9.0%
Metropolitan Total 192,725,741 20,204,818 10.5%Metroinside central cities 77,843,533 11,514,252 14.8%Metrooutside central cities 114,882,208 8,690,566 7.6%
Nonmetro 55,984,132 2,149,241 3.8%
Total Population
2000
Hispanic Population
2000
Hispanic Percent
2000U.S. Total 281,421,906 35,305,818 12.5%
Metropolitan Total 225,981,679 32,173,942 14.2%Metroinside central cities 85,401,127 16,459,217 19.3%Metrooutside central cities 140,580,552 15,714,725 11.2%
Nonmetro 55,440,227 3,131,876 5.6%
Source: U.S. Census Bureau
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Percent Change
Total Population1990-2000
Percent Change Hispanic
Population1990-2000
U.S. Total 13.2% 57.9%
Metropolitan Total 17.3% 59.2%Metroinside central cities 9.7% 42.9%Metrooutside central cities 22.4% 80.8%
Nonmetro -1.0% 45.7%
Source: U.S. Census Bureau
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Change in Rural & Urban Generations, 1990-2000
Gen X Baby Boomers
9.6%
0.1%
2.4%
12.5%
Urban Counties
Rural Counties
Born Between 1965-75 Born Between 1946-64U.S. Census Bureau
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5. Next, the relationship between federal, state, and local governments and government revenue streams have a major impact on rural areas:
• 2,305 of our nation’s 3,043 counties are rural (76% of counties, 83% of our nation’s land, and 25% of our nation’s population is rural).
• Rural economies are significantly dependent upon federal government transfer payments -- 20% of total personal income in rural America comes from federal transfers to rural community citizens.
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Rural Governance: The Challenge for “Citizen Servants”
• 72% of county governments serve fewer than 50,000 persons.
• 700 of the 3,043 serve fewer than 10,000.
• 90% of the 36,001 sub-county general purpose governmental units serve less than 10,000.
• 82% have populations under 5,000.
• 51% serve less than 1,000.
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6. Health care, education, workforce, and welfare reform remain critical rural issues:• Education:
– Recent rural high school graduation rates match or exceed urban rates.– Rural dropout rates have fallen sharply in recent years,
• But --– Rural out-migration remains largely our youngest and most highly
educated:“Rural America’s most important export remains our best and our brightest.”
– So, fewer young adults in rural areas seek post secondary education; have college degrees; and more have no high school diplomas (23.5% rural and 17.4% urban, 1997).
• Yet, --– Rural schools represented 22% of all public schools in 1997, but:
• Only received 12.5% of federal funding• 14% of all state funding• 11% of all local funding
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• Health:– 22 million rural residents live in federally-designed Health
Professions Shortage Areas, or Medically Underserved Areas, and
– Rural residents tend to have poorer health care access; lower health insurance coverage, and little or no managed care availability.
• Welfare Reform: In 1996, –21% of our nation’s welfare population was rural.–15 states had more than 50% of their welfare
population living in rural areas.– Caseloads have declined, but:
–Working age poverty hasn’t (1992-1997):Central cities 7% decline – 22 to 20%Suburbs 10% decline – 10 to 9%Rural Unchanged – 17%
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II. The potential to exploit these realities, in building a constituency for crafting a community based rural policy:• New political realities• The policy context• Alternatives for consideration
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The New Political Realities• Suburbanization of the American public policy arena
– 1990 Census– 1992 Presidential Election– The 25/25/50 rule– 2000 Census – The Congressional reality
• Devolution: “To” the states, or “through” the states?– Current downturn has changed much, but . . . – 31 states have cut taxes since 1996– Since 1990, state and local government expenditures up 15%,
in real terms– Nearly $50 billion in current state budget deficits– Federal workforce reduced by 345,000 since 1990– State and local government workforce expanded by nearly 2
million in same period
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The Rural Congressional Snapshot• 1966 – Rural Majority in 181 House Districts (42%)
1993 – Rural Majority in 77 House Districts (18%)Congressional Quarterly (60%) – 57 Districts (13%)
• Today, only thirteen states have a rural majority. These states represent 59 electoral votes. (Only 5 more than California, which is only 3% rural.)
• 1993 CRS study (1990 Census data):– No rural district in top 100 family median income
districts.– Only two rural districts in top 200 family median
income districts.– Most rural districts were in the bottom 100.
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The Challenge of a National Rural Policy: Five Key Components
• Believable problem articulation
• National voice
• Coalition consensus
• Sustained, integrative implementation strategy
• Visionary leadership - AARP!
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Why a National Rural Policy is So Difficult to Achieve• “Rural” remains synonymous with “agriculture”• A constituency has not been organized
– Many sector-level constituencies• Congressional and Administration programs
remain fragmented.– No one Congressional Committee or Administrative
Department with overall responsibility for rural policy and rural program integration
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The “Policy” Component of Rural Policy• What?
– Integrative national rural policy• Global examples
– National sector-level rural policy• Department initiatives• Congressional initiatives• Philanthropic initiatives• Private sector initiatives
– Integrative state rural policy• Governor’s initiatives• Legislative initiatives• Public / private sector initiatives• Philanthropic initiatives
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The “Policy” Component of Rural Policy• Who?
– “Change agents” for a “new rural reality?”• President• Congress• Colleges / Universities• Governors• State Legislatures• Philanthropic community• Private sector
– Building a constituency for action
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Hopeful Developments of Possible Consequence:– Congressional Rural Caucus – Presidential Letter– National Rural Network:
• New rural mission areas in many NGOs
– Farm Bill Rural Development Title– HHS Secretary’s Rural Initiative– State-level policy efforts– Emergent, new rural leadership:
• Expanding leadership role for women
– Kansas City Fed – Center for the Study of Rural America– Expanding philanthropic interest in rural portfolio– Rural “new governance”: public / private / philanthropic
collaborations– State Rural Development Councils
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III. The Rural / Urban Dialectic
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“Dialectic: n. Any systematic reasoning, exposition, or argument that juxtaposes opposed or contradictory ideas and usually seeks to resolve their conflict.”
-Webster’s Ninth New Collegiate Dictionary
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The Policy Differential
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Four Considerations of This Differential:
• Rural Housing• Poverty Rates in Female-Headed
Households• Rural Youth Substance Abuse• PROWA
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Housing Conditions:Rural vs. Urban
0
5
10
15
20
Non-poor
Rural
Non-poor
Urban
PoorRural
PoorUrban
CrowdedInadequate
Source: ERS, USDA. 1995.
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Poverty Rates among Female-Headed Families with Children
25
30
35
40
45
50
55
60
65
1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999
NonmetroMetro
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Rural Youth / Substance AbuseIn 1999:• Rural eighth graders were 32% more likely to have used
marijuana in the past month than those in large metro areas. • Rural eighth graders were 52% more likely to have used cocaine
in the past year than those in large metro areas. • Rural eighth graders were 75% more likely to have used crack
cocaine in the past year than those in large metro areas.• Rural eighth graders were 104% more likely to have used
amphetamines, including methamphetamines, in the past month than those in large metro areas.
• Rural eighth graders were 29% more likely to have used alcohol in the past month than those in large metro areas.
• Rural eighth graders were twice as likely to have smoked cigarettes in the past month than those in large metro areas.
The National Center on Addiction and Substance Abuse at Columbia University (CASA). 2000. No Place to Hide: Substance Abuse in Mid-Size Cities and Rural America. JAN 2000, Columbia University. New York, NY: Columbia University.
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PRWORA’s Labor Market Assumptions:
The labor market can absorb workers
workers and jobs)transitioning from welfare (Match between
Workers can earn enough to sustain their families
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Selected Economic Characteristics of Metro and Nonmetro Areas
Metro NonmetroUnemployment Rate, 1999
4.2 4.4
Employment Change, 1995-99
1.9 0.9
Average weekly earnings, 1999
610 485
Poverty Rate, 1998 12.3 14.3
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Characteristics of Distressed Rural Areas
· Small populations· Large minority populations· Remote from urban areas· Low human capital levels
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Average Weekly Earnings, 1999(dollars)
213
367485
610
0100
200300400500
600700
Metro Nonmetro Nonmetro Lessthan High
School
Nonmetro LTHSWomen
Calculated by ERS using data from the Current Population Survey
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Share of Less-Educated Workers in “Good-Paying” Occupations, 1999(percent)
6.613.5
32.2
44.3
30.429
05
101520253035404550
Metro Nonmetro NonmetMen
NonmetBlack Men
NonmetWomen
NonmetBlack
Women
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Highest Level of Adult Education Attainment, 2001
No High School High School Some College, Assoicate Bachelor Degree
25%
37%
17%
8%
14%
20%
29%
19%
7%
24%
Degree Degree But No Degree or HigherDegree
Nonmetropolitan Metropolitan
U.S. Census Bureau: Current Population Survey, March 2001
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Welfare, Work and Poverty in Urban and Rural Areas:Implications for Reauthorization
Bruce A. WeberOregon State University and
Rural Policy Research Institute
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Does Place Matter in Welfare Reauthorization?• Some research finds metro/nonmetro
differences in welfare reform outcomes; other research does not.
• Is this because the metro/nonmetro classification is too aggregated?
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Between 1992 and 1998, single mothers in central cities and remote rural areas had:
• lower earnings growth, • more persistent poverty, and• more persistent welfare receipt
– Findings from a forthcoming Brookings / RUPRI study
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The percent of single mothers with earnings increased across the urban-rural continuum
Figure 13. Single Mothers Reporting Earnings, by Residence: 1992 and 1998
0
10
20
30
40
50
60
70
80
90
100
central city balance of metro nonmetro adjacentcounties
nonmetro nonadjacentcounties
Place of residence
Perc
ent (
%) r
epor
ting
earn
ings
1992 1998
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But single mother median earnings did not increase in central cities and remote rural counties
Figure 14. Median Earnings of Single Mothers, by Residence: 1992 and 1998
0
5000
10000
15000
20000
25000
central city balance of metro nonmetro adjacentcounties
nonmetro nonadjacentcounties
Place of residence
Ann
ual E
arni
ngs
(US$
)
1992 1998
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And single mother poverty rates went down least in central cities and remote rural counties
Figure 15. Poverty Among Single Mother Families, by Residence: 1992 and 1998
0
10
20
30
40
50
60
central city balance of metro nonmetro adjacent counties nonmetro nonadjacentcounties
Place of residence
Perc
ent (
%) b
elow
low
-inco
me
leve
l
1992
1998
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Poverty is most persistent in central counties and remote rural counties
Figure 11. Poverty Duration, Single Mothers by Residence: 1993 to 1998
0
5
10
15
20
25
central metrocounties
fringe metrocounties
other metrocounties
nonmetro adjacentcounties
nonmetrononadjacent
countiesPlace of residence
Perc
ent (
%) p
oor
1 to 2 years3 to 4 years5 years
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Welfare receipt is most persistent in central counties and remote rural counties
Figure 10. Public Assistance Duration, Single Mothers by Residence: 1993 to 1998
0
5
10
15
20
25
central metrocounties
fringe metrocounties
other metrocounties
nonmetro adjacentcounties
nonmetrononadjacent
countiesPlace of residence
Perc
ent (
%) r
epor
ting
publ
ic a
ssis
tanc
e re
ceip
t
1 to 2 years3 to 4 years5 years
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IV. Linking policy and community practice: “Bring in the bridge builders!”
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Building a new “rural pragmatism”
or . . . .
“So, if we all care so muchabout rural America,
Why is she in such bad shape?”
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Three Questions, for your Consideration:• Given our suburban policy context and the
public’s misperception of our current rural realities, where do rural constituencies turn for support?
• Is the historic rural / ag family fight really helpful to either sibling?
• Is it possible that central city and rural residents may have more uniting them than dividing them?
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“Would you tell me please, which way I ought to go from here?” said Alice.
“That depends a good deal on where you want to get,” said the cat.
“I don’t much care where,” said Alice.“Then it doesn’t matter much which way you
go,” said the cat.- Lewis Carroll
Alice in Wonderland
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Community Policy and Constituency Convergence:
Toward a Place-Based Policy:“Why Cities Matter . . .”
The Brookings Institution
Community ConnectionsDoug Nelson, PresidentThe Annie E. Casey Foundation
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“No snowflake in an avalancheever feels responsible!”
- Stanislaus Lezcynski
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“The poet is the joiner, he sees how they join.”
- Walt Whitman, 1855
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The OECD Framework:
• Sector to Place• Subsidy to Regional Competitiveness• A Governance Structure to Accomplish
Both
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Toward a Rural Renaissance: Building a New Institutional Framework for Rural Economic Development:
• Regional Collaborations• Jurisdictional Realignments• Optimizing the “Public / Private” Moment• The Critical Role of Health Care
– Is this a “bridge too far”?
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Implications for Rural Health Care
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National Non-Health Policy Issues with Critical Rural Differential Impact:
– The Census Results / Redistricting – Workforce Investment Act Reauthorization – PRWORA reauthorization– Telecom Act– Rural Equity and Venture Capital Formation– Rural Entrepreneurship:
• Private• Public
– Farm Bill Reauthorization– Higher Education Title
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Trends Critical to Rural Areas: All Health Sector Related• Technological Change• Globalization• Localization• Rural Migration• Aging and Lifetime Learning• Settlement Patterns• Devolution and New Governance• Decentralized Public Sector Decision
Making
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Five Critical Rural Health Developments• HHS Secretary’s Rural Initiative• Recession / State Funding Challenges• Workforce / WIA Reauthorization• Welfare Reform Reauthorization • Medicaid / Medicare Reform
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The Critical Importance of Building Rural Public and Private Entrepreneurship!
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Redefining the Public Metaphor and Rhetoric Regarding Rural America!
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HHS Rural Task Force
“This internal HHS Rural Task Force will examine how existing program serve rural communities; will consider the impact of the HHS funding on rural economies; and will make recommendations to improve health care and social services to rural America. . .”
Federal Register; August 29, 2001
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“Why not go out on a limb? That’s where the fruit is”.
Will Rogers
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“The question is not what you look at, but what you see.”
-Henry David Thoreau