Rural Hospitals Not Offering Obstetric Care
A growing trend has healthcare professionals and communities concerned.
The NYT has a depressing report titled “Rural Hospitals Are Shuttering Their Maternity Units.” As is often the case, it begins with a longish anecdote that’s suffused into the later reporting. That’s particularly frustrating here, as it surrounds an Indian reservation, which is a rather distinct situation. Regardless, there’s enough data in the story to demonstrate that it’s truly a national phenomenon.
Astria Toppenish Hospital is one of a string of providers across the nation that have stopped providing labor and delivery care in an effort to control costs — even as maternal deaths increase at alarming rates in the United States, and as more women develop complications that can be life-threatening.
The closure in Toppenish mirrors national trends as financially strained hospitals come to a harsh conclusion: Childbirth doesn’t pay, at least not in low-income communities.
From 2015 to 2019, there were at least 89 obstetric unit closures in rural hospitals across the country. By 2020, about half of rural community hospitals did not provide obstetrics care, according to the American Hospital Association.
In the past year, the closures appear to have accelerated, as hospitals from Maine to California have jettisoned maternity units, mostly in rural areas where the population has dwindled and the number of births has declined.
A study of hospital administrators carried out before the pandemic found that 20 percent of them said they did not expect to be providing labor and delivery services in five years’ time.
Obviously, this is a huge problem, in that, unlike urban and suburban areas, there is likely to be only one hospital. So, if it doesn’t provide obstetric care, there is no obstetric care.
Women in rural areas face a higher risk of pregnancy-related complications, according to a study by the Commonwealth Fund. Those living in so-called maternity care deserts are three times as likely to die during pregnancy and the critical year afterward as those who are closer to care, according to a study of mothers in Louisiana.
Ambulances aren’t reliable in many rural areas like the Yakama reservation, which spreads over a million acres. There aren’t many emergency vehicles, and the vast distances make for long waits. In the fall and winter, dense fog often blankets the roads, making driving treacherous.
The lack of ambulances, of course, impacts all emergent care, not just maternity.
Not shockingly, the closing of maternity wards is tied to another phenomenon: the rise of large hospital chains.
In Toppenish, the frustration and fear erupted at a recent city council meeting, which drew such a large crowd that it spilled into the hallway outside the chambers. Astria, a health care system based in Washington State, had committed to keeping certain services, including labor and delivery, available for at least a decade after acquiring the hospital, residents noted.
Now the hospital said it could not afford to do so, and the state has taken no action.
Indeed, even in the very affluent DC suburbs of Northern Virginia, a large chain, Inova, runs most of the hospitals. There are, thankfully, a lot of them and they’re by and large quite good. But, even here, only a handful of them provide obstetric care. When my two girls were born, in 2008 and 2011, we had to drive past the Anova Mount Vernon Hospital which was less than two miles from the house to the Inova Alexandria Hospital, which was a 30-60 minute drive, depending on traffic conditions. Indeed, the Mount Vernon facility did no obstetric or pediatric care at all, so we had to do that drive many times during the course of the pregnancy and afterward.
Still, I presume the Mount Vernon facility or one of the many others in the area would have been able to do obstetric or pediatric care in an emergency. In rural areas, there are often no other facilities.
Also not shockingly, poor and minority communities are most impacted:
The United States is already the most dangerous developed country in the world for women to give birth, with a maternal mortality rate of 23.8 per 100,000 live births — or more than one death for every 5,000 live deliveries.
Recent figures show that the problems are particularly acute in minority communities and especially among Native American women, whose risk of dying of pregnancy-related complications is three times as high as that of white women. Their babies are almost twice as likely to die during the first year of life as white babies.
Women of color are more likely to live in maternity care deserts or in communities with limited access to care. According to the March of Dimes, the maternal health nonprofit, seven million women of childbearing age reside in counties where there is no hospital-based obstetric care, no birthing center, no obstetrician-gynecologist and no certified nurse midwife, or where those services are at least a 30-minute drive away.
The closure of an obstetrics unit often begins a downward health spiral in remote communities. Without ready access to obstetricians, prenatal care and critical postpartum checkups, risky complications become more likely.
I’m generally leery of international comparisons of this sort, simply because the United States is sui generis. We’re a continental nation with a very low population density compared to most OECD nations. Offhand, Australia is the only country that’s even remotely analogous.
Still, our healthcare system is a mess: a mishmash of private providers who are compensated via various private insurance programs, government subsidies, and folks expected to pay out of pocket. And we’re also incredibly litigious. So, from a business standpoint, it really makes no sense to offer rural care at all, let alone a type that’s fraught with risk.
[R]unning a labor and delivery unit is expensive, said Katy Kozhimannil, director of the University of Minnesota Rural Health Research Center. The facility must be staffed 24 hours a day, seven days a week, with a team of specialized nurses and backup services, including pediatrics and anesthesia.
“You have to be ready to have a baby any time,” Dr. Kozhimannil said.
Staffing shortages have driven costs up, and hospitals have been forced to bring in contract nurses, who can cost more than three times as much as a staff nurse. Labor and delivery nurses are in high demand, and pay for them can be even higher.
A vast majority of pregnant patients at Astria Toppenish had insurance coverage, but mostly Medicaid, which pays hospitals far less than private insurance plans do. Half of pregnant women in the United States are on Medicaid, and it pays poorly in all states.
In Washington State, Medicaid would pay $6,344 for a childbirth, about one-third of the $18,193 paid by private plans, according to an analysis by the Health Care Cost Institute that compared traditional fee-for-service rates paid by Medicaid with those paid by private plans.
In wealthier communities, private insurance helps offset low Medicaid payments to hospitals. But in rural areas where poverty is more entrenched, there are too few privately insured patients.
Naturally, what applies to obstetrics applies to a large extent to hospital care, period.
Many residents fear the obstetrics closure is a prelude to the hospital closing its doors altogether in a repeat of what happened in 2019, when the Astria Health system declared bankruptcy and later closed the largest of its three hospitals, a 150-bed facility in Yakima. Astria had purchased the hospital just two years earlier.
It’s almost as though running a healthcare system on a for-profit basis is a bad idea.
Their maternal mortality rate is a quarter of ours.
(Also “Anova” should be “Inova.”) [Fixed -jhj]
I have been part of the lead team taking over failing rural hospitals and my network has built several new hospitals in rural areas. None of them had OB services when we took over and we didnt offer them in our new places. They are major money losers. There are not enough deliveries to cover an Obstetricians salary and not enough surgical cases to offset the lack of OB. You need to have specialty nurses who will mostly not do OB since there isn’t enough work. You need an OR team and a pediatrician on call 24/7 and you will mostly be paying them to do nothing.
All of that and a lot of it is Medicaid which pays poorly or inconsistently. In PA it pays the hospital fairly well but physician fees are low. So hospitals that have large OB units and already have an OB doc and OR team in house do OK since they have fixed costs anyway.
“Still, I presume the Mount Vernon facility or one of the many others in the area would have been able to do obstetric or pediatric care in an emergency. ”
Probably not, or not well.
Steve
Rural areas are rural because they have no market for anything.
They have no market for groceries, clothing, services or anything really because the population density doesn’t make any business make much sense and this grows more true every year as technology allows people to shop remotely, bypassing what few businesses remain.
Which is why everything rural needs to be subsidized. The tax base rarely is sufficient to even pay for the roads or power lines or emergency services they consume.
And on top of this, health care isn’t a market good; Health care is the one thing no one wants, but will pay for regardless.
All of which is to say that delivering health care for any area via the marketplace is crazy, and doubly so for rural areas.
While healthcare in the US is sui generus in some respects, the most important way in which we differ is how we pay for it as a country. Healthcare reimbursement in the US is broken, perhaps beyond repair. It literally makes no sense. My company spends nearly $20K a year for any covered employee with a family, and yet the employees pay thousands more themselves. A significant portion of this expense is the bizarre two step tax system we have in health care, where people with private (usually, employer provided) healthcare subsidize those without healthcare or those whose government provided insurance pays out less than the cost of care. This uninsured or under insured makes up the majority of patients in many, many systems across the country. Roughly half the population either have no insurance or are covered by Medicare, Medicaid or the Military medical. In Florida, less than 40% of the population is covered by private insurance. (You probably won’t be surprised to find out which states have the smallest percentage of people covered by private insurance. Go Big Red!)
Why do the private insurance companies agree to pay for everyone else too? Because they are a cost plus system. The more they spend, the more they make.
For-profit healthcare advocates: “I never thought the leopards would eat my face!
Do you really think medical care in even the capitol of a rural province is better with government health care?
Here’s a guy’s experience of having a heart attack in Newfoundland. He did get the dye test weeks faster but mostly because he had Youtube clout. In the US, that happens in the first two hours of the heart attack. But, the stay in the ICU was going to be “free” while he waited.
I recall some years ago local news stories about an absence of OB-GYN doctors in Dayton OH, which is hardly the sticks. Yet somehow births continued. Once upon a time GPs routinely delivered babies. Are modern Primary Care doctors not able to handle the majority of births?
@JKB: Anecdata.
@JKB:
Why yes, because the free market is soooo perfect. You know like that time I broke my neck, got approved for surgery and then on the eve of surgery it was cancelled because MY insurance (Aetna) found out that I was also covered under MY PARTNERS insurance (BCBS). They wrangled for a month while I was left in increasing pain and lost feeling in my right arm and left leg.
In the end my insurance said they were going to pay, I had the surgery, and then Aetna denied all the claims post surgery and made BCBS pay for it all. I spent a year in medical billing hell thinking I owed half a million for my neck.
I would gleefully flamethower insurance company executives. For everyone if your “EH socialist medicine is evilllllll” whines there are thousands of financial ruined or dead people here.
@JKB:
It is objectively and measurably so. We see it in access to care, cost of care, quality of care, positive care outcomes, national average lifespans, and so on. There can be no reasonable doubt about it.
Americans are conditioned to accept terrible things nobody in any other advanced nation would accept. The ridiculously expensive and inefficient way we pay for medical care is just one.
Hmmm, a lack of hospitals in the middle of nowhere where no one lives? Sam Kinison had some advice related to this. To paraphrase, (without the screaming), move to where the hospitals are. A lack of rural hospitals? In a for-profit system? No shit. There’s also a lack of fine dining establishments for the identical reason: there’s no money in it.
Rural America continuously votes against its own best interests because they let themselves be distracted by race-baiting and queer-baiting and abortion-banning and all the other Fox News crap that turns them against the only goddamn people in this country who give a single shit about them: liberals. Left to the GOP good old Jim Bob would also have no roads, no schools, no price supports and no money coming in from Social Security and Medicare and Medicaid and all the other liberal programs that keep these ungrateful, self-harming nitwits alive.
The Republican Party has worked tirelessly to screw Americans in the inner cities and they are then shocked! amazed! that the same policies they back in hopes of screwing Black people and Hispanic people also happen to screw the goobers in Asscrack, Arkansas.
I don’t care. Sorry, but there are people all over this country who genuinely need help and who don’t demand for themselves what they would deny to people with a different skin color or sexual orientation or religion.
@JKB:
It happens if you happen to be located in an urban / suburban setting with quick access to a health care facility. If you, like the folks this piece speaks to, live out in the MOFN and have to travel a significant distance to obtain health care – not so much …
Imagine, for example, someone living in Paducah, TX. Your closest hospital of any sort of nearly there is some 50 or so miles away. If you’re unlucky enough to need a trauma center, even a level IV is 125 miles away.
In my heart, I think we could reverse this hollowing out of rural areas with a combination of good Internet access and reasonable delivery systems. Amazon Prime manages to deliver stuff to the remotest areas of Canada, for instance.
This is a political economy problem though. Democrats aren’t focused on doing this, because that’s not where their current constituency is. Republicans aren’t focused on it because they want lower taxes and smaller government, and changing things around is going to take some government intervention.
The exact right thing to do is going to be tricky to work out, probably. And so no politician is interested in that kind of risk. The rural dwellers themselves can often – but not always, please let’s don’t be binary – be part of the problem with their “there’s so much crime in the city” fears. Of course, that’s also media-driven.
@HarvardLaw92:
Also the distance traveled by first responders. Here in Colorado, in most of the Front Range urban corridor an ambulance and personnel arrive within 10 minutes of the call reaching 911. Most cities try for better than that. In more rural parts of the state, the time may be 40 minutes or longer. At least statistically, the difference is clear. Things like heart attacks, strokes, serious falls, automobile accidents, etc, etc, are more likely to be fatal events in the rural areas simply because of those delays.
Hm. OB/GYN deserts, food deserts, pharmacy deserts, banking deserts… When exactly did America become Arrakis?
BTW, capitol denotes the building or group of buildings where a legislature meets or the state government performs its main functions. I don’t think they provide much medical care, and they wouldn’t be my first choice to look for any.
In my state of Texas, this will only be exacerbated by a shortage of physicians and nurses willing to work in OB/GYN in a state where their every action and reaction to a potential lawsuit under the 3rd party anti-abortion law.
And also note that several of the largest regional / national hospital chains are nominally Catholic and severely restrict the types of pregnancy-related care that can be provided. Even if the rural community hospital stays open after being acquired, it is reasonably probably that the new owner is imposing Catholic principles on all of its service area.
@Gromitt Gunn: Example: https://www.texastribune.org/2023/01/05/jasper-east-texas-maternity-crisis/
Part of this is also caused by increasing specialization. If you go back in time to when rural areas were doing better, you will also find that medicine as a whole was smaller.
Patient outcomes were worse than they are now, but better than outcomes without access to medical care. Half a loaf is better than no loaf, after all.
All of which is a lead up to this: we should start letting veterinarians practice medicine in rural communities. There’s a lot of medicine being practiced in rural areas, it just happens to be being performed on animals. Well, people are animals too.
You might be thinking that this is a terrible plan, and you would be right. But it’s a plan, which is more than either party has for rural America.
(I would also accept a plan focused on revitalizing the smaller cities, so there’s enough of a population base that services make economic sense)
@Michael Reynolds:..Sam Kinison…
I’ve been on the Needles Highway where Sam Kinison was killed by a drunken driver, 17-year-old Troy Pierson. It’s one of two roads that I know of that enter California from Nevada where there is no California Department of Food and Agriculture Division of Plant Health & Pest Prevention Services Border Protection Station.
IT’S IN THE FUCKIN’ DESERT!
Per WikiP:
This kid killed a man.
@Michael Reynolds: “Asscrack, Arkansas.”
That is absolute poetry. Assonance, alliteration, and dripping disdain in five syllables.
@Chip Daniels:
An overlooked issue is farm consolidation:
Cropland has shifted to larger farms over the last three decades
If you go from a hundred 200-acre farms to ten 2,000-acre farms, the area is going to get even more rural as the number of people needed to run farms drops.
The US healthcare system is objectively worse on virtually every measured value. While we do as good as most European countries in outcome for those treated, we greatly exceed them in the number of people who have no access to treatment and therefore have worse overall outcomes. And of course our cost per service are multiples of Europes and the amount of time people spend dealing with billing and insurers are orders of magnitude greater . So I’m always curious about the people who come in here all trumpy and start blithering on about Canada or the UK. Are they really that ignorant? Or are they just on Medicare or Medicaid and therefore are used to a more efficient system?
It’s not just rural hospitals–this was in Atlanta last year:
The sudden closure announcement of Atlanta Medical Center (AMC), a busy downtown hospital with one of the city’s only two Level I trauma centers, is just the latest manifestation of a terrible reality: Too many hospitals are worth more dead than alive. AMC, a 120-year-old hospital, loses tens of millions of dollars treating tens of thousands of disproportionately low-income patients per year, but it sits on hundreds of thousands of square feet of glorious real estate in one of Atlanta’s most walkable neighborhoods. A county commissioner estimates the land alone is worth at least $100 million; if a three-bedroom luxury townhouse a block away from the hospital commands anything approaching its $1.8 million asking price, it could be much more.
It’s simple finance. Medicaid keeps costs down, so the ROI is better after you do the work to chop up the asset. Healthcare is not considered a public good, so it’s no different than turning an old warehouse into a loft.
@DAllenABQ: Haha, great analysis of his casually concise comment!
This has been going on for years, maybe even decades. I feel like this isn’t even the first time the NYT has run this type of piece.
It’s precisely this sort of thing happening that makes the whole “healthcare for profit” model incredibly weird. You’re always going to have some people who live in rural areas, and presumably some of those people will have babies.
The “everyone pick up and move” isn’t going to be the solution, for a bunch of reasons including expense (qualifications for jobs available in cities, leaving support systems/families, housing availability…there are a bunch of reasons that moving might not be an option).
Healthcare needs an overhaul.
@Beth: Sure. But as long as JKB is not the one suffering in pain in the hospital, how important is that suffering in the bigger picture? “Better a thousand innocent men get executed than for one guilty man to escape the gallows” isn’t just about capital punishment. Conservatives have variations on the same axiom for every social issue.
@Michael Reynolds: And once again, you move in with the “appeal to the moderates:” Fwk those hicks. They should know better than to get pregnant if there’s no hospital.
We essentially dont ha ve GPs anymore but we do have Family Practice people. Some are comfortable doing deliveries but many are not. Many dont want the extra call time and liability. But, even if you have FP people willing to deliver you need everyone else. You will need a minimum of 2 nurses comfortable with OB available 24/7. A pediatrician comfortable with newborns. You need 2 OR teams available if you want to be able to do a C-section at the sam time you are doing other surgery. You need a general surgeon comfortable doing a section. (Probably 2 since it is likely a general surgeon doing the other case.) You need 2 anesthesia people on call every night. So IOW your entire OR team, assuming you are a typical rural place with 2 ORs on call every night.
What really happens is that existing rural places cut corners and hope they never have concurrent emergencies. If they get into a major bleed they hope they can control it well enough to put the pt in a chopper and send to a major center. In order to give pts their best outcome you really want deliveries done in large centers where people do lots of deliveries so they are good at it. They have a high level blood bank and specialty staff who can help when needed like Onco-GYN or a trauma/vascular surgeon. Where you have a real NICU so you arent transporting so many kids out. You just arent going to achieve that in rural settings. No matter what you do outcomes will always be worse in a rural setting. Its more expensive to bring care to the rural area than to bring there pt to the high level care. I honestly dont know which is lower risk for Mom and Baby.
This goes well beyond OB also. All higher level care is further away. Its why your risk of early death is higher in rural areas than in cities. Homicides might be higher in the big cities but accidental deaths much higher in rural areas since it takes longer to get care. Also quality of care is a consistent issue in rural areas (poor urban areas also). Many of the staff are as good as you find anywhere, but staff who have failed elsewhere eventually migrate to rural area/small town hospitals who are desperate so will tolerate more aberrant behavior and/or a lower level of competence.
Steve
@Mister Bluster:
I did not know that, and I feel bad because I assumed it was Kinison at fault. Not the wildest assumption given that the man did consume a lot of mood altering substances. But still.
@DAllenABQ:
Thank you, I do occasionally try.
@Just nutha ignint cracker:
I’m not a Christian, I’m not required to love those who hate me. Are they not pampered enough? Do rural states not have disproportionate power in government? Are they the ones paying the bills, or are they taking while refusing to give? These are the people who defiled the White House and attacked the Capitol, and now I’m supposed to mail them a check to buy a maternity ward? People make political choices.
And as for the message, I am not a DNC spokesman.
@Michael Reynolds: Again, thank you for your contribution to allowing us to hear what “reaching out to the moderates” sounds like. Go in peace, serving whomever you will.
@Michael Reynolds:
I was today years old when I learned Kinison didn’t die from a drug overdose.
@steve:
Well, the reported murder rate, anyways…
— Arthur Conan Doyle, “The Adventure of the Copper Beeches”
@Michael Reynolds:
I don’t think most liberals give a shit about them.
Anyway, I think this is a lazy cop-out line of thinking. Neither party has done a damn thing for them, so they vote for the ones that have less open disdain for them.
Democrats offer a marginally slower decline of rural America, while Republicans offer the opportunity to eat their seed corn. Neither option is good, but one feels better right now.
@Stormy Dragon makes a very important point — fewer people are needed in rural America to support agriculture.
(Digression: There’s a lot to that, but a big part is that agriculture is often a low profit, relatively high risk endeavor, funded through borrowing with the hope being that you come out a bit better than even after the harvest — larger farms can buffer the risks better, especially if they are a multi-state conglomerate).
I think that Stormy’s point is part of a larger problem — a consolidation of the country’s economic activity into a few metropolises. Small cities have less reason to exist, and people have fewer reasons to live there, and they are losing the critical mass that enables a lot of services. And the small cities have always been the anchor for their surrounding rural areas.
The economy is creating lots of jobs, but we don’t need more jobs in Seattle*, we need them in Centralia, Yakama and places like that. And Idaho, I guess.
Build up the small cities and you have hospitals that provide services. Maybe even a fire department here and there.
Also, Seattle is full. Rent is crazy**. Homelessness is increasing. We are creating problems both where people are fleeing from for economic opportunity, and where they are fleeing to.
If we have a Democratic Party that has a plausible plan for shifting the balance of the growth to support small cities, and rural Americans vote against that, then I would accept the “voting against their own interest” arguments, but right now? No one is even representing their interest.
(My inner neo-liberal wants to adjust payroll taxes, so jobs in offices in the major cities are just more expensive for employers than small cities, and hope the market figures it out, but I suspect we need a more active plan)
——
*: Obviously we need to create one more job in Seattle, something that makes me want to bother working. Donut taster? Ocelot ocellator?
**: Many, many rentals in the US are pricing through an automated service that is effectively price fixing, so it’s not just that Seattle is full that makes rents insane. But it’s definitely part of it.
@Mikey: I think I’ve learned that Kinison didn’t die of a drug overdose about a dozen times by now. The information doesn’t stick, because it is so far from my expectations.
I suspect this happens with more important things as well, for nearly everyone. You believe what you want to believe far more readily than something that challenges your expectations.
@Chip Daniels: I am a lefty who believes that access to health care is both a right and a prerequisite for a civilized society.
That said, I am having less than no interest right now in subsidizing health care or roads or jobs or anything else for a rural America who (a) vote overwhelmingly to create the very situation they are in, (b) is unwilling to accommodate the needs for anybody but themselves and (c) are especially unpleasant about (c). They made their bed and I hope it is comfy.
@Gustopher:
I don’t know if you mean a different Centralia, but as someone from Pennsylvania, I don’t think you realize how “we need more people in Centralia” comes across XD
(For those not familiar, Centralia is an infamous town in Pennsylvania that been completely abandoned for decades because the coal mine under the town has been on fire for 60 years now.
It’s literally the RL version of Silent Hill).
@Jay: Do the poor cause many of their own problems? Sure. But so do the rich. We all do, all the time. The difference is that the poor don’t have a cushion on which to land. When they hit the ground it breaks bones. They get badly hurt, as do their children, their spouses, their communities. So yes, the problems we inflict on ourselves and our loved ones are more apparent and visible in the poor white communities of Appalachia, or the poor black communities of West Baltimore, or any one of the hundreds of thousands of tough neighborhoods all over the world. If we only try to improve the lot of the wise and virtuous, well, that would be easy now, wouldn’t it? Slam the doors on the sinners and those left inside will be, on average, that much more virtuous.
Or will they?
@Stormy Dragon: Centralia, WA is a fine small city between Olympia and Portland, OR, where there used to be a great tamale place.
Every time I went to Portland, I would pick up a bunch of tamales on the way back. Then the tamale place closed and I figured there was no point in going to Portland.
Centralia, WA needs to be built up enough that it can support a tamale place.
@Stormy Dragon:
My how times have changed. 🙁
@Stormy Dragon: There’s a Centralia in Washington that shares a city limits boundary with Chehalis–a perennial on the 10 poorest town in Washington State list.
@Gustopher:
@Just nutha ignint cracker:
That certainly sounds like a better candidate for expansion then the unstoppable mine fire. =)
@Gustopher: “Democrats offer a marginally slower decline of rural America, while Republicans offer the opportunity to eat their seed corn. Neither option is good, but one feels better right now. ”
Democrats are trying to help, and the GOP is fighting against it.
@MarkedMan: The difference between West Baltimore and Appalachia is that the former is willing to form a coalition with me where we consider each others’ interests. Indeed, one could credibly say that the blacks in Baltimore prioritize my concerns with their votes even more than I do for them, for better or worse. On the other hand, the Appalachians simultaneously crap over my concerns pretty much universally while *simultaneously* demanding that they be allowed to put their hands in my pocket and that I allow people to shoot up suburban schools at will just so they can indulge their gun fetishes.
I’m done with all that. I’m happy to vote for things that make our country better and if things that help the country also help rurals I am all for it. But prioritizing rural concerns specially? No. I’m done, at least until they give a little in return.
As a general rule, when Republican governors chose not to expand Medicaid, they were choosing to watch their state’s rural hospitals shut down because that expanded reimbursement would have been needed to keep the doors of those rural hospitals open.
@Jay:
Perhaps. But it seems to me that it is just easier to organize in a city, and organizational leaders are more likely to recognize the power of coalitions. It’s much harder to organize over vast geographical areas, especially if you are poor
Hang on, isn’t that…. REAL AMERICA????
Hmmm…. Another fine story of rugged individualists complaining that they do not have services provided for them.
Choices have consequences.
Maybe they should travel out of state to have children… much like some women need to do to end an undesirable pregnancy.
Goose. Gander.
Also: Canada
I am not sure we are quite as unique as this claim tends to suggest.
@Michael Reynolds:
74,233,369 x THAT!!