We've come a long way since Jefferson, Adams, and Madison opined that cities were "the natural enemies of virtue and happiness." While I don't want to go back to a world where more than 50% of the population is solely bound to food production, I do feel like we're losing something. The real tension in the US, rural vs urban (not red vs blue), just continues to grow worse. I don't know what the solution is, but I do know that robust systems usually avoid centralization, favoring variety and redundancy instead.
Rural living gets constantly gassed up as this incredibly serene, peaceful place to live and yet even in the age of remote work people aren’t budging. About as close as Americans get are exurban enclaves, with their major selling point being cost-effective new construction (thanks in part to more mature city’s draconian zoning policies)
People have voted with their feet and the feet have voted for cities.
To add to your comment - no man is an island and we live in a world of scarcity.
Living on twenty acres sounds great until you realize you'd like TVs, internet, toilet paper, a car, and education for your kids. Turns out those things cost money because there's only so much of them - how are you gonna make an income living in the middle of nowhere to pay people to send it all your way?
What can you do for them? Who do you know?
If you're lucky you can provide agricultural products, but likely not at a competitive scale - so you'll hemorrhage money season after season. All of those people you see on instagram selling cabbages? They're not selling the cabbages, they're selling the instagram. Your network will be reduced to a bunch of other people in the same boat. Your life will likely enter a downward spiral into irrelevance.
You either bring all of the money you'll ever need, or find a way to decouple from society as much as possible because you'll likely have little to offer it. Remote work affects all of this but even then it's a dangerous proposition - if the winds change you're done for, and your network is still going to be shot.
Piling into cities (and suburbs) is just common sense. It's where the jobs are.
This is such an odd take to me. I’m in a rural area, and I live in 15 acres.
We have pretty much every profession in the area. Teachers, lawyers, doctors, software engineers, etc. You’re probably out of luck if you’re, say, an actuary.
The real difference is you’re not going to reacher the professional peaks that you can in a city. You can be a lawyer, but you’re not going to be able to become some hotshot partner at a big, well known firm. You also might not be able to specialize in what you want. You can be a software engineer, but maybe not one that specializes in machine learning.
Of course, nowadays we have WFH and you very well might be able to have your cake and eat it too. That’s part of the reason I’m quitting my job as a wedding photographer and moving back into the SWE space this winter.
Living on 20 acres isn't even necessarily that "rural" - anyone who wants that can live in any number of exurbs surrounding large metro areas while commuting to work in the city (price permitting). I have family with a dozen acres and they still get their overnight Amazon deliveries and opera concerts while living on a well and septic tank. All funded by a position at a scientific institute on the other side of the metro area with a one way commute time under an hour (not great, but still better than some commutes they've suffered through in LA).
Rural is when you have to drive to get to your nearest neighbor. I think the vast majority of people who live in rural areas only do so out of generational inertia. The entire rural population can very easily be fit into the exurbs around metros if that's what they wanted
"Living on twenty acres sounds great until you realize you'd like TVs, internet, toilet paper, a car, and education for your kids. Turns out those things cost money because there's only so much of them - how are you gonna make an income living in the middle of nowhere to pay people to send it all your way?"
With a remote tech job, like I've been doing for over a decade while living on a rural four acre lot. I started with crappy satellite internet and now have decent satellite internet. And also toilet paper, etc.
I love it out here and can hardly imagine wanting to live in a city anymore.
>Remote work affects all of this but even then it's a dangerous proposition - if the winds change you're done for, and your network is still going to be shot.
I also moved out of the major metros - some things are worth the risk :)
Apart from farming, there is an obvious source of income - tourism services for urban people who want to relax in a more peaceful environment. Lots of old and small farms in my country have moved to that after farming wasn't profitable anymore.
Also, there's something beetween between big city suburbs and middle of nowhere. Smaller towns can offer a healthy amount of jobs and services, especially ones that are within commute distance from larger ones. Moving from a village/town of 4000 people to one of 140 000 didn't really change my daily life much, apart from having more variety of food in supermarket, and much more expensive and worse housing.
If you could afford 20 acres you can certainly afford to figure out how to make money with it.With 20 acres you can certainly be cost competitive with seasonal crops. But that is an insane level of work. The problem is getting the 20 acres. The other poster that says people aren't moving out of cities couldn't be more wrong. The price of rural land has skyrocketed in comparison on city and suburban housing. My home in the city has gone up about 50% since ~2019 and is up to about 2.5x the 2014 purchase price. My rural home has gone up nearly 4x from the 2018 price, but it is a bit more unique as it's a vacation property. The surrounding homes are all up nearly 2x since COVID but had languished prior. The crazy thing though is that the empty land is up at least 5x from ~2018. The medium size tracts that I was hoping to buy have all been sold for anywhere to 5-20x. Very large tracts are 5-10x up and these are actual sold listings.
My family raised cattle on significantly more acreage. I would characterize it as supplementary income, less income than from my dad's menial day job. Also very inconsistent with prices of cattle and crops fluctuating wildly and rain and pest fluctuations greatly affecting their production. Where I'm from we'd periodically have farmers committing suicide when their crops didn't keep up with expenses for long periods of time.
Please, people have been forced into cities. WFH isn’t near as common in other industries and even for most tech workers it has been temporary.
The rural county I live in saw an influx of people moving very far from the city, only to be forced to leave again because of RTO. We had a huge population boom, only for it to be ripped away by shortsighted managers who don’t care about what their workers want.
I have very secure WFH and I moved in closer intentionally. It's been life changing, I got rid of my car, moved in to a high end inner city apartment, and fully embraced the lifestyle. The access to social experiences in the city is unmatched. I get access to all this stuff like a pool and gym that I couldn't or wouldn't pay for if I had to maintain it myself.
Living inner city kind of makes you a social hub where everyone wants to come to your place because it's super accessible by public transport so everyone can drink and hang out in the spa/steamroom/sauna and then walk out to the local pubs and restaurants.
Meanwhile I see all my rural family stagnating, getting addicted to drugs, stuck on welfare, and living subjectively depressing lifestyles.
> I have very secure WFH and I moved in closer intentionally. It's been life changing, I got rid of my car, moved in to a high end inner city apartment, and fully embraced the lifestyle.
Honestly? I did too and I'm am absolutely not sold on this lifestyle at all. I told myself I wanted to try it and see what it was like for a year and I have never been more lonely before in my entire life. Unless something changes I will move back after my lease is up, because a boring life is better than a lonely life.
There are more social events, but IMO they're very surface level, people don't want any deeper connection.
> Meanwhile I see all my rural family stagnating, getting addicted to drugs, stuck on welfare, and living subjectively depressing lifestyles.
I mean you're making pretty harsh judgments about their lives. If someone lives rural and is happy, that should be good enough even if you don't want the same lifestyle.
Getting addicted to drugs? I walk past junkies literally all the time now in the city, rural areas don't have a monopoly on drug issues.
Living in inner city might make you a social hub if you're an extroverted person in the first place. For an introvert like me it didn't make much of a difference, though I did find a spouse, which probably wouldn't have happened in the countryside.
I think everyone should move away at some point of their life, but permanent city-life isn't for everyone. I simply enjoy gardening, small-scale farming, tinkering and trekking in forests way more than any services cities offer.
> I think everyone should move away at some point of their life, but permanent city-life isn't for everyone.
I think this is the key, people should experience different cultures, lifestyles, and social opportunities. I'm an introvert myself, but I'm passionate about certain topics and enjoy discussing them with people who are also passionate about them.
Finding these niche communities or people who shared my ideas was impossible for me where I grew up, which was much less densely populated than where I live now. Now I have access to additional sharing of ideas, gatherings, and social bonds that I couldn't have imagined before I came to an urban area.
I never thought of myself as a city person, but after living in a rural area, a midsize city, a huge city, and a small town, I've found that my current large to midsize city is where I thrive.
People have been forced into cities by the cold hard reality of the physical world.
That reality is that it's dramatically cheaper to provide services to people that are living close to eachother.
Unless we get to a post-scarcity utopia, or someone repeals the law of economics, city services will continue to be, as a rule, better and, in relative terms, cheaper than rural ones.
It's possible that people have moved to cities for jobs more than anything. I spent over a decade living in Chicago, and it grows tiresome. Now that remote work is prevalent in our profession, I'll never live in a city again. Access to high quality medical services is a concern though.
> It's possible that people have moved to cities for jobs more than anything
It's not just possible, that's exactly why. The vast majority of people live in cities because of economics, not because they inherently prefer cities.
First of all, what do you mean by "Rural living"? Living in a town of 20k people? 10k? 500? Or on an acreage/cabin a half mile from neighbors? All of these are pretty distinct experiences.
Let's just say any town <20k people is considered rural. From what I've seen, it is almost unheard of for someone who was not raised in a rural area to successfully live long term in an area like this.
I have plenty of anecdotal evidence of seeing retirees leave the city and try to live full time in a remote cabin on a recreational lake. None of them lasted more than a couple years. A surprising number of divorces. Growing up in a small town I have plenty of similar stories of families moving in from a larger city and leaving shortly after.
I'm not exactly sure how to explain this but generally I think the challenges of rural living (weather, social, economic, isolation, etc.) are very difficult if someone isn't familiar. As you mention, people see the benefits (incredibly serene, peaceful place, etc) but I think many aren't expecting or prepared for the challenges.
> Rural living gets constantly gassed up as this incredibly serene, peaceful place to live and yet even in the age of remote work people aren’t budging.
One big reason is that remote work was never guaranteed to last. It's starting to crumble now with big tech requiring RTO x days a week or factoring in physical presence into performance reviews. People that aren't already independently wealthy couldn't risk buying a house in the country. In my rural home town your options for work if you lost your tech job(easier because crappy internet options) would be hard labor on a farm or dairy or maybe work at the grocery or fast food joint - nothing else.
Anecdotal counterpoint, since the beginning of the pandemic response my wife and I moved onto a farm with a few dozen acres and are slowly building it up to a homestead.
A catw majority of people stayed in cities, or are moving back, but some did vote with their feet and left for the country.
It's important to not that it might be easy to#if hear from those that started in cities, anyone that moved more rural may be out of your field of view and seemingly not exist.
Using a very small window of 3 years in a society built around the automobile as anecdotal evidence isn't as concrete evidence as you might believe.
Macro-trends always contain variance which can infer an opposite micro-trend.
The housing supply is infamously constrained right now. Many counties have a cap on density which simply don't allow people to pick up and move on a whim to rural areas.
For me personally, it is not some "nature vs dirty streets" argument at all. When I read the writings of the mentioned, it's not all "ag is beautiful." They had specific experience with how power became centralized in European cities which led to governance and societies which were short term/locally optimized to the detriment of all.
And yet, this is exactly what is happening now. Despite being given disproportionate political power (the Senate), the closure of rural hospitals has not stopped or slowed. Politicians are not farmers, they're not rural laborers, they're overwhelmingly lawyers and white collar workers who spend their times in cities, or at best, rich enclaves within the district they represent.
Politicians are not selected today like they were when the founders lived. In rural districts, when given the choice between
A. A carpetbagger endorsed by the most recent Republican president who talks about wedge issues whose outcome has almost no impact on daily life
B. A local star who promises to make his votes cost his party a lot of pork (money for projects in his district, like keeping hospitals open), and represent his district's very specific economic interests
most districts are voting for candidate A in the primary.
I think it's just a natural realignment. Urgent cares take a lot of the hospitals action. Pretty much everyone can afford a decent car and knows that the better hospital isn't the rural one. Expanding ambulance and air evac is a big thing right now. Even in urban and suburban settings you are still dealing with fair travel times to hospitals. If you can get decent ambulance, air ambulance, and urgent care there's really not as much of a need for rural hospitals.
And the airlift company sells me a coverage plan for $120 a year (which also covers skiing accidents), while there is nothing I can do to reduce an ambulance rides price that will be in the thousands.
I'd argue that remote work hasn't normalized for long enough yet for this conclusion to be reached. Also, it doesn't account for the 3.6 million Boomers who retire every year, begin collecting Social Security, and who can then move to rural areas with their income not tied to a physical wage earning location.
Most people don’t move that far from where they grow up. City populations have more to do with a select few choosing where they want to live and either having lots of babies, or convincing other people to come to them. Once the city is established, most of its population growth is self-sustaining.
I think local effects are still at play. I know many rural places that are still shrinking, but my town has nearly doubled in size and shows no signs of slowing.
We’re over 2 hours from the nearest airport (on a highway), so pretty “out there.”
For 2020 the Census Bureau redefined what qualifies as “urban” living (population thresholds were doubled). Despite this, the share that live in rural areas only increased 0.7 points (19.3 -> 20.0). Using the previous metrics, rural populations shrank relative to urban.
>Rural living gets constantly gassed up as this incredibly serene, peaceful place to live
It is indeed peaceful. It is just a lot of physical work and being in the sun. At least half the year or so.
Lots of people are leaving the cities. Many of the major cities in the US fit the definition of a failed state. Including SF.
"A failed state is a state that has lost its effective ability to govern its populace. A failed state maintains legal sovereignty but experiences a breakdown in political power, law enforcement, and civil society, leading to a state of near-anarchy." [1]
And most of them aren't moving to Flyover, Nowhere. They are moving 8 miles down Main Street, to another part of their metro area.
> definition of a failed state
You have a very strange definition of a failed state. Are there rival warlords conscripting people into their liberation armies at gunpoint? Is drinking the tap water going to kill you? Does SF have to make do with 8 to 18 hours of electricity a day? Is there no food at the grocery? Are the schools and universities open? Are there multiple acts of terrorism a week, caused by plain-clothes insurgents? Has unemployment hit 30%? Have employers stopped paying people?
Are pensioners lining up on Market Street every day, to try to sell strangers their fur coats and toasters and jewelry, so they can afford to feed themselves next week? Has life expectancy dropped by a decade or so?
>Are there multiple acts of terrorism a week, caused by plain-clothes insurgents?
Gang shootings every day?
>Are pensioners lining up on Market Street every day, to try to sell strangers their fur coats and toasters and jewelry
No the pensioners couldn't afford to live there and moved out. You have immigrant people selling [stolen] toasters and shampoo on the street.
>Has life expectancy dropped by a decade or so?
Life expectancy is significantly shorter for a large segment of the population via overdose, because lawlessness pervades.
> Are the schools and universities open?
Yes I believe SF has reopened schools again, finally.
You have masses of people living on the street in tents. And rampant open air drug use and sale. Lawlessness. I suggest you re-evaluate what you are willing to tolerate.
SF has some crappy stuff, but putting up rural America as an example of how things are good is quite a take. Religious fundamentalism, racism, homophobia, and outright Nazism are taking over a huge portion of rural America. A huge portion of rural America supported a coup.
Usually when people talk about leaving cities, it's because of the cost of living in many cities.
Plus, are people leaving cities? Click on Population Change at https://mtgis-portal.geo.census.gov/arcgis/apps/MapSeries/in... and zoom a bit. Rural America is emptying out. It's one of the reasons that services like hospitals are becoming harder to support. The counties containing Raleigh and Charlotte in North Carolina have grown by 25% and 21% while rural northeastern North Carolina is seeing double-digit declines. In Georgia, the Atlanta and Savannah metro areas are growing and there's a lot of decline in rural areas.
You might not like cities, but it's rural areas that people are leaving and it's rural areas that are failing.
Rural America, in the sense that the OP meant it - "It is just a lot of physical work and being in the sun" - effectively no longer exists. "Rural America" is largely a term used by people who live in cities for people who don't live in cities, but the latter are by and large not "rural" by historical standards.
If you fly over the midwest, what you will see in terms of land use is a large amount of farmland broken up by enormous neighborhood networks and mid-size cities. People who live here are largely not working on farms. They are commuting to office jobs, service work, or gig economy positions. They don't walk anywhere, so they're not "in the sun"; even getting to the grocery store or a friend who lives nearby is practically untenable without a car. They certainly aren't living off the land. "Rural" America is basically the leftovers of farmland, and in many locations it's actively being partitioned into subdivisions.
I lived more than half my life to this point in a "rural" area, but for me this meant ~5 unfarmable acres. Virtually everyone else I knew lived in a neighborhood (isolated from other neighborhoods by miles of driving). This lifestyle isn't the idyllic thing it's made out to be.
> Religious fundamentalism, racism, homophobia, and outright Nazism
I don't think I'd point to rural areas specifically as the source of this problem. Instead, I'd point to the "Orange-County-ification" of the US. The heat centers for the problems you're talking about are relatively wealthy subdivisions full of people who can afford F150s that they don't need and keep small arsenals in their basements. Think people like the McCloskeys in suburban St. Louis: https://www.bbc.com/news/world-us-canada-53481537
As for racism - part of the truth of the "crime problem" in cities is the fact that huge segments of their populations are effectively a permanent underclass living in poverty or near-poverty.
You are correct there are very few people living on small farms. Most people in rural areas live in small towns, are very poor, and yes transportation is an issue. Many should and do move to cities to find more opportunity.
> Religious fundamentalism, racism, homophobia, and outright Nazism are taking over a huge portion of rural America.
This is a massive mischaracterization. Do you have first-hand experience with these people? I specifically have an issue with your phrasing: "taking over". It may be more common, relatively, to find this sort of thing in rural areas, but that does not mean it's taking over.
Surely such an unstable and violent state must make it hard to run any kind of business. There's definitely no way any giant tech organizations would ever put offices there, much less headquarters.
We're literally in a thread about rural America being unable to keep basic necessities like hospitals open, but if someone poops on the sidewalk it's a failed state? Very cool, reasonable definition.
I also don't know the solution, but I'm reasonably sure closing essential services like hospitals is not part of it. Unfortunately, the kind of policies that might keep those places open get soundly rejected by people who live in those communities, or at least by the people who represent them. I grew up in a rural community and am sometimes wistful for it, but I don't want to move far away from medical care, internet, reliable power, and other basic services and all of those have only gotten worse where I grew up.
I hope we see ebikes become a valid option in more places. There's alas many places where there's poor/no shoulder or it's just otherwise be way to unsafe. But it's soo nice having such an unencumbered light way to get around.
Ebikes would help, but I honestly don't think anything of that sort other than electric cars and trucks will get much uptake. As you said, there's often no shoulder, and, due to low population density, there's little upkeep done on roads, especially in the winter and after storms. In short, unless your vehicle can handle snow, ice, and animals, it isn't a complete solution, not to mention the cargo capacity needed to not have to go shopping every day when the grocery store is miles away.
> We've come a long way since Jefferson, Adams, and Madison opined that cities were "the natural enemies of virtue and happiness."
A casual search for that quote shows no results, is it a paraphrasing of something?
Either way, some skepticism is needed when one considers the source: Wealthy landowners that didn't need a city near them in order to command conveniences and comforts in their mansions, estates, and/or plantations.
The US have a large number of large and important cities, so it's not that centralized. It's not like the UK / London thing.
Redundancy and resilience have n associated cost. Not everybody is keen to pay this cost, especially when the benefits do not seem large. As every complex thing, it's a matter of balance.
> The real tension in the US, rural vs urban (not red vs blue)
As usual, it depends.
For example, out west the tension is with water rights. All other political issues are like molehills to the mountain that is water.
To be clear, the western US states aren't running out of water, they are running out of cheap water.
Usually, this pit the mountains against the farmers/ranchers, but it affects the whole population of a state in changing and varied ways. Divides are formed and forgotten every 20 years or so.
So, no, the real tensions aren't in the US's population centering methods, it's in dozens of different ways at dozens of different times and places. Thinking that ~350M people can be divided in any black-white manner for any length of time is a failure of imagination.
Devils advocate: isn't this just the same rural/urban divide illustrated through a different lens?
It could be similarly portrayed as rural agriculture water rights vs. city dwellers water rights. Both want cheap water. Both point to the unsustainable practices of the other regarding water usage.
In CA, there is a huge North-South divide when it comes to water. Northern CA constantly complains about LA 'stealing' all the water. In this case, it's urban vs urban.
In CO, it's rural mountain areas where the water comes from versus the rural plains ranchers where the water is needed. Frontrange cities mostly have their own water rights figured out, mostly.
In UT, it's just a hell of a mess and everyone is angry at everyone else and the Great Salt Lake becomes ever more that little brine pond over there.
Then you add in all the compacts along the Colorado and everyone just has more to fight about.
I guess you can sorta squint and say it's urban v. rural in some cases. And that would only be due to the square mileage per capita in the definitions. But, it's so much more than that and so much more complicated and legalistic and messy. The only common thread in the western US is water and how there just isn't enough of it for cheap.
Thanks for explaining. My anecdotal experience is from talking to people in NM, which may be different than the dynamics you're describing. E.g., as rural agriculture has grown, the Rio Grande is dry for longer and longer periods when it used to flow year-around decades ago. Residential construction has also grown fast, with an emphasis on water-hungry non-native species.
>The only common thread in the western US is water and how there just isn't enough of it for cheap.
Isn't this specifically because agricultural water is disproportionately (severely) discounted? I.e., it is extremely cheap for agriculture, which drives them to use more water, especially on crops that wouldn't otherwise be well-suited to that climate. Which leads to non-agricultural water to disproportionately more costly. I've read on HN that 80% of water in the west is used for agriculture, which would seem to confirm this dynamic.
The cost structure and usage defies any simple explanation. Meaning that it's not easy to tie up in a HN comment.
Honestly, each waterway can have it's own rules and it's own rights. In CO, until recently, you weren't able to collect rainwater from your own roof, as that water was already earmarked for the right's holder of the water the second it touched the ground. They've changed that and are more in line with other states, but such strange little provisions and regulations exist in other manners all over the US West. I wouldn't doubt your stats on water usage though, 80% is the right ballpark. But again, that system is the result of a bazillion little laws and regulations that would each have their day in court.
It's interesting to have learning in various parts of the country as it pertains to property rights. The West, in particular, seems strange in terms of mineral and water rights compared to other regions. I'm assuming it's an artifact of the frontier culture.
Putting aside the rest of the comment: I don't know how living away from where all of the redundant infrastructure in any given country is can be considered "robust" in any meaningful sense.
>We've come a long way since Jefferson, Adams, and Madison opined that cities were "the natural enemies of virtue and happiness." While I don't want to go back to a world where more than 50% of the population is solely bound to food production, I do feel like we're losing something. The real tension in the US, rural vs urban (not red vs blue), just continues to grow worse. I don't know what the solution is, but I do know that robust systems usually avoid centralization, favoring variety and redundancy instead.
One of the big issues (at least AFAICT) is the lack of good paying jobs in reasonable proximity to rural areas.
Why is that? Among other things, one issue seems to be a lack of specific kinds of infrastructure in rural areas: High-speed rail and high-speed internet connectivity.
High-speed rail with hubs in urban (or urban-adjacent) areas can provide reasonable access for folks to commute to where the jobs are.
High-speed internet connectivity would allow for (some) businesses to start and thrive in rural areas.
Improving such infrastructure in rural areas would encourage (at least for a while), urban/suburban dwellers to move to more rural areas without compromising their earnings ability.
And if such a migration is made possible/desirable, other businesses supporting those new residents (apartment buildings, bars/restaurants, cultural activities and a raft of other opportunities will present themselves for other, local, businesses.
Would moving stuff like this be easy? No. There are a whole bunch of issues that block creating such infrastructure and the business environment that would depend upon such infrastructure.
That said, urban/suburban folks moving to a functional (in terms of access and services) rural areas will increase the incentives for other businesses (hospitals, anyone?) to come to, remain and/or expand in rural areas.
This would reduce some of the pressure on housing prices in urban/suburban areas and revitalize the economies of rural areas.
I don't expect to see such movement in the near to medium term, and more's the pity. But that doesn't mean we shouldn't advocate for such things.
You can't have HSR in rural areas. Rural areas, by definition, have very low population density. HSR is horrifically expensive to build and operate, and only works economically (like here in Japan, where there's lots of it) because there's huge ridership between the large cities it operates between. There's no HSR to rural communities because there aren't enough people riding it frequently enough to make it work, and the people who'd like to use it are too spread out over too large an area for the logistics to work. You can't have a bullet train that stops every 10 miles at some small town to pick people up; you'll end up with an average speed that's too low to even be called "HSR". Your whole post really makes no sense in the real world.
It's very simple: if you want the benefits of living in civilization, like medical care, bullet trains, and other infrastructure, you need to move to cities because those are the only places where economies of scale exist to make that stuff work.
>And if such a migration is made possible/desirable, other businesses supporting those new residents (apartment buildings, bars/restaurants, cultural activities and a raft of other opportunities will present themselves for other, local, businesses.
If you have a place with a bunch of apartment buildings, bars/restaurants, and all this other stuff, what you have is not a "rural area".
>You can't have HSR in rural areas. Rural areas, by definition, have very low population density. HSR is horrifically expensive to build and operate, and only works economically (like here in Japan, where there's lots of it) because there's huge ridership between the large cities it operates between.
>There's no HSR to rural communities because there aren't enough people riding it frequently enough to make it work, and the people who'd like to use it are too spread out over too large an area for the logistics to work. You can't have a bullet train that stops every 10 miles at some small town to pick people up; you'll end up with an average speed that's too low to even be called "HSR". Your whole post really makes no sense in the real world.
Which is why I suggested a hub and spoke system, where the ends of a spoke services several thousand square miles.
Nor am I talking about "making stops every ten miles," either. It seems you didn't read my comment very closely and applied my thoughts to systems that exist today.
I don't disagree about economies of scale, but there's certainly room for better communication and transportation infrastructure outside urban/suburban metro areas.
In fact, over the long term (after both of us are dead, I'm sure) such initiatives could increase economic activity in the US enormously.
>If you have a place with a bunch of apartment buildings, bars/restaurants, and all this other stuff, what you have is not a "rural area".
Yep. That's true. I never said "rural areas need to stay rural forever." In fact, reviving the economically struggling rural areas necessitates increasing population density and economic activity. And that's a good thing.
>Which is why I suggested a hub and spoke system, where the ends of a spoke services several thousand square miles.
Do you really think people are going to pay ~$200 each way to commute to the city every day? Because that's the kind of ticket price you can expect with HSR. Train systems like that are not cheap to run. They work great here in Japan for traveling between cities, where they're competing with airplanes, but the tickets are not as cheap as you seem to think. Your idea means far more miles of track to build and maintain.
>In fact, reviving the economically struggling rural areas necessitates increasing population density and economic activity. And that's a good thing.
Why? Just because you like those places? If they were economically viable, they wouldn't need all this help. And if you increase the population density, suddenly it's no longer "rural" but is now a "city", which is exactly what most of the people there don't want, or else they would have moved to a city.
> High-speed rail with hubs in urban (or urban-adjacent) areas can provide reasonable access for folks to commute to where the jobs are.
You don't need HSR for this. Actually, high-speed rail and commuting are mutually exclusive, because commuter rail lines stop way too often to reach even rural two-lane highway speeds.
The TGV is very nice and will get you from Reims to La Defense, about a hundred miles of commute, in an hour and a half (via Paris l'Est), but only because Reims happens to be on the TGV trunk line and has a stop. If you're coming in from Vaires-sur-Marne, which that same TGV line goes through but doesn't stop at? About an hour to La Defense on the commuter RER despite covering less than a third of the distance.
>You don't need HSR for this. Actually, high-speed rail and commuting are mutually exclusive, because commuter rail lines stop way too often to reach even rural two-lane highway speeds.
A fair point, high speed rail is really only good for point-to-point travel. That said, using the hub and spoke model could alleviate that issue significantly.
Have high-speed rail spokes in a ring, with spoke ends at 75-100 mile intervals around the ring, with the urban area at the center of the ring, along with good roads and feeder rail to the spoke ends could work. Trains from the spoke ends wouldn't make any stops (or perhaps one or two, if you wanted to create concentric rings), and so wouldn't need to continually stop.
That assumes (unlike Amtrak's Acela) railroad track on the spokes which allow for 200-300mph (~340-510kph) speeds. And without stops, you can get from say, Fort Sumner, NM (in the 48th most rural county in the US[0]) to Albequerque, NM in less than an hour. While folks would still need to travel to such spoke hubs, such hubs, along with more hybrid/WFH jobs, that could absolutely work.
It would be a huge undertaking, but construction of such rail lines while laying fiber along the track rights-of-way could kill two birds with one stone.
Is it a perfect (or even a good one) solution? Maybe not. But anything that can both revitalize rural areas and mitigate the housing shortages in urban/suburban areas is a good idea. Perhaps you have a better, more workable solution?
> And without stops, you can get from say, Fort Sumner, NM (in the 48th most rural county in the US[0]) to Albequerque, NM in less than an hour.
Fort Sumner has less than 1000 people, the whole county is at 1,680. That sounds like about the least productive use of funds. Japan has high speed rail trains that could transport the entire town, with room to spare, in one go. It's a huge gamble to build it in the hopes people move to Fort Sumner and use it.
>But anything that can both revitalize rural areas and mitigate the housing shortages in urban/suburban areas is a good idea. Perhaps you have a better, more workable solution?
Yeah, it's simple: fix the glaring problems in urban areas, and have people move there. If there's a housing shortage, build more housing. Fix the stupid zoning laws that prevents that. That's a lot easier than this ridiculous HSR ring idea.
>Yeah, it's simple: fix the glaring problems in urban areas, and have people move there. If there's a housing shortage, build more housing. Fix the stupid zoning laws that prevents that. That's a lot easier than this ridiculous HSR ring idea.
And leave folks who live in rural areas to rot, without even a hope of revitalizing their communities? That seems both reductive and likely harmful.
Because the issue isn't just housing shortages in urban areas, it's also the decline of much of the US by flight from rural areas. Which has been the source of a great deal of the economic dissatisfaction in the US for many folks for a long time.
I'd point out that people who live in rural areas are humans too and, at least in the US, for the most part Americans, with just as much right to exist and thrive as anyone else.[0]
I'm not saying that you feel this way, but the sense I get from your response is: "I don't like rural areas or the people who live in them. In fact, I hope they all leave or die." If that's not what you're trying to say, my apologies -- although you might want to try to be more clear about what you're saying if you don't want to be perceived that way.
[0] I'd note that I was born, raised and have lived almost all of my life (and still do) in the most urban city in the US.
If people in rural areas want the services and conveniences of urban areas, they should move there. It's very simple.
>"I don't like rural areas or the people who live in them. In fact, I hope they all leave or die."
No, my attitude is that rural people live an unsustainable lifestyle that demands subsidization by city dwellers. Why should rural dwellers get this if they're not able to afford the extravagance of rural living on their own? If they want money and jobs, they need to move to where the jobs are. Human societies have been working this way for thousands of years now. This isn't something brand-new.
If rural dwellers like it so much in rural areas, they need to learn to accept and live with the downsides that go with that, such as lack of medical services, instead of complaining.
> rural people live an unsustainable lifestyle that demands subsidization by city dwellers
I see this idea in a lot of places but don't understand it. You could equally fairly say that city dwellers live an unsustainable lifestyle that demands subsidization by farmers in Kansas or oil drillers in North Dakota.
You have trouble understanding this? Try this: can 90% of the population live in cities, supported by food and oil produced by the other 10%? The answer is yes. Now, can 90% of the population live with the farmers and oil workers (in a very rural lifestyle) and still yield the level of civilization and economic development we have now? The answer is no. Without cities, there's no modern economy: just look at any place that's still agrarian, or was in the recent past. Or even the US during its civil war (the agrarian, rural South had no chance against the industrialized North).
Manhattan/NYC is as expensive as it is because the housing stock in the NYC metro area has actually reduced in the past 20 years, even though the population has increased significantly. For context, between the 2010 and 2020 censuses, a period where NYC growth was considered slow, NYC added a 1.5x Atlanta's worth of population, but with hardly any additional housing.
I'd add that changing zoning laws and building more densely in urban areas is absolutely a good thing -- and we should definitely do that as well.
But doing so does absolutely nothing to revitalize lower population density areas, where 20% of the population[0] lives. I'd expect that better communication/transportation infrastructure would increase that somewhat as well, since if you don't need to live in an urban metro area to have a good job, a whole bunch of people would move to those areas. Potentially making them not rural any more, but why does that even matter?
Or should we just tell folks in rural areas to fuck off and die? I don't support that, although I'm sure there are some (you, perhaps?) who do.
There is plenty of housing in shrinking urban areas, like Detroit. You mean build new housing in popular urban areas, where people want to move to. Maybe if Seattle is as dense as Manhattan it will be as cheap as Manhattan, right?
The suburbs around Detroit aren't doing that bad, but there are plenty of "failed" cities around the USA if you look close enough. Any city without a mild climate and access to nice outdoor areas nearby is considered a failed city in many people's books...who wants to move to Tulsa these days?
The tension is not rural vs urban. It is educated vs the uneducated.
It is urban vs rural because rural folks are less educated and therefore more susceptible to forces that are predatory to those who do not make a practice of critical thinking, such as fox news (or worse).
I don't think it's controversial to say that education liberalizes.
Here's Nate Silver talking about education as a predictor of the 2016 election:
> rural folks are less educated and therefore more susceptible to forces that are predatory to those who do not make a practice of critical thinking
> I don't think it's controversial to say that education liberalizes
Highly-educated city folks make totally preposterous claims with zero critical thinking all the time. So you're right that education tends to liberalize, but wrong that education somehow makes people engage in more critical thinking.
I posit that for every piece of garbage that comes out of Fox News, there's an equal and opposite piece of garbage coming out of MSNBC.
The tragedy of the commons is a tragedy because it requires the fishermen who would otherwise fish the sea empty to not fish as much as they could.
Why would any individual fisherman be happy with quotas?
So I won't deny that they don't want (some of) those values, but that is why education is important, to see that if you aren't willing to make sacrifices (to say fight global warming) then you will be forced into even worse situations.
A lot of rural hospitals (and indeed many healthcare providers) are really poorly managed as businesses. This has been exacerbated by the labor shortage in healthcare, which is one of the industries that immigration alone can save at this point. (Hi Flint: https://withflint.com/)
Scarce talent is being recruited away by higher paying providers in urban centers, which is why you see occasional headlines about the skyrocketing pay of travel nurses. COVID made this more acute, and while that crisis has faded, the secular trends have not gone away, notably America's demographic aging.
A sub-issue is that even when the hospital stays open, you often get poor care. My family has been on the receiving end of that, with my aunt dying prematurely because her cancer was missed by a subpar rural GP.
The reason for the scarcity of talent/ doctors is due to a regulation change in 1983/1996 that wasn't adjusted until last year that was restricting the number of residency spots for doctors in the US.
*Also note this has been slightly fixed with an increase of residency spots, but still puts the US in position to have fewer doctors per person than almost all other developed countries.
That may explain the overall lack of doctors in the US but seems irrelevant to this thread about rural healthcare.
All you have to do is look at other countries and see the same issue playing out. Germany, Vietnam, and Australia are all very different from the US, and from one another, and all have issues with rural health care.
The reality is that low populations make it hard to provide any service and most of the "first world infrastructure" they do have is provided by federal or state/provincial government (i.e. not their own tax base). They aren't attractive places to live for many professionals, who usually trained in bigger cities and are used to small comforts like being able to eat a variety of cuisines or seeing live events (sports, music, drama) or having good schools for their children. The cost structure and (relatively) low demand affect the financial side of the equation. Etc etc.
Many countries allow "foreign doctors" provided they do some kind of provincial work (think of the old comedy series Northern Exposure) but that hasn't exactly proven to be a panacea.
Why does the federal government need to pay for every single residency? Ok, maybe they messed up in 1983/96—no other entity in the entire nation was capable of picking up any of the slack?
This is beyond the scope of my knowledge, but what I can say is that the original issue in the 90s arose from a fear of too many doctors coupled with too much spending on said doctors which resulted in multiple regulatory changes to prevent this outcome.
I never got this either. Residents, from my understanding, are paid poorly. Hospitals charge immense amounts of money. Surely they can squeeze a few residents in there without begging the government for money.
Residents are poorly paid, but residency programs are expensive to operate and expand. The non-profit and public sector teaching hospitals which operate most such programs are generally doing better than small rural hospitals but they're still in a precarious state. They take losses treating a lot of uninsured and Medicare/Medicaid patients.
Residencies lose money. The doctors that teach in them generally do not enjoy it(source my father who is a doctor and chairs a residency) and need to be paid extra to participate. There would be close to none without the federal subsidies.
The federal government has a lot of money. So does the California government. So does the San Francisco government. So does the Bill and Melinda Gates Foundation. So does Harvard University. So does Amazon. So does UnitedHealth Group. So does NY Presbyterian.
I reiterate: Why does the federal government need to pay for every single residency?
Or rather, misaligned incentives. If they aren't paying for residencies today, there's no reason to believe they'll magically do so tomorrow. Also, if a state decides to do so, that still leaves every other state with insufficient funding for residencies.
There’s a bunch of people that think the federal government should fund more residencies. Some of them raised money, hired lobbyists, made slick websites etc. Others are on websites like this talking up the issue.
They don’t seem to be getting anywhere. Looking at the current state of Congress and the trend line I’m not super optimistic they will pass any sort of “common sense” laws in any area anytime soon.
What I’m suggesting then, is perhaps all these advocates should find some other trees to bark up. Maybe they’ll get no where, maybe they’ll be pleasantly surprised.
Or they can just keep doing what they are doing. I don’t especially care.
Which other entity would you suggest? Residency programs mostly run in non-profit or state government teaching hospitals. They are already financially struggling.
The “non-profit” hospital systems* by me are neither non-profit, nor struggling. They are distributing their large profits to their de facto owners—the executives.
* Systems not hospitals. These groups are gobbling up the entire industry. Hospitals are only a part of their diversified portfolio of businesses.
—-
What about the universities with the medical schools? How many of them are sitting on giant endowments?
It does not restrict the number of residencies, but the number of federally-funded ones. And for some propaganda reason that is always presented as a cap on residencies, not on their funding. With for-profit healthcare why can’t private market step in? I guess it’s not profitable. Who could have guessed.
How does one fix expensive education and a cartel limiting the number of qualified doctors with immigration?
Why would I, a qualified and respected doctor in my country want to move to the US (or Canada) if it involves going through 4 more years of bullshit just to get re-qualified for a system that adds even more red-tape, expenses, and middle-men between me and the patient?
I know, you're probably saying, "oh, but so many people have" - but hey, that was in the past. Unless my country is getting bombed to hell, I'm probably making a damn good living where I am, because, guess what? There's a shortage of doctors everywhere outside of Cuba!
It doesn't help doctors since they have to pass the same residence process before they can practice in the United States but lots of countries like Mexico and the Philippines have nursing degrees that are valid in the US as long as they pass the NCLEX-RN exam. Each university's program is evaluated individually but it's a standardized process.
Once they're here they can follow the nurse practitioner process which allows them to do many of the same things as doctors.
You don't. Immigration is not a "solves all problems" solution. Its a "drive down wages so that we live in a 3rd world country like the immigrants we are paying" solution.
I used to be a big libertarian proponent for immigration and now I've become the complete opposite after seeing how much money wall street (and almost exclusively corporate special interests) puts into increasing immigration.
can you be more specific in how letting qualified doctors and engineers from other countries (doesn't even have to be third world, a lot of british doctors would move here given their starting salary of 30k) will turn us into a third world country?
also, the wage argument doesn't make sense because rural doctors earn more than urban doctors due to the low desirability of the location, and despite med schools specifically selecting for students who are willing to become rural doctors, they still cannot find enough doctors to fill those spots.
(https://medrecruit.medworld.com/articles/how-much-do-rural-d...)
its also concerning that the reason you decided to oppose immigration was not for a tangible reason, but because wall street supports it. seems like contrarianism run amok. did you become a communist because wall street supports capitalism?
Immigrants from poorer countries will do anything for a buck. It becomes a race to the bottom. As long as conditions here don't get worse than where they came from they'll be happy. But for us, its just down, down down in terms of quality of living.
If rural hospitals need to pay doctors even more than so be it. I want that job going to an American.
Is it concerning because I don't care about what society thinks? Is it concerning that I don't care about getting an attaboy (e.g. karma) for towing society's latest groupthink?
"Immigrants from poorer countries will do anything for a buck. It becomes a race to the bottom. As long as conditions here don't get worse than where they came from they'll be happy. But for us, its just down, down down in terms of quality of living."
would you be open to mass immigration from europe and east asia, in that case? some of the countries have even higher standards of living, so logically those immigrants will demand better and raise our standards of living. Also, most cities like san diego, miami, dallas, atlanta etc have all become safer, cleaner, and the QoL has increased dramatically from 30-40 years ago. These cities have all become increasingly immigrant populated relative to 30-40 years ago, many of these immigrants coming from latin america or asia.
"If rural hospitals need to pay doctors even more than so be it. I want that job going to an American."
the crux of the issue is that there literally aren't enough american doctors. med schools giving recruitment preferences to doctors willing to work in rural areas + a much higher salary + a much lower COL still aren't enough to attract american doctors there. I don't know what magical solution you have to make thesecommunities desirable destinations but I am all ears.
"Is it concerning because I don't care about what society thinks? Is it concerning that I don't care about getting an attaboy (e.g. karma) for towing society's latest groupthink?"
no? There are many valid arguments to heavily restrict immigration, largely based on middle class incomes and cultural attrition, i just don't see how any of those apply to doctors in rural areas. and i was responding to how you openly admitted that you dislike it because wall street likes it. seems like a bad way to approach policy!
It's not that straightforward. There is a shortage of CNAs, RNs, and LPNs willing to work in current conditions for current pay. Lower patient ratios and higher pay would naturally bring more labor into the healthcare labor pool. If you're going to import healthcare labor and still subject them to the existing suck that is US healthcare labor, that is not sustainable.
(light edits made to capture nuance vs absolutes, previous comment version started with "there is no healthcare labor shortage", which is not accurate)
Oh, it's perfectly sustainable. It allows wealthy hospital shareholders to continue reaping huge profits without having to improve conditions, wages, or staffing ratios. Unlike America, which has a finite supply of people willing to be nurses, we can simply hire immigrant nurses and replace them as they burn out.
You're right to an extent, but there legitimately is a shortage of physicians. The supply can't expand to meet demand regardless of working conditions and pay because Congress has capped funding for residency program slots.
The baby boomer generation has more chronic health problems than the generation before them. And, there are more of them. This leads to more health care services needed.
Yet, where I live the nursing schools have not expanded the number of graduates per year.
Supply and demand. Demand is going up. Supply is staying constant.
It's usually less of a zero-sum game than we might expect.
Also some people have a plan to leave their country either way, so giving them opportunities in fields that might be useful for everyone should be a net positive.
Other countries subsidizing education and the more developed ones reaping the results is very much a zero-sum game. Immigrant myself, I'm all for people getting better lives, however if you're talking churning 10-20% of a small country's doctors or nurses to the US it would be catastrophic.
There's more nuance, in that it's not just a one-way transfer, and education is not just subsidized by the country.
On the former, Phillipines are sailant example of sending people abroad to get goods and money back, but this happens at some scale for all other countries with a significant emigration. The money fed back in the original country is usually not something to sneeze at.
The other part is, education benefits everyone beyond the single individuals. Having a strong enough education programs that opens the door to move to other countries with strong requirements is an asset that also benefits the origin country. In most countries only a small portion will go abroad, so improving the overall level of students stays important, and the bigger the pool the more you have inter-student emulation + economy of scale effect.
Also the monney spent by the country into education is not just for single children and has a global societal effect.
All in all, IMHO it's not a black and white as "that kid wasted our tax dollars by going abroad"
Here's an archive from 2020 https://archive.is/AYEyC which shows that the number of closures has been gradually increasing from 2010 onwards, agreed that it's not politics as much as another removed commentor claimed it was.
Rural hospitals were always on a time limit, there isn't enough people sticking around for rural or small town to keep the business running. The same goes for any business there. Death of the town is exacerbated by the cities who offer greater salaries and sometimes better activities at the cost of some living space, which can be offset by enough salary.
We will see whether or not the lure of cities stay true over the next decade or two, but nothing is here to save anything small from their death.
>Rural hospitals were always on a time limit, there isn't enough people sticking around for rural or small town to keep the business running.
That seems overly focused on the economics. Which are important, but when someone in one area needs to travel 100 miles to the nearest hospital, while another has a dozen hospitals within a 35sq mile area, there's a problem.
Considering only the operating costs ignores the people rural hospitals serve.
Which is why a single-payer system of some sort in the US is how we get out of this, reducing overhead/profit/middlemen and (potentially) redirecting those resources to providing decent care to everyone in the US.
If we don't move that forward, healthcare company execs will continue to channel Maxey Eckstein[0]:
On his first day as a bus driver, Maxey Eckstein handed in receipts of $65.
The next day his take was $67. The third day's income was $62. But on the
fourth day, Eckstein emptied no less than $283 on the desk before the
cashier.
"Eckstein!" exclaimed the cashier. "This is fantastic. That route never
brought in money like this! What happened?"
"Well, after three days on that cockamamie route, I figured business would
never improve, so I drove over to Fourteenth Street and worked there. I tell
you, that street is a gold mine!"
> That seems overly focused on the economics. Which are important, but when someone in one area needs to travel 100 miles to the nearest hospital, while another has a dozen hospitals within a 35sq mile area, there's a problem.
Probably because economics is the determining factor to everything. Notice how you went directly into the same issue, and then kept the same focus for the remainder of your comment.
> Which is why a single-payer system of some sort in the US is how we get out of this
This is a massive jump of logic with no attempt, let alone meaningful, in connecting ideas together.
>Probably because economics is the determining factor to everything. Notice how you went directly into the same issue, and then kept the same focus for the remainder of your comment.
My point was to compare the utility of hospitals to the utility of city buses.
Yeah, if you go where all the people are, you'll have more customers. But that leaves the folks who depend on a hospital (or a bus route) without any service.
>This is a massive jump of logic with no attempt, let alone meaningful, in connecting ideas together.
There's no "jump of logic" here. At all. Removing the profit motive provides more resources to, you know, provide health care.
Reallocating resources to more broadly provide services, in this case, to the "rural" (which is, as broadly defined by the US Census, anything that's not an urban area or adjacent suburban area -- as defined by population density, includes most small towns) population.
I didn't specifically spell that out, as it seemed intuitively obvious. But I guess not, at least not for you.
> when someone in one area needs to travel 100 miles to the nearest hospital, while another has a dozen hospitals within a 35sq mile area, there's a problem.
put another way, when someone who needs hospital access chooses to live 100 miles away from one while other living options offer a dozen hospitals within a 35sq mile area, that person has caused a problem for themselves
Rural hospitals/communities have serious medical staffing problems throughout the world, not just the US. As it turns out, there's a reason most people with means want to leave them. (Even if they don't mind owning a summer datcha in one.)
The US doubles down on this problem, due to not having a single-payer system.
Modern educated young people generally don't stay in their small rural towns devoid of opportunity, so the supply of willing healthcare workers dwindles and the population of these towns trends older and sicker. 30 years ago I suspect people had more kids and they had a greater propensity to stick around due to sheer ignorance of outside opportunity/QoL pre-internet age.
Traveling nurses like myself can fill the holes, but we don't come cheaply as we give up a lot to work away from friends and family in undesirable locations. Traveling docs (locums) feel the same, and are even more expensive- 20k to work a weekend in an ER isn't unheard of.
My personal opinion having driven all across America over the last few years and working in a bunch of these small to mid size cities is that they really have no reason to exist and would fade away without government welfare prolonging the misery. Most were founded near a mine or factory that has long since left and is extremely unlikely to ever return. In the past you'd quickly get a ghost town, today you get an economically depressed meth town that stumbles along for decades consuming lives.
That's not what's going on. Things didn't start going downhill until the bill hospital outfit in our state started buying everything up. Now that they own all the doctors offices, immediate meds, and hospitals, they've started shutting down anything they feel is redundant. This has caused medical professionals to leave the area as the increased competition for jobs has driven wages down and, more importantly, work hours up. All in all, everything has gone to crap. There are few facilities left in the area and the ones that are near by have TERRIBLE reviews as the constant turnover has taken it's tole on the practices.
This. It's called block scheduling. They want every minute of every resource every day to be filled or even overbooked. Rural medical centers are difficult to do this with, so they get shut down, forcing people to drive further. A single rural medical center can't be full, but if you close down 5 of them and force everyone near those 5 locations to drive an hour or three to a bigger one, it's much easier to fill. It's corporate consolidation and greed.
And every single diagnosis is reduced to rote procedure. I have no less than 3 lingering issues that I've been dealing with for YEARS that I cannot seem to get cleared up. I'm pretty sure more costly diagnostics (cat scan or colonoscopy) will pinpoint the issue, but they refuse order them and instead shrug off the problem because "all of the lab work looks healthy."
About 20 years ago, the rural town I was living in built a new, larger (40 beds - previous one was 20 beds) hospital. It was greatly debated in the community because the federal government was pushing the grants that would build it but there was no ongoing money to keep it running.
For the last 10 years, they've struggled to keep it staffed and pay the bills because the rural community and economy continues to shrink. It should have never been built but it's difficult to say 'no' when all those 'free' federal dollars are waved in front of the local powers that be.
In my opinion, in modern civilization, concentration in megacities is inevitable. I think it is unavoidable whether it is a centralized country (France, Korea, etc.) or a decentralized country (USA, Japan, Germany, etc.). Since the benefits of globalization are concentrated in cities, the high-skilled workforce tends to stay in big cities. As in the example above, poor quality of care in rural areas is just one consequence. (In Korea, where I live, this issue has recently been on the rise.)
I believe healthcare as a business (in the US) relies on the fact that the utility function of healthcare services become infinite. All other utility relies on an individual's good health. As such, it becomes completely determined by wealth distribution, not the value or cost of the product being traded. It's natural that a healthcare system that attempts to follow market based solutions follows the money. In the US, all the money has moved to cities so healthcare is following.
Some of these are super tiny...20 beds doesn't really seem like a hospital to me. Not saying this is a good trend but I'm not sure how you stay afloat with such a small footprint.
Mount Graham Regional Medical Center in Safford, AZ, is a Level IV trauma center. It has 25 staffed beds. Safford has a population of just over 10,000, and is approximately two hours to Tuscon by car. A Level IV trauma center provides initial evaluation, stabilization, diagnosis, and, perhaps, surgery and critical care, but what it mostly provides for serious cases is transportation to a bigger hospital, especially in the case of Mount Graham, which is listed as a short term acute care facility.
This comes directly from combat medicine: Small facilities save lives, especially if they're geared up to send serious cases to bigger units. Level IV trauma centers are at the bottom of what the American College of Surgeons recognizes as a trauma center, but they're still a vital part of the infrastructure.
No it wouldn't IMHO. It cannot have the expertise, the equipment, the clubs, the social opportunities, the field trips, the sports or 101 other things that a facility with even just 10 classes can offer.
Those are very different institutions and pretending they are the same is likely deceptive when they will produce vastly different outcomes for their users.
It costs a lot to have infrastructure (hospitals, roads, power, water, etc.) across the country. I wonder if this is one of the long (long) term effects of moving from an agricultural, to industrial, and then knowledge economy.
It absolutely is. All these rural communities only existed in the past because there was an economic need for them, usually because of the mining or agricultural industries. The mining industries have dried up in many places, leading to "ghost towns" (this was happening back in the 1800s), and agriculture these days doesn't need nearly as much labor, so there just isn't much reason for many of these communities to continue to exist without some new industry to support them. So people are moving away to other places where there's jobs. This isn't a new story; it's been happening for centuries, or even millennia. But now, all of a sudden, people are bemoaning it for some odd reason.
Can we take all the people suffering from fentanyl addiction and get the federal government to pay for their medical care to prop up these hospitals? In my opinion this is the only way we can manage this crisis.
If I have a surgery, I want it done by a surgeon and team that does this surgery every day, not by a surgeon in a rural hospital that does whatever surgeries someone needs within 50 miles.
Yeah, but in a rural area that's often not possible. My rural family has been helicoptered/jetted out to city hospitals(thank deity they had Medicare/insurance to pay), but that still takes an an hour or two to get you to the hospital, sometimes more if the helicopter is occupied with another emergency. The tiny local hospital that's a 10mi ambulance drive, or the slightly larger hospital 30mi away is your only chance if you're bleeding out quickly.
What do they define as rural? Because I’m in a small town that now has a hospital AND two urgent cares and I suspect most people would call it rural but it might be “urban”.
Rural is simply defined as "not urban". Urban is defined as a cluster of at least 5,000 people in sufficient density. I don't know exactly what the density is. But I believe anything you would recognize as a small town is dense enough. So if there are 5,000+ people in your town you are urban.
Ultimately it's the nature of capitalism and it's something that's going to keep happening as rural areas vote for individuals that exacerbate the issue. Hospitals, doctors etc are going to move to where they can earn the most profit and rural towns are both not profitable enough and don't have the amenities that a high-earning profession would normally expect.
To fix this problem you would either need to accept that rural areas will need to be subsidized by urban tax payers or you would need to build a proper transportation system that allows for easy and quick movement between urban and rural areas.
