Analysis

Trump’s Executive Order on ‘Welfare’ Is Designed to Pit Workers Against One Another

On Tuesday night, President Donald Trump signed an executive order that sums up how little he understands about poverty in America.

The order, titled “Reducing Poverty in America by Promoting Opportunity and Economic Mobility,” carries little weight by itself. It directs a broad range of federal agencies to review programs serving low-income people and make recommendations on how they can make the programs harder to access, all under the guise of “welfare reform.”

The order’s main purpose appears to be smearing popular programs in an effort to make them easier to slash—in part by redefining “welfare” to encompass nearly every program that helps families get by. To that end, the order reads as follows:

The terms “welfare” and “public assistance” include any program that provides means-tested assistance, or other assistance that provides benefits to people, households, or families that have low incomes (i.e., those making less than twice the Federal poverty level), the unemployed, or those out of the labor force.

Redefining everything from the Supplemental Nutrition Assistance Program (SNAP, formerly known as food stamps) to Medicaid to Unemployment Insurance to child care assistance as “welfare” has long been part of conservatives’ playbook, as my colleague Shawn Fremstad has pointed out. The term has a deeply racially charged history in the United States, evoking decades of racial stereotypes about poverty and the people who experience it. By using dog-whistle terms like welfare, Trump is erecting a smokescreen in the shape of President Reagan’s myth of the “welfare queen”—so we don’t notice that he’s coming after the entire working and middle class.

Decades of research since TANF was enacted show that work requirements do not help anyone work

The fact is, we don’t have welfare in America anymore. What’s left of America’s tattered safety net is meager at best, and—contrary to the claim in Trump’s executive order that it leads to “government dependence”—it’s light-years away from enough to live on.

Take the Supplemental Nutrition Assistance Program. SNAP provides an average of just $1.40 per person per meal. Most families run out of SNAP by the third week of the month because it’s so far from enough to feed a family on.

Then there’s housing assistance, which reaches just 1 in 5 eligible low-income families. Those left without help can spend up to 80 percent of their income on rent and utilities each month, while they remain on decades-long waitlists for assistance.

And then there’s Temporary Assistance for Needy Families (TANF), the program that replaced Aid to Families with Dependent Children in 1996 when Congress famously “[ended] welfare as we know it.” Fewer than 1 in 4 poor families with kids get help from TANF today—down from 80 percent in 1996. In fact, in several states, kids are more likely to be placed in foster care than receive help from TANF.

Families who do receive TANF are lucky if the benefits even bring them halfway to the austere federal poverty line. For example, a Tennessee family of 3 can only receive a maximum of $185 per month, or a little over $6 a day.

Yet TANF is the program Trump is holding up as a model—hailing 1996 “welfare reform” as a wild success—despite the fact that TANF has proven an abject failure both in terms of protecting struggling families from hardship and in helping them get ahead.

In particular, this executive order directs agencies to ramp up so-called “work requirements”—harsh time limits on assistance for certain unemployed and underemployed workers—which were at the heart of the law that created TANF. But decades of research since TANF was enacted show that work requirements do not help anyone work.

Make no mistake: Pushing for “work requirements” is at the core of the conservative strategy to reinforce myths about poverty in America. That “the poor” are some stagnant group of people who “just don’t want to work.” That anyone who wants a well-paying job can snap her fingers to make one appear. And that having a job is all it takes to not be poor.

Workers are forced to turn to programs like Medicaid and SNAP to make ends meet, because wages aren’t enough

But in reality, millions of Americans are working two, even three jobs to make ends meet and provide for their families. Half of Americans are living paycheck to paycheck and don’t have even $400 in the bank. And nearly all of us—70 percent—will turn to some form of means-tested assistance, like Medicaid or SNAP, at some point in our lives.

Trump claims his executive order is intended to eliminate “poverty traps.” But if he knew anything about poverty—aside from what he’s learned on Fox News—he’d know the real poverty trap is the minimum wage, which has stayed stuck at $7.25 an hour for nearly a decade. That’s well below the poverty line for a family of two—and not nearly enough to live on. There isn’t a single state in the country in which a minimum-wage worker can afford a one-bedroom apartment at market rate. Many low-wage workers are forced to turn to programs like Medicaid and SNAP to make ends meet, because wages aren’t enough.

If Trump were really trying to promote “self-sufficiency”—a concept he clearly doesn’t think applies to the millionaires and billionaires to whom he just gave massive tax cuts—he’d be all over raising the minimum wage. In fact, raising the minimum wage just to $12 would save $53 billion in SNAP alone over a decade, as more low-wage workers would suddenly earn enough to feed their families without nutrition assistance.

Yet there’s no mention of the minimum wage anywhere in Trump’s order to “promote opportunity and economic mobility.”

Which brings us back to the real purpose of this executive order: divide and conquer.

Trump and his colleagues in Congress learned the hard way last year how popular Medicaid is when they tried to cut it as part of their quest to repeal the Affordable Care Act. And it’s not just Medicaid that Americans don’t want to see cut. Americans overwhelmingly oppose cuts to SNAP, housing assistance, Social Security disability benefits, home heating assistance, and a whole slew of programs that help families get by—particularly if these cuts are to pay for tax cuts for the wealthy and corporations. What’s more, as polling by the Center for American Progress shows, Americans are less likely to vote for a candidate who backs cuts.

By contrast, vast majorities of Americans across party lines want to see their policymakers raise the minimum wage; ensure affordable, high-quality child care; and even enact a job guarantee to ensure everyone who is able and wants to work can find a job with decent wages. These sentiments extend far beyond the Democratic base to include majorities of Independents, Republicans, and even Trump’s own voters.

That’s why rebranding these programs as welfare is so important to Trump’s agenda. Rather than heed the wishes of the American people, Trump’s plan is—yet again—to tap into racial animus and ugly myths about aid programs in order to pit struggling workers against one other. That way, he can hide his continued betrayal of the “forgotten men and women” for whom he famously pledged to fight.

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First Person

Medicaid Work Requirements Would Have Killed Me

In the Japanese practice of Kintsugi, broken pottery is repaired with gold. During this process, the pieces of the broken vessel are held together patiently by the steady hands of the artisan, and filled in with lacquer, which is dusted with gold.

I am that vessel, broken and restored.

I was born addicted and given up for adoption.

Dismissed from social groups and bullied in high school.

Sexual trauma as my first sexual experience.

Subsequent suicide attempt.

My sense of self began to leak, falling away from me, slipping through the cracks.

I survived Hurricane Katrina.

And the looting.

My husband was deployed to war.

My child almost died at birth—and so did I.

Another deployment.

My marriage is crumbling.

I’m a single mother.

I can’t take it anymore.

Heroin.

On December 7, 2011, after 7 years of addiction, I was arrested and taken to Campbell County jail. I stayed there for 9 months and was released to shock probation Shock probation is when a judge orders a person serve a short stint in jail, then releases them to serve the remainder of their sentence on probation. The theory behind the practice is that the short prison sentence will reduce recidivism for first-time offenders. in a halfway house.

I tried so hard to adjust, but I couldn’t do it. I didn’t have health insurance, so my ADHD and anxiety disorders were not being treated. I was getting recovery material from participating in substance abuse treatment, but I couldn’t concentrate or remember things. Three weeks later, I returned to jail because I wasn’t doing the laundry chore the right way—I kept forgetting to empty the lint trap in the dryer and use the sign-in/sign-out book.

Once I was back in prison, I had health care and didn’t need insurance. I was able to complete a six-month program for women who have dual diagnosis—mental illness and substance abuse. I graduated and was released in May 2013, a completely new human being with an education on the most important subject I could ever learn about: myself. I had a 30-day prescription and a suggestion to follow up with my primary care physician and go to a meeting.

All I needed, yet again, was health insurance.

I couldn’t work for several months after being released. My only experience was serving in bars and restaurants, but I was terrified that the job would make me relapse. I have severe back pain, and I’m allergic to the only medicine that’s legal for me to use to relieve it. Even when I was mentally and emotionally capable of going back to work, I struggled to find employment as a convicted felon on parole. I had no license, no transportation, no birth certificate. I had no money.

I lived at home with my parents and felt like a tremendous burden as they shuttled me to and from probation and parole, to free clinics, to prescription pharmacy program buildings, and to my meetings. They watched me struggle in disbelief at first, thinking I could try harder. But soon they realized how hard it was to get a job interview, let alone a job.

That’s how, almost 10 months after my release, I found myself sitting in my empty bathtub. I was fully dressed and weeping, screaming silently at a god I didn’t believe in anymore to “fix it,” or I was going to end it all.

That’s when I heard the mailman. He rang the bell and brought me a package for my father, and on top was my approval notice from Medicaid. In that moment, I literally felt like President Obama had done that just for me—to keep me here, so I’d keep fighting for myself.

I can tell you with absolute certainty that people will die if these restrictions are implemented

Just as the vessel is held together by the hands of the artisan, I was held together by Medicaid.

My doctors and I worked together fill the cracks in my life with things far more valuable and precious than gold.

Love for myself, my family, and the rest of humanity.

Coping skills for the times when I am not well.

Dedication to a beautiful, intelligent 11-year-old son.

Now, I’m pursuing a bachelor’s degree at Northern Kentucky University, with two years of experience working on the front lines of the opioid epidemic as a Kentucky State Certified Peer Support Specialist. I have helped people navigate their own road to recovery by partnering with them to identify and knock down the very same barriers I faced.

But last night, President Trump issued an executive order that could make stories like mine a lot less common. It asks any federal agency that provides assistance to low-income people to re-examine their programs and add work requirements whenever possible. It builds on a letter that the Centers for Medicare and Medicaid Services issued to state Medicaid directors earlier this year, allowing states to strip coverage from people who can’t find a job.

People like me.

People who aren’t working because they can’t: because they’re sick or they have a record or they have a disability or they can’t find a job or they’re taking care of their aging parents.

People who need help.

I’ve been on both sides of the opioid epidemic, and I can tell you with absolute certainty that people will die if these restrictions are implemented. I had to fight way too hard and for far too long to get where I am today.

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Feature

Sending Troops to the Border Will Cause More Migrant Deaths

Late Friday night, Defense Secretary James Mattis approved the deployment of up to 4,000 troops to the U.S.-Mexico border. The order, which came after President Donald Trump called for an increase in troops in response to a caravan of refugees making their way north to seek asylum, is not the first time the National Guard has been sent to the border (President George W. Bush sent 6,000 troops in 2006 and President Barack Obama sent 1,200 in 2011). However, many people living in the borderlands believe the action escalates an already-weaponized war zone, and at a time when the United States is seeing the lowest border crossing numbers since 1971.

The National Network for Immigrant and Refugee Rights (NNIRR) defines border militarization as “the systematic intensification of the border’s security apparatus, transforming the area from a transnational frontier to a zone of permanent vigilance, enforcement, and violence.”

The NNIRR further states that “the outcome of border militarization has not been to deter migration, but instead to create more vulnerability.”

Sixty miles south of my home in Tucson, at the U.S.-Mexico border, a crude steel wall cleaves the town of Nogales in half. Once a single town, relatives now stretch their arms through slits in the wall to hold hands. North of the border, Interstate 19 runs through a scrubby desert, past dusty Arizona ranch towns and gated retirement communities, paralleling the green line that marks the Santa Cruz River. The desert stretches out as far as you can see: thousands of acres of rocky mountain ranges, remote wilderness areas, First Nations land, and cattle ranches.

In 1994, the U.S. Border Patrol began a new strategy called Prevention Through Deterrence. Urban areas from Brownsville, Texas, to San Diego, California, were outfitted with more Border Patrol agents and military-style equipment, including cameras and walls. As a result, it was no longer possible for migrants to cross the border in urban areas. They now had to traverse remote stretches of desert by foot.

In the Sonoran Desert, summer temperatures can climb up to 120 degrees near some of the most commonly used crossing routes. Monsoon storms turn bone-dry arroyos into dangerous flash floods. In winter, below-freezing nighttime temperatures can induce hypothermia. There is little shade and the only water might be found inside the belly of a cactus, or an algae-filled cattle tank. There are rocks to turn ankles, rattlesnakes, and miles upon miles of spiny cacti.

In the last two decades, more than 7,000 bodies of migrants have been found in the Arizona desert, most having died of exposure or dehydration. Thousands more men, women, and children have disappeared. In 2015 alone, more than 1,200 missing persons cases were opened by the human rights organization La Coalición de Derechos Humanos, in response to people looking for loved ones who went missing on the journey through the desert.

A report co-authored by La Coalición de Derechos Humanos and humanitarian group No More Deaths reads, “The region has been transformed into a vast graveyard of the missing.”

*                    *                    *

In the late 1990s, southern Arizona communities began to witness the effects of increased border militarization. Human remains were found in the desert. The Medical Examiner’s morgues continued to fill up throughout the early 2000s, as missing persons reports and phone calls increased from frantic family members. Border Patrol checkpoints appeared along rural roads and highways. Reports of racial profiling in urban areas increased, as did raids in neighborhoods and workplaces.

A widespread citizen response began—one that, full disclosure, I joined as a volunteer for La Coalición de Derechos Humanos and No More Deaths when I moved to Tucson in 2005. Several groups were formed to provide legal support, missing migrant searches, public education, and direct humanitarian aid. Others continued the work they’d been doing to support border crossers since the Sanctuary Movement of the 1980s. Local volunteers—including retirees, pastors, nurses, and youth activists—drove desert roads and hiked into remote areas to leave gallons of water along migrant trails, hoping it would save lives. “¡Hola, hermanos! Somos amigos de la iglesia. Tenemos comida y agua,” they called as they walk through the desert brush. Hello, brothers! We’re friends from the church. We have food and water.

In the last two decades, more than 7,000 bodies of migrants have been found in the Arizona desert

Over a three year period between 2012 and 2015, No More Deaths tracked approximately 31,000 gallons of water they placed in an 800-square-mile radius. Eighty-six percent of the water was used, demonstrating high need. But over that same period of years, water jugs were vandalized by humans at an average of twice per week. “Although it is likely that multiple actors are responsible for the destruction of humanitarian aid at our water-drop sites, the results of our [geographic] data analysis indicate that US Border Patrol agents likely are the most consistent actors,” states the report.

A series of videos taken by wildlife cameras and personal cameras clearly show Border Patrol agents destroying water jugs and other humanitarian aid supplies. In one video, a female agent kicks a line of water jugs one by one, smashing the plastic containers against the rocks. In another, a male agent looks into the camera and sneers at the unseen videographer. “You’re gonna’ get a good shot. Just picking up this trash somebody left on the trail,” he says. “It’s not yours, is it? All you have to do is tell me that it’s yours.” He pours out water from the jugs as he talks, his forehead glistening with sweat.

On January 17, 2018, just hours after the above video footage was released, eight No More Deaths volunteers were apprehended by Border Patrol. All are being charged with federal misdemeanors, except for Scott Warren, a faculty associate at Arizona State University and a longtime No More Deaths volunteer, who is being charged with a felony for harboring migrants after agents witnessed him providing two people with water and food. If convicted, he could face five years in prison. In Cabeza Prieta National Wildlife Refuge—where the volunteers had been looking for distressed migrants and leaving humanitarian aid supplies—No More Deaths volunteers discovered 32 sets of human remains in 2017.

This is not the first time that the federal government has brought charges against No More Deaths volunteers. In 2005, Shanti Sellz and Daniel Strauss were arrested while transporting three severely dehydrated migrants to a medical facility, and charged with smuggling and conspiracy felonies. They each faced a maximum sentence of 15 years in prison and a $500,000 fine. After over a year of legal proceedings and a widespread grassroots campaign in support of humanitarian aid, the charges against them were dropped. In 2008, Walt Staton, then a seminary student, was cited for littering after U.S. Fish and Wildlife officers found him leaving water containers on trails in the Buenos Aires National Wildlife Refuge. Several months before Staton’s citation, Dan Millis was cited for littering, also by U.S. Fish and Wildlife officers, for leaving water containers in the wildlife refuge.

For Millis, the citation came just two days after he and three other No More Deaths volunteers found the lifeless body of a 14-year-old Salvadoran girl in a nearby remote area. Josseline Hernandez and her 10-year-old brother had been traveling with a group of other border crossers when Josseline became ill and was left behind. The siblings were on their way to California to meet their mother. Millis spent months in court fighting the littering charges, arguing—as Sellz and Strauss did—that “humanitarian aid is never a crime,” and that water containers left in the desert with the intent to save lives is not litter. He won the case in an appeal to the Ninth Circuit Court, which ruled that the water containers were not garbage.

*                    *                    *

Todd Miller, a journalist and the author of two books about the militarization of the U.S.-Mexico border, says the Trump Administration’s decision to send the National Guard troops to the border “reinforces, supports, and frees up the U.S. Border Patrol, a self-described paramilitary agency.”

Since 1993, the U.S. Border Patrol’s annual budget has increased more than ten-fold, from $363 million to over $3.8 billion, and the number of agents increased from 4,000 to 21,000. The combined budgets for Customs and Border Protection and Immigration and Customs Enforcement in 2017 was $19 billion—more than the FBI, DEA, and U.S. Marshals Service combined.

“The Border Patrol not only operates on the international boundary line, but also in 100-mile jurisdictions, and they do it with extraconstitutional powers above and beyond what normal law enforcement can do,” says Miller. “They can put up checkpoints, pull people over in roving patrols, and essentially violate the 4th amendment—the right to not be searched or seized. This is why the ACLU calls the borderlands a ‘constitution-free zone.’”

The effects of militarization also spill into courtrooms in communities along the border. In 2005, under President George W. Bush, Operation Streamline began, a daily assembly-line courtroom processing of undocumented migrants found crossing the border. During the Obama presidency, Operation Streamline increased dramatically. In just two hours, up to 70 people can be tried and sentenced.

Miller has spent the last eight years researching the private military companies that also want to cash in on border militarization. He describes attending border security conventions with “vendors and companies adamantly discussing their desire to break into the border security market.” In the early 2010s, as U.S. military operations were winding down in Iraq and Afghanistan, Miller says many of those companies expressed that they were in search of new markets. “One vendor, who had before sold his company’s products to the U.S. military, told me ‘we are now bringing the battlefield to the border.’”

In the years since Prevention Through Deterrence began, poverty and violence have continued to force those fleeing for their lives to head north. And so they come—exhausted from the journey, some with babies in their arms, seeking work, seeking a good safe life—and when they reach the border, they are inhumanely squeezed into the gauntlet of the desert, where, as Miller says, “death has become one of many deterrents.”

“When you consider human security, such as the right for a person to have shelter, food, health, education, a future, you see quickly that the billions of dollars put into border militarization are drastically misplaced,” Miller says, joining the many border residents who say that the U.S. government should address the socioeconomic and political reasons driving migration in the first place.

But instead of tackling those root causes of migration, Miller says the U.S. government has focused on putting up walls and bringing the military to the border. In an April 5 interview with Democracy Now, he said, “There will be more agents. There will be more walls. There will be more technologies. There will be more checkpoints. There will be more drone surveillance. There will be more expansion of this apparatus into these 100-mile jurisdictions. And I think that’s the intention.”

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Feature

Six Months Into #MeToo, We Still Aren’t Helping Victims Heal

Living with post-traumatic stress disorder (PTSD) is, in many ways, similar to living with cockroaches. When you first notice the infestation, it’s all you can think about. Even if it’s small, even if you only see a little black bug scuttling across the kitchen floor once every few days, you are consumed by panic. You feel their legs brushing your face as you lie in bed trying to fall asleep. You imagine their wiggling antennae poking out from the bottom of your coffee cup. Under every pillow, behind every cabinet, you imagine you will uncover a new nest, writhing with horrible little bodies that scurry across your toes as they try to escape the sudden exposure.

Then, after a while, you get used to them. They get worse; they multiply. But you stop noticing. Eventually, you flick them off your body like nothing. You watch with dull reserve when you uncover yet another nest. They become a part of your life. Once you have roaches, you can never really get rid of them—you can only try to mitigate their effects.

Women have been dealing with a lot of roaches. The viral MeToo hashtag has brought to light the horrifying impact of sexual and physical assault against women, which is an inarguable advance from the (sometimes not-so-distant) times when violence against women was so widely accepted it was used to sell household products. Like any powerful social movement, however, it has its critics. “Why now?” has become one of the biggest questions detractors are asking. If this is such a major problem, why didn’t survivors come forward earlier? Why do so many still hold back from reporting, or testifying in court?

People still ask me those questions. They ask even though it’s 10 years after the end of my abusive relationship, and even though I still live in a world overrun by my trauma. They ask even though providing the testimony that would incarcerate my abuser meant inviting a lifetime of PTSD, which arises only in the aftermath of trauma, when the long-used survival mechanisms fail to shut off.

I still live in a world overrun by my trauma

The events that took place between the ages of 15 and 20 remain trapped in my body like shrapnel too precarious to be extracted. They are distanced from the rest of me by dissociation and selective amnesia; psychological post-traumatic scar tissue. I can’t always recall the details attached to each trigger, but I know them by their symptoms: anger, shame, debilitating self-doubt, panic attacks, suicidal ideation, substance use, an unshakable sense of not belonging.

I didn’t know exactly how much the aftermath would hurt until I finally walked away, but I had inklings every time I tried. I would spend days cycling between joy and misery; torn between my desire to live free from violence, and the despairing knowledge that healing would require painful, arduous work. When I finally testified, it was in spite of myself. I had already recanted previous reports countless times before I finally gathered the courage to stand my ground.

Domestic violence is so intensely damaging because it is personal, targeted, isolating, and private, but that pressure to recant is nearly universal. In a 2011 study of abuser-victim dynamics, Amy Bonomi and other researchers listened in on recorded conversations between jailed male abusers and their female partners. In 17 of 25 pairings, the abuser was able to convince his partner to recant her testimony (the other conversations were inaudible or included people who were not the primary victim). All of these conversations followed a pattern: The abuser first minimized the assault, then elicited sympathy from his victim by describing the hardship of life in jail, before romanticizing the “good times,” bonding over a shared dislike of a hostile authority figure, and finally requesting that she recant.

Given the likelihood that victims recant, it’s no wonder prosecutors seemed concerned when my abuser’s conviction hinged on my testimony. The county assigned me a victim’s advocate who coached me through the court process and periodically checked in on my welfare and willingness to speak in court. But after the sentencing, it was four years before I heard from their office again—and then only to meet with me briefly about his release. I was not set up with a network of trauma care workers. Nobody followed up to learn whether I had stable housing, or how my job search was going after school. I was left alone to deal with the aftermath, and 10 years later I am still struggling to overcome that oversight.

Studies have found that women who survive intimate partner violence suffer myriad long-term physical and mental consequences. (Although domestic violence happens across the gender spectrum, it is most common between male assailants with female partners; because of this, most research focuses on couples that fit this dynamic). Digestive problems, eating disorders, issues with reproductive organs, headaches, and blackouts are some of the most common physical ailments associated with domestic violence. PTSD develops at a 74:3 ratio in women who have been abused versus those who have not.

I’ve always lived below the poverty line, but before developing PTSD, I never struggled for what I really needed. The aftermath of abuse left me floundering for everything. No one warned me how hard it would be to stay alive after the relationship was over. I was able to complete graduate studies in writing, but not without a good dose of heroin—and that, of course, came with its own set of debilitating consequences. Before building enough contacts and credits to work as an income-earning freelance writer, I was mostly unemployed, occasionally bouncing between telefunding jobs, and constantly struggling to keep my family housed and fed. Even recently, when my husband suffered a costly health complication, we ended up with an impending eviction that we were only able to skirt through an online fundraiser.

PTSD develops at a 74:3 ratio in women who have been abused versus those who have not

The financial devastation I experienced is not unique. Since the 1990s, health officials have known that battered women experience significant interruptions to their jobs that include unemployment, missing work, being late or leaving early, and even being fired. More recent data confirm that financial insecurity continues to be a major issue for abuse survivors—domestic violence is thought to account for a combined total loss of 8 million work days each year. Couple that with the fact that 99 percent of women who are physically abused also experience financial abuse, and the well-recorded difficulties associated with escaping poverty (especially if mental illness is involved), and you begin to see a very grim picture—one that leaves already-vulnerable victims struggling to access enough resources to survive.

Survivors of intimate partner violence should not disappear into a black hole after escaping the abuse, nor should we assume they are okay just because they are “safe.” The evidence says they are not. And so, six months into #MeToo, we need to start dealing with the wreckage.  #MeToo allowed women to realize that they were not alone—that many of us have cockroaches, and the filth does not belong to us. #MeToo allowed women to let out a long-awaited sigh of relief. But it also triggered some survivors, who weren’t ready to face their trauma. It made women feel guilty for not being ready. It made those on the outside think that sending the aggressor to prison was the end of the story. It made people forget that domestic violence survivors still need help, even after the relationship ends.

There is no longer any basis to argue that domestic violence doesn’t have a long-term physical, psychological, and financial toll. The question is now, what are we going to do about it?

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Feature

Hospitals Are Leaving Rural America. Rural Americans Are Staying Put.

Kendra Colburn spent a decade uninsured. During those years, she worked as a carpenter near her hometown in rural Vermont, earning just enough that she didn’t qualify for low-income health care, but not enough to afford health insurance on her own. While uninsured, she suffered two major work injuries that landed her in the emergency room—once, a nail shot through three of her fingers, and another time, a piece of wood kicked back on the table saw and sliced her arm. When she was unable to pay the emergency room costs, her credit took a hit for years.

Today, Colburn works on her brother’s farm and is covered by Medicaid. As a manual laborer, Colburn has developed nerve damage, which flares up in her hands and wrists with overuse. “I cut back my hours to deal with it. I can’t afford to not be able to use my hands,” she says. “That’s how I make all of my money.”

As a child who grew up in a farming community, Colburn says she observed that pain is just a part of being a farmer. “It’s taken for granted that your body hurts every day, that your back always hurts.” That’s true for workers employed in some of the most dangerous jobs: Many manual laborers with high rates of injury and repetitive stress injuries are also more likely to be uninsured. In fact, a 2015 study found that 65 percent of commercial farmers identified health insurance costs as the most serious threat to their farms.

Alana Knudson, co-director of the Walsh Center for Rural Health at NORC at the University of Chicago, prefers to discuss rural health care in terms of strengths, but she does recognize the real barriers demonstrated by statistics. “Overall, we know that people who live in rural communities are likely to have lower incomes than their urban counterparts,” she says. Rural residents are also more likely to have multiple chronic conditions and lower educational attainment, and they’re more likely to face barriers in accessing transportation to medical care.

But there are also less tangible barriers. Colburn says that many people she knows don’t feel comfortable navigating the complicated web of professional medical interventions when experiencing health issues. And the Medicaid system can often lack efficiency. Colburn says her state’s website often doesn’t work, and she still hasn’t figured out how to find a primary care doctor who takes her insurance. Once, a computer glitch resulted in her being removed from her insurance plan, and she was charged hundreds of dollars in out-of-pocket expenses. Even though it was an error on Medicaid’s part, Colburn was still responsible for the bill. “Generally when we’re talking about rural health care issues, we’re talking about access, as if once you get access that actually means something. But when you get access, it still can be a nightmare,” she says.

77 percent of rural U.S. counties are considered Primary Care Health Professional Shortage Areas

Faced with whether to seek medical attention or “make do,” Colburn says many people simply don’t go. She notes that farmers especially have a hard time leaving their farm obligations to take care of themselves. They also spend significant time outdoors, and it’s difficult to imagine a hospital stay. Colburn says, “I have treated myself or not gone a million times.” One spring, she stepped on a potato fork and punctured her foot. Instead of going to the doctor, she spoke with a community herbalist, used an herbal tincture, and soaked her foot in salt water.

“I know for a fact that I need a root canal,” Colburn says, “It used to hurt and now it doesn’t hurt, so I just deal with it.” She pauses. “I know a lot of people who just get their teeth pulled. And the dental piece is important because what your teeth look like has [a] direct impact on what opportunities you have.”

This reality is echoed by rural journalist Sarah Smarsh. “In the past year, the Affordable Care Act, or ‘ObamaCare’, has changed many lives for the better—mine included,” she wrote in an essay for Aeon. “But its omission of dental coverage, a result of political compromise, is a dangerous, absurd compartmentalization of health care, as though teeth are apart from and less important than the rest of the body.”

*          *          *

The fabric of rural America is shifting, in large part due to changes in agriculture. Knudson grew up in North Dakota and says she’s seen that change firsthand. “Our neighbors are farming our land and they seed over 10,000 acres. A lot of the small farms are not there anymore.”

Many children of farmers choose not to take over the farm. Land is then sold or leased to larger farms. Small businesses that once depended on a critical mass of farm families as customers also go out of business. The effects of this rural migration are particularly severe on rural elderly with complex medical needs—and no younger generation remaining in the area to care for them.

Last year, a photographer and I drove across Kansas and Iowa to report on the hidden crisis of farmer suicide. We visited Onaga, Kansas, a small town with a newly renovated hospital. Just blocks from the hospital’s beautiful lobby and squeaky-clean floors were empty streets and boarded up storefronts. One doctor said the hospital had a hard time attracting medical professionals to practice there. The therapist had left months ago, she said, and they were struggling to fill the position.

An online search for “benefits for rural medical professionals” turns up a slew of sites about attracting medical talent to rural communities. Rural medical establishments are advised to advertise the lower cost of living and ability to buy acreage, less traffic, a quieter life, student loan forgiveness in certain underserved areas, “the potential to become the ‘town hero,’” more time spent with patients, and increased proficiency due to physicians seeing “a broader scope of illness.”

Still, rural communities are facing the closure of hospitals and clinics. In 2016, The National Rural Health Association (NRHA) announced that 673 rural hospitals were at risk to close. Of those, 210 were at “extreme risk” of closure. The NRHA warns that “Medical deserts are forming across the nation, significantly adding to the health care workforce shortage in rural communities. Seventy-seven percent of rural U.S. counties are already considered Primary Care Health Professional Shortage Areas.”

Knudson says the health care industry is undergoing a significant transformation in terms of how medical care is being reimbursed. “Our reimbursement system is moving from a volume to value,” she says. ”Historically hospitals have been reimbursed by the number of hospitalizations they provided—you have 10 hospitalizations and you get reimbursed for 10 stays. Our country has really shifted as much as possible to outpatient to make health care more affordable.”

That means a decrease in admissions, more outpatient procedures, and less reimbursable care for hospitals. Additionally, Knudson says many of the rural hospitals closing are in states that have not expanded Medicaid, which has led to a higher number of uninsured patients. “When people are uninsured, it’s difficult to collect payment for that hospitalization.”

Hospital closures can be devastating to rural communities, creating gaps in access to the detriment of residents. “Many of these hospital closures are happening in areas with the highest concentration of heart disease and diabetes, and in some of the poorest communities in the country,” says Maggie Elehwany of the NRHA. “When that hospital closes, it’s like putting a nail in the coffin of that community. You can’t attract businesses or families with kids or keep retirees. So we’re fighting not only for rural hospitals, but also for the economies of these rural communities as well.”

Rural communities are known for being innovative, self-sufficient, and organizing quickly in an emergency

In June 2017, Missouri Congressman Sam Graves introduced the Save Rural Hospitals Act (H.R. 2957). The bill doesn’t increase reimbursements, but it does offer stability for “the closure crisis” by eliminating cuts and Medicare Sequestration for rural hospitals. It also establishes a new Medicare payment designation, called the Community Outpatient Hospital, that would guarantee rural access to emergency care and give hospitals the choice to offer outpatient care. The bill was co-sponsored by 21 representatives (14 Republicans and 7 Democrats), but it is still waiting for a vote.

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Rural residents can’t afford to wait, so they are using the assets they have. Rural communities are known for being innovative, self-sufficient, and used to organizing quickly in an emergency. Families may have been rooted in one area for generations, which manifests in a deep knowing of their neighbors, as well as each other’s talents and stressors. And rural communities are often filled with people who want to help one another.

One story Alana Knudson tells me goes like this: One winter, in a northern rural community, an elderly man was treated for chronic urinary tract infections. He was treated and advised by medical staff to flush his kidneys as much as possible by drinking water. But he soon returned with another infection. When a community health worker visited his home, she discovered the man lived in the back of a shed, did not have an indoor toilet, and had to haul his own potable water.

At last, the urinary tract infections made sense. Knudson says, “It was not easy for this elderly man to traverse the snow and the cold in the dark to access the outdoor restroom, so he limited his fluid intake which contributed to reoccurring UTIs.”

To serve the health care needs of the nearly 60 million Americans who live in rural communities, Knudson says “it takes an entire team.” Ideally, Knudson says community health workers are part of that team. As public health workers who are also trusted members of the community, community health workers are particularly equipped to provide valuable connections between health or social services and the community. Primary care providers, pharmacists, social workers, health departments, and even agriculture extensions are critical members of the rural health care team. Knudson says, “A lot of different entities come together and complement each other. We can’t afford the luxury of duplication, so we really work together.”

“People come together to support others,” she says. “In my home community in North Dakota, we had a neighbor who had a heart attack during harvest, and all of us got together and finished the harvest for him. If you needed the help, you could count on your neighbors doing that.”

This frame is important, Knudson says, as much of the media attention about rural communities has been negative. As a result, she says, “There is such dystopia about rural America. We’re hearing from some rural communities that potential businesses are saying ‘we’re not interested in investing in rural America.’”

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