S RA THE STATE OF RURAL AMERICA

Seeking Refills: Aging Pharmacists Leave Drugstores Vacant in Rural America

By Tim Markian Hawryluk

Courtesy of Kaiser Health News

Ted Billinger Jr. liked to joke that he would work until he died. That turned out to be prophetic.

When Billinger died of a heart attack in 2019 at age 71, he was still running Teddy B’s, the pharmacy his father had started more than 65 years earlier in Cheyenne Wells, Colorado. With no other pharmacist to work at the store, prescriptions already counted out and sealed in bottles were suddenly locked away in a pharmacy that no one could enter. And Cheyenne Wells’ fewer than 800 residents were abruptly left without a drugstore.

Pharmacies were once routinely bequeathed from one generation to the next, but, in interviews with more than a dozen pharmacists, many said the pressure of running an independent drugstore has them pushing their offspring toward other careers. And when they search for a buyer, they often find that attracting new pharmacists, especially to rural settings, is difficult. With a large group of pharmacists nearing retirement age, more communities may lose their only drugstore.

“It’s going to be harder to attract people and to pay them,” said David Kreling, a professor emeritus at the University of Wisconsin-Madison School of Pharmacy. “If there’s not a generational thing where someone can sit down with their son or daughter and say that they could take the store over, there’s a good chance that pharmacy will evaporate.”

Tom Davis, Billinger’s friend and coowner of Kiowa Drug in Eads, Colorado, stepped in to sort out the mess in Cheyenne Wells. With permission from the State Board of Pharmacy, the county sheriff let Davis into Teddy B’s in the eastern Colorado town to take an inventory of

Tom Davis, pharmacist and co-owner of Kiowa Drug, outside his store in Eads, Colorado.

(Rachel Woolf for KHN)

the remaining drugs. Customers who had dropped off their prescriptions before Billinger died were able to pick up their medications.

Davis then bought the pharmacy from Billinger’s estate. He runs it as a convenience store and six days a week delivers prescriptions to it from Eads, 44 miles away.

“By the time you paid a pharmacist, the location there was borderline unprofitable,” Davis said.

He has received numerous requests to open pharmacies in other eastern Colorado towns, but making that work financially would be difficult. Reimbursements from insurance plans have dwindled, and customer bases have eroded as health insurers push patients toward mail-order deliveries.

“I fill prescriptions every day where my reimbursement is less than the cost of the drug,” Davis said. “In other settings, you might tell a patient, ‘We don’t have that in stock,’ or ‘Why don’t you go down the street to the chain?’ But down here, we just take care of our patients, and we just eat it.”

He can survive, he said, because, after 48 years, he no longer has any business debt.

“I look at my bottom line,” Davis said. “With the amount of profit that I had at the end of the year, that would not have been enough if I was having to pay a mortgage.”

Studies have found the number of pharmacists nationally to be sufficient, even more than enough, to meet current needs, although supply and demand don’t always line up. Finding pharmacists is more difficult in rural areas.

“Once they get a taste of the big city,” Kreling said, “it’s hard to get them back to the farm.”

Workforce data also shows worrisome trends. Concerns about a shortage of

pharmacists led the federal government to pour money into pharmacy schools in the 1970s, creating a temporary bump in the number of graduates. The people in that bulge in the pharmacist pipeline have hit retirement age.

“Many of them owned independent pharmacies, and they were working in rural communities,” said University of Minnesota pharmacy professor Jon Schommer, who studies workforce issues.

Now, as the demand for pharmacists to provide testing and vaccinations during the covid-19 pandemic increases, drugstore chains are offering incentives — such as large salaries, signing bonuses and help paying off school loans — that are often more enticing than anything a rural pharmacy could muster.

How pharmacy graduates envision their careers has also shifted. Many no longer want to own a pharmacy and are content to work at pharmacy chains or other health care organizations, according to several pharmacy school professors. As of 2018, only about half of pharmacists worked in traditional retail drugstores.

That makes rural recruitment more difficult.

Denise Robins had worked at R&R Family Pharmacy in Springfield, Colorado, for 18 years when the owner retired. She and three family members bought the drugstore in a last-ditch effort to keep it open.

“None of us are pharmacists, so that made it a little tougher,” Robins said. “We just knew it was really going to make it hard for people here if they had to travel an hour to get to a pharmacy.”

But finding a pharmacist to work in the southeastern Colorado town of fewer than 1,400 people was a challenge. The first pharmacist Robins found commuted 48 miles one way from Lamar. But after a year and a half, the trip became too much.

She then hired someone who wanted to work for only a year, to make enough money to travel. Then Robins interviewed two

Dia Giron, manager at Teddy B’s convenience store in Cheyenne Wells, Colorado, transfers prescriptions to a locked case after Kiowa Drug delivers them.

(Rachel Woolf for KHN) University of Colorado pharmacy school graduates. She hired one, but that didn’t work out. So she called back the second candidate, who still had not found a permanent job. He had two young kids, and he and his wife were working opposite schedules. He took the job two years ago and has remained there since.

In Berryville, Virginia, pharmacist Patricia White opened Battletown Pharmacy in 2011 because she wanted to carry on the family business. Her father had owned a local pharmacy and had recently died. But when turning a profit with Battletown proved a struggle, White decided to retire.

She lined up two potential buyers, but neither went through with the sale. She then hoped to transfer the pharmacy to a recent graduate but didn’t want to saddle him with a failing business.

“I told him he couldn’t make any money, and he said, ‘Thanks for being honest,’” White recalled.

Closing seemed like the only palatable option. Battletown shut down at the end of August. “I did not want to sell out to a chain,” she said. “That’s always been my mentality.”

When a chain buys a pharmacy, it doesn’t always decide to run it. Instead, it might close the pharmacy and transfer the pharmacy’s prescription files to one of its outlets. Retiring pharmacists who spent decades serving a community generally don’t want to see that happen, said David Zgarrick, a Northeastern University pharmacy professor.

“They’d like to sell their pharmacy to another pharmacist who would continue to run it very much in the same manner,” he said.

Some plan ahead, hiring another pharmacist and offering that person an equity stake in the business. Over time, the new pharmacist can buy out the owner. Many independent pharmacistowners plan to live off the profits from selling their pharmacy, its inventory and its prescription records.

“Their pharmacy is their retirement savings,” Zgarrick said.

But, Zgarrick said, the added pressure from the pandemic may be pushing more pharmacists into retirement. And a long-running bull stock market may mean some pharmacists have enough in their retirement portfolios to call it quits without a sale.

In Eads, Davis, 70, still loves being a pharmacist. He and his brother co-own seven pharmacies and have started to plan for retirement by hiring five young pharmacists and allowing them to buy ownership stakes in those pharmacies over time.

He had wondered how long he could keep the Kiowa pharmacy running, though. With fewer than 700 residents, Eads may be the smallest town in Colorado with a pharmacy. Combining Davis’ customer base with Cheyenne Wells’ may have saved pharmacy access for both communities.

“So maybe where we could have lost two pharmacies in the area, we’ve been able to exist. We’re stronger now than we had ever been,” Davis said. “That wasn’t the original plan. We cared about those people and just wanted to take care of them.”

In the midst of a national housing shortage, towns on the Kansas plains are giving away free land and ultra-cheap houses. Is the offer worth it?

By Mark Dent

Reprinted with permission from The Hustle

Sitting in the basement of a historic courthouse in Lincoln — a wind-swept town in north central Kansas — Bradley Roberts laughs while comparing his current situation to his previous life in San Francisco.

Roberts was like many people in the Bay Area: Savvy, successful, and drowning in housing expenses. When he bought a house ~15 years ago, he and his partner went $300k over their budget. Rent at his last place in San Francisco was nearly $4k a month.

“It was awful,” Roberts, 50, told The Hustle.

Roberts, whose grandparents were from Lincoln, bought a converted barn home in the middle of town last year for $22k. His annual housing costs in Lincoln are about the same as what his monthly

Bradley Roberts started a handyman business and says he “fell in love with

Lincoln, again.” (The Hustle) housing costs were in San Francisco.

“When I moved to Kansas,” Roberts said, “I was like, ‘holy shit, they’re giving stuff away.’”

Roberts is exaggerating, but only slightly.

In Kansas small towns, the houses are cheap, with quality homes going for $100k and fixer-uppers costing far less. Land, a commodity over which NIMBY battles rage throughout the country, can actually be obtained for free in several counties.

The downside to living in rural Kansas, of course, has always been economic opportunity. High-paying jobs don’t grow as easily as the milo.

But price-conscious urban dwellers have been drawn to places they never thought they could live. After a year of soaring real estate prices in every city and suburb, long-depressed and depopulated Kansas is going through a lower-key real estate boom of its own.

“It always used to be the case that we said there’s a big difference between what’s going on in the larger cities and the rural areas,” said Stanley Longhofer, a professor and founding director of the Wichita State University Center for Real Estate. “And the answer now is not as much. It really is kind of across the board.”

Are the Great Plains the greatest option left for an affordable lifestyle? And can small towns reverse the market forces that have long made them financially risky

Vacant storefronts in Lincoln (The Hustle) and undesirable?

The boom and bust of the Great Plains

In the mid-1800s, after breaking treaties and forcing the removal of Native Americans, the United States had thousands of miles of land in the middle of the country — and almost no Western settlers wanted to live there. Then, in 1862, Abraham Lincoln pulled the ultimate Manifest Destiny power move with the Homestead Act. The government granted individuals 160 acres of free land as long as they lived on and farmed the land for 5 years, enticing Americans to claim 270m acres in states like Kansas, Nebraska, and North Dakota. Free territory was also distributed to railroad companies, which sold their surplus land to new residents at dirt-cheap rates. Buoyed by the free and inexpensive land, small towns sprung up overnight, often just a few miles from each other. These hyperlocal economies thrived with farming at the center of life. But in the 1920s, the mechanization

(The Hustle)

of agriculture reduced the need for farm work, and population loss followed. The outflow accelerated in the coming decades as commercial farming operations consolidated family farms and interstate highways took away visitors.

Once-bustling Main Streets are now pockmarked with shuttered buildings, and elder care facilities are often small towns’ top employers.

Kansas embodies the ups and downs of the Homestead Act as much as anywhere. • The state boomed from ~100k residents in 1860 to 1.4m in 1890, making it larger than New Jersey. • But the vast majority of Kansas counties experienced peak population before 1950. • Farms in the state have declined from 167k in 1920 to 58.3k today, while growing in size from an average of 272 acres to 784 acres.

My own family deserted the Great Plains. My great-grandmother’s parents farmed in Osborne in the early 20th century, but her daughter moved to larger, less-agrarian McPherson, and her daughter, my mother, moved to the Kansas City area. With dwindling populations, the large number of small towns has turned into a logistical and financial headache. Many of Kansas’s sparsely populated 104 counties and 627 incorporated municipalities (compare that to 58 counties and 482 municipalities in 13x larger California) struggle to pay for government services, recruit civic leaders, and hold onto businesses, health care, and schools. Towns can’t survive without enough people, and people are hard to recruit when the local economies are in shambles. So to attract newcomers, towns have attempted a dizzying array of stunts and initiatives.

One of the most influential was a modern remix of the Homestead Act by Marquette. To save its school and stanch its population loss in 2003, Marquette’s leaders offered ~60 free lots for anyone willing to move in and build a house.

A Hutchinson News story picked up by the Associated Press led to a national media sensation, culminating in a visit from “CBS Evening News.”

At least 27 Kansas towns have enacted free land programs since the late 1990s. Only a few have had success.

Even in Marquette the population rose for about 10 years before falling again, and its elementary school was only temporarily saved, closing in 2014. Roughly 20 lots are still available.

Why can’t Kansas give away land?

It’s because the rural areas’ biggest

Free but flawed

On a cold day last November, Lincoln County Economic Development Foundation director Kelly Gourley drove me to the east side of the town, where an asphalt cul de sac backed into a sea of yellowing grass.

Lincoln (pop. 1.2k) is not overly small for rural Kansas. It has a theater, a high school that ranks among the top 25% in the state, and even a luxurious Airbnb in a downtown loft. But the population has fallen by 25% since 1980, and numerous storefronts are boarded up on the main drag. A coffee shop below the Airbnb closed just a few weeks before my trip.

The grass on the east side is another sign of frustration. It was supposed to be covered by homes, symbolizing a Lincoln repopulated by the free land program. But only 2 of 21 lots have been developed, one by a former mayor and another that functioned as a spec home.

Kelly Gourley stands near the lots Lincoln can’t give away. It doesn’t help that a nearby creek means some are in a floodplain. (The Hustle)

Their landlord hiked their rent, and they were asked to pay $320k to buy the building where Frankie’s was located.

Seeking an affordable alternative, they moved to Lincoln in January and found a much cheaper building for a restaurant. They also bought a house that’s big enough for their family of 5 for $70k.

In Lincoln, houses that used to sit on the market for a year were selling within weeks in 2021, Gourley said. She can’t recall ever having fewer houses available after more than 30 were sold each year in Lincoln County in 2019, 2020, and 2021, up from 14 in 2018, per Lincoln County statistics.

Other rural Kansas counties experienced the same rush. MLS data of 15 small counties across the state showed

Downtown Lincoln, Kansas

(by Faith Wilson from Woodinville, WA, U.S.A. - Small town evening, CC BY-SA 2.0, Wikimedia) 2021 housing sales up 11% from 2019, and median time on the market last summer was ~33% lower than in 2019.

Gourley, who started her job after the program was enacted, explains why a free giveaway can still be a questionable deal. • A new house would cost ~$100k-$200k to build but is likely to sell for less, given the low real estate prices. • Buyers also struggle to get homes appraised at the cost of construction and sometimes need to cover the difference out of pocket.

Lincoln has shifted to prioritize its inexpensive existing housing stock, a strategy that has its own drawbacks. Similar to many Kansas towns, ~30% of Lincoln’s houses require significant repair or outright demolition.

Given how this shortage of good homes and economic risk for new construction scares off people who would even want to move to rural Kansas, it’s easy to see why towns have sunk in a downward spiral.

But the insane real estate prices that have challenged the rest of the country have led to a spark in interest.

Building up supply

Priscilla Frankenstein loved the views in Whitehall, Montana, pop. 1k. On clear days, she could see peaks and snow in almost every direction.

But after moving in 2019 from California and opening a restaurant, Frankie’s, with her husband, Charles, prices got too high as the rapid growth in nearby Bozeman spread to smaller towns. “We’ve seen a lot of people coming back to rural communities because the cost of living is lower and because there’s a quieter, calmer lifestyle here,” said Betsy Wearing, coordinator of programs at the Kansas-based Dane G. Hansen Foundation. The momentum has led to a new challenge: preparing the housing market to meet the demand. Economic development corporations are scouring for grants to pay for demolition and rehabilitation costs, as well as payments that bridge the difference between the cost of new housing and the amount a bank will cover for a mortgage. In Lincoln, Gourley secured $150k in grant money late last year to help prospective buyers rehab 5 chronically vacant houses. Residents have also gotten involved in renovations. Vicki Hook, a native of nearby Beverly, moved back to Kansas from Florida and bought a 2nd home as an investment. She paid $7.5k, put in ~$60k in repairs, and hopes to sell it for $85k+. In crowded housing markets in large cities, house flipping is often viewed as a driver of inequality. That’s not a major concern yet in Lincoln, given the sheer quantity of neglected homes and the lack of outside speculators. But the lower incomes in Kansas small towns mean Vicki Hook, left, returned to Lincoln after decades away. Pam Morgan greater sensitivity to increasing costs, moved to Lincoln from Kansas City not even for prices that look cheap to people long after a chance side trip in central on the coasts. Kansas. While Charles Frankenstein doesn’t (The Hustle)

want Lincoln prices escalating as high as in Whitehall, he expects property values to increase.

“We look at Lincoln as a place we’re moving to and investing into,” he said, “and we want to watch it grow and be on the ground floor of it as it grows.”

Eric and Emily Wolgamot bought two vacant homes in Lincoln for $5.5k

(The Hustle)

Making a living on the Plains

Eric and Emily Wolgamot had all but given up on homeownership before they found Lincoln.

In the last few years, they moved out of California, where Emily Wolgamot struggled to pay $1.2k in monthly rent on a telemarketer’s salary in San Diego, to Seligman, a tourist town outside Flagstaff.

The cost was manageable — $400 a month for a plot in a trailer park — but they needed a larger space for them and their 3 kids, and yet taking the next step seemed impossible.

They saw off-grid 3-bedroom houses listed at $150k. Houses with basic necessities, like plumbing, were going as high as $500k.

“And I kind of wanted to turn on a faucet,” Wolgamot said.

She and Eric started searching online for houses across the country. Lincoln had the best deal: 2 vacant houses for a combined $5.5k. They paid cash and now only owe taxes, which run ~$150 a month.

Since moving in spring 2020, Eric has rehabbed their homes while starting his own tree trimming and junk removal business. The work is far different from the service-industry jobs they had in California and Arizona, but they say it has been enough to provide for their family, given the low cost of housing.

Entrepreneurship is encouraged for newcomers to Lincoln.

A website advertising the town lists new or transitioning opportunities for restaurateurs, contractors, accountants, attorneys, and veterinarians. Gourley has plans to open a gym. Roberts, the San Francisco transplant, started a handiwork business.

Life isn’t the same as in the Bay Area, where he owned a flower business and drove a Mercedes. But last fall, while visiting a friend in Palm Springs who was barely scraping enough money to afford a mortgage, Roberts realized the advantages of rural Kansas.

“I feel fortunate to be here because now I’m back to where I feel comfortable,” he said.

That isn’t to say Lincoln doesn’t have its drawbacks. The diminished, aging population makes it hard to grow business. This is one reason why Gourley wants to recruit remote workers, who can increase the need for services while not being dependent on the local economy for their earnings.

Reliance on the local economic base is still a significant risk.

Dil Darjee, a Bhutanese refugee, moved with his family from St. George, Utah, and opened the Post Rock Motel & Restaurant in 2020. Lincoln was one of the few places he found a business opportunity he could afford.

The motel has drawn rave reviews online for cleanliness and professionalism, and his restaurant serves a range of Himalayan and American cuisine. But that’s not enough to guarantee success. Although his revenues had picked up during hunting season in November, he said he struggled to cover his expenses in the summer months.

“I’m hoping for better days,” he said.

Somewhere between Marquette and Lincoln (The Hustle)

The free fixer-upper in Lincoln (The Hustle)

The narrowing gap between urban and rural

After my conversation with Darjee, I drove back to the Kansas City area.

The next day I enjoyed the various things people enjoy in bigger cities: going to a coffee shop, watching live jazz at a bar. I’m fortunate to have enough stability to afford increasingly expensive urban life, and I prefer hustle and bustle over calm and quiet.

Besides an urban area’s multitude of options and luxuries, there are more pressing needs rural Kansas does not meet. Anybody who doesn’t drive would have extreme difficulty getting around, and people who want racial and cultural diversity will not find it (small towns in north central and northwest Kansas are usually 90%+ white). Child care is also hard to come by, although nonprofits have begun incentivizing it.

This lack of amenities, coupled with the shortage of quality housing, are why Longhofer, the Wichita State professor, does not expect rural Kansas towns to find lasting salvation from recent real estate trends.

“These have been issues that are not new with the pandemic. They’ve been long term,” Longhofer said. “And so often we want to come up with this magic amulet that’s going to fix all the problems, and it’s just a challenge for small-town America.”

Yet people who need to move may find life in the city and life on the Plains is more similar than ever. The Wi-Fi is still fast in towns like Lincoln, the same shows are still on Netflix, and Amazon packages still come to your door. The communities are small, but friendly.

And it’s so, so much cheaper.

During my visit, Gourley showed me the ultimate real estate bargain: an olive-green Dutch Colonial house with, an ad states, “enough woodwork to cause anyone to swoon.” It’s a fixer-upper but not beyond repair.

The price tag: $0.00.

The only catch is the house must be moved. But the free lots are just down the street. A buyer could put the free house on a free lot.

There’s more: One of the grants Gourley secured can be used on the house, meaning income-eligible buyers could get $30k to spend on renovations.

As of late January, the house was still available. It could be yours, if you’re willing to have someone pay you to take it.

Telehealth May Be Here to Stay

by Michael Ollove

Reprinted with permission from The Daily Yonder

This article was produced by Stateline, an initiative of The Pew Charitable Trusts.

Before the Covid-19 pandemic, medical executive Lyndi Church and her colleagues at Caring Hands Healthcare Centers in southeastern Oklahoma had been intrigued by telehealth, but they feared it was unworkable in their rural corner of the state.

Many residents of the area lacked reliable broadband or didn’t have the devices or technological savvy to use telehealth services. Church, the chief operations officer of Caring Hands, anticipated significant resistance. “We weren’t sure how our patients would take to it,” she said.

Then the pandemic hit, and everything changed.

Early on, Caring Hands stopped treating patients in its facilities. Health workers saw some patients in the centers’ parking lots, but other than that, Church said, all medical care occurred virtually. To her surprise, despite occasionally spotty mobile and broadband service, patients took to telehealth.

“The majority of our patients were incredibly appreciative of the service, especially when they were so fearful about coming into an office,” she said.

The use of remote health services soared during the pandemic, opening the eyes of many medical providers and patients to telehealth’s convenience, efficiency and relative low cost. But its future depends largely on whether state lawmakers extend emergency measures that made telehealth a viable alternative for patients and providers wary of in-person contact. The most important changes most states made were to expand Medicaid coverage to different types of virtual appointments and to enact telehealth coverage requirements for private insurers.

Mei Wa Kwong, executive director of the Center for Connected Health Policy, a nonpartisan organization widely regarded as an authority on telehealth, estimates that the number of telehealth visits increased by as much as 40% during spring and summer 2020 and remains 30% higher than it was before the pandemic. According to a survey conducted by the National Association of Community Health Centers, the percentage of health centers using telehealth jumped from 43% before the pandemic to 98% during the early months of the crisis.

“The telehealth temporary policies helped so many people receive care they otherwise wouldn’t have received or may have put off getting until it became a more serious issue,” Kwong wrote in an email to Stateline. “To suddenly have that access taken away by a policy change could have significant, adverse impacts on many.”

Many states already have extended temporary telehealth measures that were set to expire with the lifting of public health emergencies, and other states are considering doing the same. Kwong estimates that there are more than 1,000 telehealth bills pending in state legislatures, many of which would allow more services to be provided virtually or mandate that public or private insurers cover them.

No organized opposition has emerged to the legislation, though it’s unclear how much providers will want to use telemedicine once their patients feel less anxious about exposure to the coronavirus.

“It is all about change management, teaching people to do things differently in

Dr. Vibin Roy, medical director of Doctor on Demand, types notes as he listens to a patient during an online primary care visit from his home in Keller, Texas, in April. Many states are extending telehealth policies adopted during the Covid-19

public health emergency. (LM Otero / The Associated Press)

their practices,” said Mary Zelazny, CEO of Finger Lakes Community Health in rural upstate New York, which used telehealth before the pandemic but ramped up during the crisis.

Telehealth, she said, has increased the efficiency of her health centers, saved money and improved care.

“We’re not going back.”

Making Changes Permanent

Many of the pending telehealth bills pertain to Medicaid, the joint federal/state health plan for low-income Americans. Twentyseven states already have taken advantage of relaxed federal rules to expand Medicaid coverage of telehealth services, according to the National Conference of State Legislatures..

For example, many states, including Arkansas, Connecticut, Kentucky, and Vermont, permanently authorized Medicaid coverage for audio-only medical consultations, without a video component. Colorado, Kentucky, and Mississippi enacted legislation to ensure post-pandemic Medicaid reimbursement for telehealth services delivered by community health centers. And New Hampshire from now on will require its Medicaid program to pay providers the same amount for telehealth and in-person visits.

Arkansas also approved a law permanently extending Medicaid coverage to a raft of behavioral health and substance use services delivered through telehealth. The state’s Medicaid program now covers remote therapy provided by psychologists, clinical social workers, and marriage and family counselors. It also covers crisis intervention, substance use assessments, group therapy for those over 18 and mental health diagnosis assessments for patients under 21. Both chambers of the Arkansas legislature approved the measures last spring without a dissenting vote.

Dr. Lee Johnson, a Republican state representative who sponsored the Arkansas bill, said during the pandemic he came to appreciate that behavioral health services were particularly suited to telehealth. Generally, there is no need for a physical examination or lab work, and it gives greater privacy to patients who may be worried about the stigma of visiting a mental health provider.

“If you’re in a small community or even bigger communities and you have to go to psychologist or psychiatrist, maybe you’re nervous that someone will see you,” said Johnson, an emergency room physician. “This gives you the anonymity of being able to be at home and still accessing those services.”

Congress cleared the way for states by allowing Medicaid and Medicare to pay providers for telehealth services delivered to patients in their homes while also lifting the limited restrictions on where providers could be located. It also extended coverage to different types of telehealth services and providers and to audioonly appointments, which were previously excluded.

Taking advantage of the new rules, Colorado made telehealth services provided by physical therapists, occupational therapists, hospice care workers, home health providers and pediatric behavioral health specialists eligible for Medicaid reimbursement. The state also specified that home health agency services and therapies, hospice care and pediatric mental health services could be provided over the telephone. However, all the changes are tied to Colorado’s ongoing public health emergency, and it’s unclear whether they will be extended beyond that.

Medicare, the public health plan for older Americans, also loosened many of its telehealth reimbursement rules during the pandemic. The Biden administration announced this summer that Medicare will continue to cover virtual behavioral health services, but that the federal Centers for Medicare and Medicaid will evaluate other telehealth services before deciding whether to extend coverage beyond 2024.

Proponents of telehealth, including the National Association of Community Health Services, are pushing Congress to make the

Dr. Charles Sawyer holds a telehealth visit in the summer of 2020 with Gladys Etters from the Roanoke Chowan Community Health Center’s Ahoskie Comprehensive Care site in eastern North Carolina.

(Source: Roanoke Chowan Community Health Center)

changes permanent.

More than two dozen states also have made permanent some telehealth coverage requirements for private insurers. For example, after the pandemic is over, Arizona, Iowa, Massachusetts and New Hampshire will require private insurers to cover all telehealth services and to reimburse providers at the same rate as in-person services. At least four states—Massachusetts, North Dakota, Vermont and Washington—extended the requirement for private insurers to reimburse for audio-only consultations, though not necessarily permanently.

The state laws on private insurers generally apply only to individual health insurance policies or those to which an employer does not contribute. Employer-funded plans are regulated by the federal government.

Barriers Remain

Although patients have embraced telehealth options during the pandemic, that is no guarantee that they will continue to do so once it is over. Kim Schwartz, CEO of the Roanoke Chowan Community Health Center in a rural area of eastern North Carolina, said that at the height of the pandemic, 90% of primary care visits were held virtually. Now, 80% of her patients come for in-person visits, even if it means long drives.

“Culturally, the dynamic of convenience wasn’t as high a value as the in-person relationship,” she said.

Schwartz noted that broadband availability and computer literacy remain barriers. Nevertheless, she said, telehealth must be part of her center’s future because of the advantages it offers in terms of stretching limited staff resources. The challenge, she said, is to increase the comfort level of her patients.

Rural areas aren’t the only ones with barriers to more use of telehealth. Dr. Sachin Shah, an internist and researcher at University of Chicago Medicine, studied the racial disparities in the use of telehealth on the South Side of Chicago during the pandemic. Many of his Black patients live in urban neighborhoods that, as in rural areas, struggle with broadband access, computer literacy and technology availability.

“That leaves a huge, really vulnerable segment of our patient population behind,” Shah said. Many of his older Black patients who do not own smartphones, he said, benefited from temporary changes that made telephone consultations reimbursable. Policymakers, he said, must consider inequities as they draft telehealth measures.

Despite the barriers and the unique circumstances of the pandemic that brought telehealth to the forefront, many in health care insist the service has proven its value in complementing inperson medical care.

“This wasn’t the result of great planning; it fell into our laps,” said Shah. “But it’s such a great opportunity. I would hate to see us go backwards.”

The Shrinking Rural Workforce: Jobs Increase, but Number of Workers Declines

by Bill Bishop

Reprinted with permission from The Daily Yonder

Rural areas have lost workers in the last year, as the workforce in the nation’s nonmetropolitan counties shrank between October 2020 and October of 2021, the most recent month for which county-level data is available.

Metropolitan counties, on the other hand, gained workers between October 2020 and 2021.

Workforce consists of all people working plus all those looking for work. In the last year, that number has declined by 220,000 in rural counties. The workforce in the rest of the nation has increased by nearly 1.3 million.

The latest county-level data from the federal Bureau of Labor Statistics tells a mixed story about employment in rural America. Rural counties as a whole continued to gain jobs in the last year. But they still don’t have as many jobs as they did before the beginning of the pandemic. (Rural counties have 520,000 fewer jobs compared to two years before.) But rural America’s job losses over this time period are proportionately the same as the nation as a whole.

Job gains in rural America, however, have slowed. In the year ending this October, the rate of job increase in rural counties was less than a fourth of the national average increase. Nationally, jobs increased by 3.2% in the last year. In rural America, however, jobs increased by just 0.7%.

Only one out of 10 rural counties reported job gains that matched or exceeded the national average.

And, the rural workforce is declining. There are simply fewer people now in rural America available to work. In two-thirds of rural counties, there are fewer workers today than a year ago.

As always, the jobs picture changes from place to place. The map above shows the change in jobs from October 2020 to October 2021 in every county: • Red counties are rural areas that lost jobs. Orange-colored counties are rural areas that gained jobs, but at rates lower

than the national average of 3.2%. Beige counties are rural places that gained at or above the national average gain of 3.2%. • Light blue areas are metro counties that had job gains below the national average or job losses. Dark blue counties are urban areas that gained at or above the national average.

You can see on the map how job growth is clustered in and around major cities, such as Austin, Los Angeles, Atlanta, Houston, Portland, Salt Lake City and Denver. Three-quarters of all job gains in the last year were in the nation’s largest cities. Their rate of job growth topped 4% in the last year.

The past year – a time spanning two presidential administrations – has been a jobs bust for most rural counties. Look at all the red on the map. Forty-four percent of all rural counties lost jobs in the last year and only 11% matched the national rate of increase of 3.2%.

What about the decline in workforce? Are working-age people leaving rural counties, retiring or just not looking for work? You can’t tell from this data. What you can see is that while urban areas have been building their workforce over the past year, rural counties have been losing their supply of potential workers.

This story was originally published in the Daily Yonder. For more rural reporting and small-town stories visit dailyyonder.com.

(The Daily Yonder)

Lecturer’s Playbook seeks submissions

Have you run a successful program or contest in your Grange?

Do you organize an annual event or fundraiser?

Are you looking for inspiration or ideas to make your Grange’s programming and community connections stronger?

Ann Bercher, National Grange Lecturer/Program Director is beginning to compile submissions for the “Lecturer’s Programming Playbook,” with simple steps to success that any Grange could replicate.

Bercher is hoping to receive submissions from every state - so look at the examples and get in touch. The goal is to debut this Programming Playbook at the National Grange session in Sparks, Nevada this November.

“I know there are thousands of great ideas and programs happening in Granges across the country,” Bercher says. “Whether it’s a 10-minute program for members of your Grange Playbook Example or a day-long event for your community, your ideas are worth sharing!”

Each year, Lecturers and Program Directors across the country are looking for new ways to engage and activate their members and the community. This Playbook will be a simple guide for Granges to reproduce their own programming.

Your “Playbook” entry should include: • “Play” Topic – contest, game, educational program, fundraiser • Description of the “Play” • Intended Audience • Goals and Objectives • Time required – 10-15 minutes (part of a regular Grange Meeting), 25-45 minutes (a full meeting or workshop), longer (event or fundraising activity) • Space Required (Zoom, tables and chairs, room set up, etc) • Materials Needed (handouts, PowerPoint, internet, paper, pencils, etc) • Number of Presenters (team players) – people needed to help plan, set up, present, cleanup and/or follow up) “Nothing is too simple or too out-of-the-box to share,” Bercher adds, “The programs from your Granges make you special, and we hope to share with everyone!”

Playbook Example

Submit your Ideas!

Send your “playbook” with clear directions, pictures and your contact information (in case we want to hear more) to: lecturer@nationalgrange.org as soon as possible!

by Ethan Edwards

Communications Fellow Lecturer, Illinois State Grange

Storytelling has been with us from the beginning of human memory. The ancient cave paintings in France record a particularly important hunt. The documents at the core of the world’s faith texts began as oral stories, crafted to preserve culture. From our own cribs, we remember the stories our parents told us to educate and entertain.

It is easy to relegate storytelling in our lives as merely a quaint way to entertain within our families and network of friends. But in doing so we may be missing a powerful way to build bridges in our broader communities and uniquely create a shared vision for creating unity of purpose in our world that seems so mired in conflict. Certainly, it is a communication style that might serve us well as we seek to strengthen connections between our community Granges and our local environments.

In a recent episode of the podcast Everywhere Radio, a production of the Center for Rural Strategies, host Whitney Kimball Coe invited two thought leaders to share their ideas about how the radical gift of storytelling can serve to unify communities.

Kiran Singh Sirah is the president of the International Storytelling Center in Jonesborough, Tennessee. Sirah believes storytelling in its many forms—from the Appalachian tradition of porch-sitting to the newer practice of video calls among strangers from across the country—shapes our understanding of ourselves, our relationship with others, and our place in the world.

The Storytelling Center is located in the Appalachian Mountains of eastern Tennessee, so it is not surprising that Sirah speaks of singer-songwriter Dolly Parton as one our very best storytellers. From humble roots, Parton followed her ambitions and dreams to take her from rural Tennessee to enormous success in the world of Country Music in Nashville.

But even more significant than her commercial success is that Parton has always come back “home” to share her wisdom, ideas, and knowledge in Appalachia but also wherever she appears. That she overcame obstacles to achieve great success is important, but what is even greater is that she shares that process through her songs and her stories to transform others. And through her stories she inspires great works in others.

Sirah looks to storytelling as an ideal vehicle for shaping our understanding of ourselves, our relationships with others, and our place in the world. Humanity seems to respond fully to a story that is rooted in people and actions but carries some higher purpose. The emotional response to stories can build commitment to an idea that motivates action far beyond the literal facts of the situation.

Sirah finds powerful imagery in comparing storytelling to The Force from the Star Wars movies. It can be used for good or evil, as significant in forging nations and shaping identities as well as creating propaganda and sowing division. But Sirah views storytelling as inherently “good.” There is something important in each of us and stories are a way to connect that in each of us.

The really powerful result is that sharing stories builds understanding, empathy, and connection with others, even among strangers and people we may think we do not even like. This vital connection, Kiran said, ties people and groups together, and is the basis for the political, cultural, and social movements that transform our communities.

It is this potential for connection and understanding that drives Coe’s other podcast guest, Harry Gottlieb, the founder of Jackbox Games and Unify America. Gottlieb is convinced that this possible enhanced connection can play a huge part in transforming America from a country of divisive politics to a country of problem solvers.

The goal of Unify America is to help people join together with the awareness that we mainly desire the same outcomes even though political forces make it impossible to work together. Unify America created the Unify Challenge, in which people from opposing ends of the political spectrum work together to complete a survey about the vision they have for the future of the country. The exercise helps its participants to understand their political opposites as fellow citizens instead of adversaries.

In addition to building personal connections with people with whom we disagree, Gottlieb says the goal of the challenge is to point out all the things that Americans do agree on. Problem solving and storytelling can reduce the contempt we in America feel about those on the “other” side. Disagreements over politics prevent people from connecting over the outcomes in which they are, for the most part, in agreement.

Both Sirah and Gottlieb are optimistic about the opportunity that storytelling creates for connecting across traditional barriers. It is an approach that leadership of Community Granges might look to when striving to reach across barriers within their own communities.

The full podcast is available at dailyyonder.com.

To hear more, attend the upcoming virtual festival, Rural Assembly Everywhere, on April 20 and 21, 2022. Both Sirah and Gottlieb will be participating in this event for the curious and critical, geared toward rural allies, neighbors and admirers. Free registration is available at ruralassembly.org/everywhere.

Courtesy of Brandpoint

If you have backyard chickens, you understand that your feathered friends provide more than just a steady supply of fresh eggs. Backyard chickens become part of your family and giving them the best helps them to thrive. From nutritious food to enrichment activities like music and games, there’s a lot you can do to make your hens happy.

“Chickens are talented, productive and wildly entertaining,” said Scott Schraufnagel, director at Hen Up Organic Food for Chickens. “Backyard hens are part of the family and provide endless joy. That’s why chicken owners are going above and beyond to give their hens the best.”

What can you do to make your hens extra happy? Schraufnagel shares three ideas:

Activities and enrichment

Chickens are known for their unique, endearing personalities. They are curious creatures that need mental and physical stimulation to thrive. Just like you would get bored with the same thing day in and day out, they get bored as well. That’s why smart backyard chicken owners will take steps to keep chickens active and engaged.

Need ideas? Try expanding your free-range or run space. Add ladders, ramps, perches, stumps, scratch pads, swings and even a mirror. Add a pile of hay and watch them scratch and kick it flat. A sheltered dust bath space is like a spa for hens. Anything new or unusual will intrigue your chickens, so keep them guessing what’s next.

Bonding through music

Did you know chickens enjoy music? Whether it’s grooving to guitar, strutting to salsa or relaxing to reggae, play some outdoor music and spend time bonding with your flock. Crank tunes during backyard chores or simply play music when enjoying the day with your feathered friends. You may even notice certain hens have music they prefer, adding to their quirky personalities.

To celebrate how much chickens enjoy music, Hen Up presents Coopstock, the first annual backyard concerts for chickens and their owners. Backyard chicken enthusiasts across the country are hosting these events starting Sept. 12. They will feature live music, themed decorations and much more. Learn about the events and

be inspired to cluck out your own jams by following along on Facebook or Instagram.

Food and treats

From freshly hatched chicks to egg-layin’ ladies, provide your flock with balanced nutrition including essential vitamins, minerals and amino acids that they need to live their best life. Hen Up makes organic, non-GMO food for chickens from ancient grains, superfoods and other ingredients you’ll recognize.

Food also provides a great opportunity for nutritional enrichment activities. For example, place food in whiffle balls and watch as chickens roll and peck at it to get the delicious tidbits out. You can also sprinkle food in hay or a pile of leaves nontoxic to chickens so they can hunt for treats. Finally, hang a head of cabbage or lettuce from a rope covered in stiff tubing for a fun chicken piñata.

“A little extra effort can make a big difference for backyard chickens,” said Schraufnagel. “They’ll love these activities and you’ll enjoy them, too.”

Courtesy of Brandpoint

While credit scams have been around forever, they’ve recently exploded in number. According to Mint, from 2019 to 2020, the number of identity theft reports went up by 113% and the number of reports of identity theft by credit cards increased by 44.6%. The amount of fraud by new credit card accounts saw a 48% increase from 2019.

As more information is digital today, on top of the increase in health and financial stressors, scams designed to access your credit accounts or personal information are on the rise.

Having financial or credit accounts hacked can have long-lasting implications, beyond financial loss and inconvenience.

Here are tips to help protect your credit and personal information.

1. Practice good cyber hygiene

Use long, strong passwords unique to each account or website - or use a password manager to help create better passwords and keep track of them. Change the password on your home’s router. If you’re using the same password for several accounts, or haven’t changed passwords in a while, now’s the time to clean up your digital act.

2. Back up your data

Having digital and physical backups for your data protects you from not only losing important information, but also from ransomware attacks - when a hacker freezes or destroys your data unless you pay them in bitcoin. While this is more likely to happen to businesses, it can give you peace of mind to have your data backed up.

Consider both a Cloud backup as well as on a physical hard drive - and/or printing out vital information or documents.

3. Monitor your credit report

Keeping an eye on your credit reports alerts you to attempts to steal your identity, such as someone opening an account in your name. You can check any of the major credit reporting companies for free once a year. However, because identity theft is becoming more frequent, you should check your credit score more often. One tactic is to rotate which company you request a report from, requesting one every few months.

You can also check your credit with VantageScore, which uses credit scoring models that provide lenders and consumers with highly predictive credit scores that are easier to understand and actually score more people. Access yours for free through the providers at VantageScore.com. Check your credit reports for: • Credit accounts/debt that isn’t yours. • Inquiries indicating a company accessed your report without your permission. • An address where you’ve never lived. This could be a sign someone’s tried to use your identity to open an account.

If you see items like these on your report, contact the credit agency right away. A change to the Fair Credit Reporting Act (FCRA) in 2018 allows consumers to put a freeze on their credit reports for free, so credit reporting companies will restrict access to your reports, not allowing lenders with whom you do not have an existing relationship to pull them. This can help prevent fraudulent credit applications from being opened. Then you can choose when to “unfreeze” the credit reports and put them back into circulation.

4. Be alert to common scams

You may receive an email saying one of your credit accounts has been blocked or suspended. It may look like an email from a legit company. Never click links within the email, as they may take you to a fake website (that looks real). Instead, access your account from the website you always use to see if there’s a problem. Contact the company directly, not through the email. Most likely it’s a phishing attempt to get your personal login or financial information.

Scammers may take advantage of current crises, claiming to be COVID-19 contact tracers, or referring to government stimulus checks. Never give personal or financial information like your birthdate or Social Security number over the phone or via email. Other common scams involve taxes or unemployment compensation.

View any email or text asking for information or to reply with an account login or other personal information as suspect, and contact the supposed sender directly.

Learn more about tips and credit strategies at VantageScore.com.

6 ways to help businesses in your community thrive

Courtesy of Family Features

Small business owners faced the challenges of the past couple of years head-on. Nearly all re-evaluated their operations to accommodate new ways of doing business amid changing safety standards and local protocols, and many plan to make these changes permanent.

Over the past year, pandemic-related operational challenges, combined with a surge in physical and verbal attacks, have been uniquely difficult for a group of small business owners.

Asian American and Pacific Islander (AAPI) businesses comprise nearly 10% of small businesses in the United States. Among them, 92% faced difficulties keeping their businesses open and operating amid the pandemic, according to Bank of America’s 2021 AAPI Business Owner Spotlight.

“While almost all AAPI entrepreneurs said the pandemic created additional stress around running their businesses, they remain determined and resilient,” said Carol Lee Mitchell, head of small business strategy at Bank of America. “Even as they faced immense obstacles, AAPI business owners took steps to move their businesses and communities forward.”

Local companies, including AAPI businesses, have proven to be fundamental to strong, healthy economies and inclusive communities. These entrepreneurs remain solution-oriented, quickly adopting new tools and strategies; however, they require support from customers and community members to thrive.

Consider these ways you can support small businesses, including AAPI owners and the community at-large, from the experts at Bank of America:

Choose to Shop Local and Small

Small businesses are ingrained in many local communities. When you choose to purchase from a small business, you’re directly supporting neighbors, friends and the people in your community. This support isn’t taken for granted by entrepreneurs; more than half of AAPI small business owners noted the importance of community support amid the pandemic. Also consider leaving a generous tip when you receive exceptional service - it can make a big difference for small business staff.

Gift Local

Keep the impact that your support could have on local community businesses in mind when shopping for gifts, whether they’re for loved ones near or far. For locals, a gift card to a nearby eatery or business such as a spa, salon or recreation center makes for a welcome gift that keeps your money local. When gifting those who live farther away, you can still benefit small businesses in your community by purchasing a thoughtful gift and packaging locally then shipping it with the help of a business in your area.

Help Spread the Word

Small businesses don’t usually have the means to invest in big marketing programs, so referrals and word of mouth can make a major difference. However, in today’s world, a great deal of consumer research happens online. That means you can be most helpful by taking your stories of great service and quality products to the internet, too. Seek out your favorite small businesses and write reviews on their social media channels. Take it a step further and give them a shoutout (with tags, if possible) on your own social media accounts where your friends and family are more likely to notice.

Photo courtesy of Getty Images

Help Fill Open Positions

The job market has shifted noticeably over the past year, and local businesses have been struggling to find the talent they need to continue to serve their communities. Small business owners

recognize this and are shifting benefits for their employees, allowing for more flexible schedules and additional paid time off.

Since these business owners are looking for employees to help fill some of the uptick in demand, you can help by tapping into your own network and recommending people for different positions you see, whether it be through “Help Wanted” signs or based on the needs you hear from the businesses you patronize.

Be Mindful of Business Challenges

Finding a work-life balance can be difficult for small business owners even in non-pandemic times because they wear so many hats within their businesses, from CEO and salesperson to human resources and everything in between.

Business owners were more conscious of their mental health over the past year, as nearly all AAPI business owners acknowledged additional stress and more than half set aside specific time for selfcare and mental wellness.

As a consumer, it’s important to be mindful of the fact that business owners are both short-staffed and dealing with supply chain issues. Take an understanding approach and work with local businesses to make sure they know they are supported by their community.

Check In on What’s New

Just as you’ve changed your consumer habits and needs, small businesses have adapted in dozens of ways. That could mean you have access to new services or options you never considered. For example, your favorite yoga studio may offer streaming classes or a favorite breakfast cafe you haven’t visited in a while might have an all-new menu. Take time to stop in and learn how your favorite businesses are changing with the times and see how those changes may suit your needs.

Look for additional resources designed for small businesses at bankofamerica.com/smallbusiness. Photo courtesy of Getty Images

Courtesy of Brandpoint

Did you know honey bees are responsible for over 35% of the foods you eat, as well as the honey you enjoy? Honey bees are vital to the health of the planet and to the food chain, as they are necessary for pollinating more than 90 food crops including fruits, vegetables and nuts - plus alfalfa, which is used as feed for the livestock that supply our meat and dairy.

There are many ways you can enjoy the fruits of the honey bees’ labor, while also helping to support their habitats and ensuring they’ll be around for generations to come. The National Honey Board has partnered with registered dietitian Maggie Michalczyk, RDN, to bring you her favorite planet-friendly tips and ideas.

“Honey is one of my go-to staples because of its pure qualities and positive impact on crucial pollinators,” said Michalczyk. “I like to recommend honey to my clients who want wholesome ingredients they can feel good about consuming, without having to compromise taste - as honey is a flavorful addition to a variety of foods and beverages.”

Here are Michalczyk’s tips for enjoying and celebrating the hardworking pollinator.

1. Celebrate pollinator foods

Honey bees pollinate plants and trees in all 50 U.S. states, and are needed to pollinate over 90 crops. So the next time you are enjoying apples, avocados, cherries, almonds or sunflower seeds, you can celebrate the fact that all of these foods are made possible by hardworking honey bees.

2. Sweat for bees

Movement is key to a balanced life. Skip the pesticides in your yard and pull weeds by hand instead. Then make sure to plant bee-friendly flowers and flowering herbs in your garden and yard. Get the whole family involved and let kids know which flowers are good for bees, so they’ll know to get excited when they see bees around in the future.

3. Expand your produce palate

Pollinators, including honey bees, are responsible for 1 in every 3 bites of food that everyone eats, including many fruits

Photo courtesy of Maggie Michalczyk, RDN and vegetables. Eating a wide variety of produce plays a role in enhancing the diversity of your gut microbiome, which has been reported to be good for your overall health.

4. Work in daily natural energy boosters

Consider a mid-afternoon break with a cup of tea sweetened with honey. Green and black tea both contain beneficial antioxidants, and honey is a 100% pure and natural energy booster.

5. Make it Mediterranean

Take a page from the popular Mediterranean diet and fill your plate with whole grains, lean proteins like fish, unsaturated fats, fruits and veggies - and use honey whenever possible. Honey is traditionally part of the Mediterranean-Style Dietary Pattern, as recognized in the 2020 Dietary Guidelines for Americans.

Next, try Michalczyk’s tasty recipe, which features honey and other foods that have been produced by the work of honey bees:

Honey Apple Flatbread

Ingredients 1 tablespoon honey 1/4 cup mascarpone or cream cheese, softened 1 whole-wheat flatbread, pre-cooked 1 Honeycrisp apple (or any other favorite apple variety), thinly sliced 1/4 cup pecan pieces 1 tablespoon pumpkin seeds 2 teaspoons cinnamon

Directions

Mix honey together with mascarpone or cream cheese until combined.

Spread a thin layer of the cheese-honey mixture on flatbread and top with apple slices, pecan pieces, pumpkin seeds and cinnamon - plus an extra drizzle of honey, if desired.

Makes 1 serving.

Visit Honey.com to learn more about honey and honey bees.