Generations_Summer2019

Aging in Rural America SUMMER 2019 volume 43 number 2

Journal of the American Society on

AGING IN RURAL AMERICA

Why we should care about rural aging

Rural elders and the opioid crisis

The first rural community: Indian Country

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GENERATIONS – Journal of the American Society on Aging

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is the quarterly journal of the American Society on Aging.

Each issue is devoted to bringing together the most useful and current knowledge about a specific topic in the field of aging, with emphasis on practice, research, and policy.

Peer review consists of the following practice: the Genera- tions editorial board invites a guest editor, selected because of prominence within his or her subject area, to organize an issue of the publication around themes identified by the board. Authors are then proposed by the guest editor and are evaluated by the board on the basis of demon- strated knowledge, achievement, and excellence in their respec- tive fields. All manuscripts are reviewed by the guest editor, editor, and, when appropriate, members of the editorial board. As occurs in any peer review process, revisions may be re- quired, and articles that do not meet the editorial standards of Generations will not be published. Generations (ISSN 0738-7806) is published quarterly by the American Society on Aging, 575 Market Street, Suite 2100, San Francisco, California 94105-2869. www.generationsjournal.org www.asaging.org The American Society on Aging (ASA) is the essential resource to cultivate leadership, advance knowledge, and strengthen the skills of those who work with, and on behalf of, older adults.

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GENERATIONS – Journal of the American Society on Aging

ASA Executive Committee Chair, Board of Directors Karyne Jones, Washington, DC Chair-Elect Michael Adams, New York, NY Immediate Past Chair Robert B. Blancato, Washington, DC Secretary Jean Accius, Washington, DC Treasurer Lisa Gables, Alexandria, VA ASA Board of Directors Ginna Baik, San Diego, CA Connie Benton Wolfe, Fort Wayne, IN Richard Browdie, Cleveland, OH Yanira Cruz, Washington, DC Robert Espinoza, New York, NY Paul Downey, San Diego, CA Brian M. Duke, Radnor, PA Maria Henke, Los Angeles, CA Brooke A. Hollister, San Francisco, CA Karen N. Kolb Flude, Chicago, IL Daniel Lai, Hong Kong Rebecca C. Morgan, Gulfport, FL Scott Peifer, San Francisco, CA Kevin Prindiville, Oakland, CA Deborah Royster, Washington, DC Phil Stafford, Bloomington, IN Joyce Walker, Richmond Heights, OH Interim CEO Cynthia D. Banks, San Francisco, CA

GENERATIONS STAFF Editor

Alison Hood Senior Editor Alison Biggar Typography & Production Michael Zipkin | Lucid Design, Berkeley Generations cover and book design by Lisa Rosowsky, Blue Studio. Generations Editorial Advisory Board Wendy Lustbader Chair Susan C. Reinhard Immediate Past Chair Tobi Abramson Jean Accius Patrick Arbore David Bass

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AndrewMacPherson Robin Mockenhaupt Vyan Nguyen

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Aging in Rural America

inside generations Aging in Rural America

4 Our Guest Editor Dennis Dudley

62 Suicide Prevention Among Rural Older Adults By Patrick Arbore

life in rural America: reflections and realities 6 Why People Choose the Rural Life By Kathy Greenlee 9 Rural America by the Numbers By Steven Hirsch 17 Home Sweet Home: Aging in Place in Rural America By Suzanne Anarde 24 From Farms to Food Deserts: Food Insecurity and Older Rural Americans By Jean L. Lloyd 33 Getting Around in Rural America By Virginia Dize 40 Rural America: Secure in a Local Safety Net? By Mandy Weirich and William Benson aging in rural America: particular challenges to well-being 46 Aging Well in Rural America— the Role and Status of Healthcare By Clinton MacKinney, Dennis Dudley, and George Schoephoerster 55 Why Are Rural Older Adults Turning to Opioids? By William Benson, Kendra Kuehn, and Mandy Weirich

caring for rural America: making policy, making progress 66 Perceptions of and Policy Making Around Aging in Rural America By Donna Harvey 71 Building the Rural Healthcare Workforce: Challenges—and Strategies—in the Current Economy By Linda J. Redford 76 The First Rural Community: Indian Country By R. Turner Goins, Lisa Scarton, and Blythe Winchester 84 The History and Growth of the Rural PACE Center By Shawn Bloom 88 Can Emerging Technologies Buffer the Cost of In-Home Care in Rural America? By Nicol Turner-Lee conclusion: a call to care for rural America 94 Why We Should Care About Rural Aging By Dennis Dudley

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Our Guest Editor

Keeping the Faith in Rural America: A Longtime Denizen Speaks About Equity and Advocacy R ural Americans appear to be ignored and discounted, as they live in parts of the country considered “lesser than” by those in urban enclaves.

better able to work toward fnding cre- ative solutions. For more than half a century, I have played, lived, and-or worked in rural Northern California: I have been an eye- witness to the “rural experience,” with all of its adversities, diversities, and suc- cesses. During work hours, I served as a rural Area Agency on Aging director and lived in the “suburbs” of a town that housed fewer than 600 residents. This was Planning and Service Area 2 of the Area Agency on Aging out of Yreka, Cal- ifornia, the seat of Siskiyou County, just north of Mount Shasta. I also have served in a fve-county region near Yosemite National Park. And from 1993 to 2019, I had the priv- ilege of being the Administration on Aging appointee as staff to the National Advisory Committee for Rural Health & Human Services, out of an office in Washington, D.C. As a Committee member, I was able to travel throughout America, focusing on rural health and human services issues and, during my Committee tenure, we provided direct communication to the U.S. Secretary of Health and Human Services on subjects ranging from domestic violence, to care- giving, to healthcare access, and more. I also have served as vice presi- dent of the National Council on Aging’s National Council on Rural Aging. And

‘I believe home- and community-based services originated in rural America.’ DENNIS DUDLEY

But these Americans have become the new silent majority. When speaking of these rural, so-called fly- over states, the pub-

lic chooses not to notice the abundance that comes from scarcity—the creative spark that produces solutions to tackle the unique issues facing rural America. My esteemed colleagues and con- tributors to this Summer 2019 issue of Generations highlight many efforts by rural Americans to emphasize prog- ress in meeting older rural residents’ needs. For instance, telecommunica- tions and telehealth may address some of the challenges to accessing and deliv- ering services in rural areas; however, these innovations likely cannot address all core issues. How, then, can we meet these needs? Although technology can be immensely helpful, it lacks the physi- cal contact and face-to-face connections that are critical to everyone’s day-to- day existence. We hope this issue of Generations can help readers to better understand rural aging issues and be

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it was my extreme honor to be the frst recipient of the Anne McKinley Excel- lence in Aging Award, for commitment and services in the feld of Rural Aging. The topic of aging in rural America does not get the attention it deserves. Due to geographical isolation, econom- ics, and rural residents’ sense of inde- pendence, the needs of persons aging in rural regions often are overlooked. I want to raise this issue in a public way, which is why it is my privilege to play a part in highlighting rural needs and challenges in Generations . There has always been a soft spot in my heart for those who are under- served or overlooked. I feel the need to seek social justice for rural Americans, to ensure that rural older adults receive the same services and programming as do their urban counterparts. What is important to people in urban areas is of equal importance to rural Ameri- cans. This concept of equity to access has driven me to be the advocate I am today; and the dedicated people I have encountered and worked with fostered my passion. I believe that what we call “home- and community-based services” originated in rural America. I have wit- nessed the unique capacities of neigh- bors to help their neighbors get things done—from facing and overcoming catastrophes to ridding a neighbor’s roof of snow. I grew attached to work- ing with organizations and individuals who developed programs and services to help their constituents and communi- ties. They inspired me.

I hope there will be ingrained in all long-term-care service providers and support advocates the need to adopt an “equity to access” stance. Each time we ask, “What is effective in a particular feld or endeavor?” we should also ask, “How might that affect people in our rural American communities?” I also believe in the promise of rural America and I think its future remains strong, due to the atti-

‘Long-term-care service providers and support

tude and tenacity of the people who live there. In this issue’s articles, you will see evidence of talented, dedicated, and vision-

advocates need to adopt an “equity to access” stance.’

ary people who are working to trans- form their visions into realities. My sense for the future is that there will be a “new rural America” composed of people, organizations, and communi- ties—no longer such a silent majority— who will implement those visions. At the end of my career, but not of my advocacy for rural elders, I wish to publicly acknowledge Anne McKinley, my mentor in rural aging issues. Her passion and encouragement helped to make me the advocate I have become. I also want to recognize those who have helped to guide me on my journey— including Ray and PamMatura and my Arizona friend, Dennis Garbey, as well as Richard Browdie, Patrick Arbore, and all the other people who challenged me to grow, learn, and understand the sub- ject better. I thank you all. —Dennis Dudley

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GENERATIONS – Journal of the American Society on Aging

Why People Choose the Rural Life By Kathy Greenlee

People may choose to be rural for an opportunity to start over, but remain rural because it is home.

I s there a place where you feel centered? A place that evokes within you a central calmness, a sense of purpose and peace, a place where life seems most treasured? That special place, for each of us, represents an outward reflection of our inner selves. I am a ffth generation Kansan. I grew up in a small town near a bigger city. Clearwater, Kan- sas—my hometown—is an easy drive fromWich- ita. My maternal grandparents were farmers and ranchers. (Those are different things. Farmers grow crops. Ranchers raise cattle. My grand- parents did both.) From Clearwater, I moved to a college town, then to a suburb of our nation’s capital, and now I live in a major metropolitan midwestern city. Growing up rural does not necessarily mean that you will choose to remain rural for life. Because of where and how I was raised, I feel bicultural. I enjoy the full sensory engagement of a big city. I love the variety of activities, the restaurants, the shopping, the arts. But a big city does not evoke in me a sense of centeredness. Perhaps it does for others. In many ways, urban culture is my second language. I am simply not that far removed from the farm. Ritual, Space, and Contour in Rural Life In grade school, my sister, cousins, and I partici- pated in an odd ritual we did not understand.

After dinner at my grandparents’ house, we would go outside and sit on the steps of the porch and wait for the yard light to come on. That was it. That was the after-dinner entertainment on the farm. We rolled our eyes and made fun of this ritual for many years. When I gave the eulogy at my grandmother’s funeral, I fnally understood. By then, I was age 44. After dinner at my grandparents’ house, we would go outside, sit on the porch, and wait for the yard light to come on. It was quiet on the porch and we had to sit still. Sometimes you could hear men—yes, mostly men—still working in the felds. As the sky grew dark, gathering near the barn you could see and hear the Black Angus cattle. The freflies came out, then the yard light came on. And, fnally, you could see the stars. The purpose of the ritual was the time-out. It was a pause at the end of the day for silence, for listening, for being together, and for appreciating what we had, being outside on the farm. The reason my family chose to live rural is found in the texts of our history books and reflects the westward expansion and settle-

abstract Former Assistant Secretary for Aging Kathy Greenlee reflects on the draw of rural life, its challenges—especially for older adults—and her emotional connection to her rural roots. | key words: rural America, rural life, aging, healthcare access

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ment of our nation. My family, like so many oth- ers, came to Kansas for opportunity and land. My ancestors fought in the Revolutionary War, moved west to Ohio, fought again in the Civil War, and in the 1880s migrated to Kansas. The land that remained in my family for generations was the traditional land of the Osage Indians. Life in rural America is different. It is quiet. The pace is slower. Personal space is abundant. Ease of movement is an afterthought. You can physically and emotionally spread out. The air is cleaner. You can smell grass, trees, freshly cut wheat. You can see the stars and the Milky Way. In the vast middle portion of America, you can see the entire sky, from one horizon to the other. People who live in cities or in rural areas with mountains and trees do not live with the sky the same way we do on the Great Plains. The sky brings rain, violent weather, lightning strikes that spark prairie fres, migrating birds, and spectacular sunsets. In the middle of the United States, we obsess about the weather. It is friend and foe. Curved mountain roads, flat, broad main streets, and small hill towns illustrate the wide variety of rural communities and regional topog- raphy. The look of rural communities tells the story of shifting economic fortunes. Small towns from coast to coast often reflect long-abandoned dreams, witnessed by crumbling barns and shut- tered mine shafts. People live rural because it was always an opportunity to start over, to build a fortune, to live off the land. The reasons varied, but people chose the rural life because of what it offered. People remain rural because it is home. In the contours of rural America, you will fnd all that is good about our country, all that is challenging, and living reminders of the most troubling aspects of our past.

[rural] counties tend to have much older popu- lations than do metro [urban] counties.” Thus, there is a growing divide between urban and rural America, from both an economic and an age perspective. People confront problems when aging regardless of where they live. Functional limi- tations, cognitive impairment, caregiving, and transportation are challenges common to all ‘The look of rural communities tells the story of shifting economic fortunes.’ older people. Old is old, wherever you are. It is equally true that rural people encounter diffi- culties regardless of age. Difficulties in access- ing healthcare, absence of public transportation, insufficient housing, lack of broadband Inter- net, and limited employment opportunities are challenges common to rural communities every- where. Rural is rural, whatever your age. Old people in rural communities epitomize aging in place. But a person cannot successfully age in a rural area without the basic resources needed for people of any age. The closure of a rural hospital has a devastating impact on a rural community and surrounding region. The loss of every physician, psychologist, and pharmacist strikes a blow that falls particularly hard on older people. But the loss of basic access to healthcare is a setback for everyone, not only the old. Greensburg, Kansas, is rural by any defni- tion. It is located 110 miles west of Wichita, and forty-fve miles from Dodge City (yes, that Dodge City). Greensburg is also the county seat of Kiowa County, population 2,553. A county seat, should you be unfamiliar with the term, is the home of local county government and, typically, the rural community with the most resources. At 9:00 p.m. on May 4, 2007, the town of Greensburg was hit by an EF5 tornado, deci- mating 95 percent of the community. In tornado parlance, EF5 tornados are the most severe and

Realities and Challenges of Living and Aging in Rural America

One in fve people in the United States live in an area considered rural. And, as Steven Hirsch points out in his article on page 9, “Non-metro

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GENERATIONS – Journal of the American Society on Aging

‘I was raised rural because my people were rural. My hometown is also my family history.’ Governor Kathleen Sebelius. Can you guess which local business became the centerpiece of concern? The grocery store. For rural communities to thrive, certain assets are essential. I look forward to reading the article by Jean Lloyd in this issue (page 24) about farms and food deserts. What should be an oxymoron—a food desert in farm country—is not. Each rural community is unique. The opportu- nities and challenges they face often reflect the presence or absence of people with a specifc skill. In my partner’s rural Missouri hometown, for example, the sheriff is also the preacher. Rural people have to adapt. They take care of each other. Rural communities fgure it out. They protect each other. When I was a child, it was a big deal to be downtown when the fre alarm sounded. It was the call to assembly of the volunteer fre department. Men raced on foot and by pickup truck to the downtown gas station in which the fre truck and ambulance were housed. If you share this experience, you are rural. most deadly, as was the one occurring that eve- ning. At the time, Greensburg had a population of 1,544, eleven of whom were killed and sixty injured from this catastrophic storm. The tor- nado laid a path of destruction for twenty-two miles and reached a width of 1.7 miles. It was horror come real. In the aftermath of the destruction, members of the community decided to rebuild. A total of 961 homes and businesses had been destroyed. Of these, one particular business became the focus of attention by the community, media, local Chamber of Commerce members, and Rural Mainstays: People, Community, Faith—and the Stars

The old people living in small towns and rural areas are not strangers in their communities. They are known by name by the mayor, the banker, the barber, and the preacher. Social isolation is a men- ace gaining increasing attention, which is all for the better. Older rural people are at risk for social isolation. But what they have going for themmay be a lifetime of community involvement. Our best advice for rural communities may be as simple as asking rural leaders to check up on older residents and ask about their needs. I continue to believe faith communities are an untapped resource, especially in small towns. In my town, church and school were the social hubs of community. I know where I am from. I have a physical sense of my roots. I was raised rural because my people were rural. My hometown is also my fam- ily history. I remain friends with people I have always known. I have no concept of how it feels to be a stranger in grade school or high school. My immediate family, my grandparents, aunts, and uncles graduated from the same high school. Our individual pictures hang in a collection on the wall. People are raised rural and stay. People are raised rural and leave, often for educational or economic opportunities. Some urbanites move to the country. I live in Kansas City, but will even- tually return to be buried with many generations of my family. For now, you can hear the rural girl inside of me each time I complain because I can- not see the stars. It breaks my heart. Hon. Kathy Greenlee, J.D., is president and CEO of Greenlee Global LLC. From 2009 to 2016, she served as the Assistant Secretary for Aging, at the U.S. Department of Health and Human Services. References U.S. Census. 1993. “Population: 1790 to 1990.” tinyurl. com/y2xvm6bp. Retrieved February 14, 2019.

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Rural America by the Numbers By Steven Hirsch

A demographic snapshot, past and present, of who resides in rural America, and what has caused population shifts over time.

T he story of the population of the United States is one of transformation. One of the duties of the federal government, specifed in the U.S. Con- stitution, is to perform a decennial Census, which must count every person in the country. The Cen- sus of 1800 showed that only 6.1 percent of the population of the United States was urban (U.S.

close to 60 million people living in rural areas (see Figure 1 on page 10). It is important to distinguish the difference between the way the Census Bureau designates rural areas and the Office of Management and Budget’s designation of Metropolitan Statistical Areas. The Census Bureau does not defne what

Census Bureau, 1993). The U.S. population was overwhelmingly rural at that time and, though the rural pro-

is rural. “The U.S. Cen- sus Bureau defnes rural as what is not urban— that is, after defning individual urban areas,

In 1800, only 6.1 percent of the American populace was urban.

portion of the population declined through the nineteenth century, the majority of the popula- tion was still rural until the early decades of the twentieth century. In 1920, for the frst time, the majority of the U.S. population lived in urban areas and, since then, the urban majority has increased, reaching a new high in 2010 when it made up more than 80 percent of the total population. While the rural population as a percentage of the total has declined, the number of people living in Amer- ica’s rural areas has remained fairly stable over the past thirty years, with each Census showing

rural is what is left” (Ratcliffe et al., 2016). Late in the nineteenth century, the Census Bureau defned urban areas as “incorporated cit- ies and towns with at least 2,500 people . . . ” (Ratcliffe et al., 2016). The Census still uses places of at least 2,500 people to designate urban areas, but it no longer defnes the border of the urban area as the end of the incorporated place. Instead, it uses “a defnition based on population density and other measures of dense development when identifying urban territory. The defnition seeks to draw the boundary around an urban area’s ‘footprint’ to include its developed territory”

abstract The U.S. rural population, as a proportion of the entire population, has been declining for decades, and economic forces have pushed younger people to leave rural areas. This population is older, has more health problems, and has less wealth than the urban population. Although it varies by region, the racial and ethnic background of the rural population tends to be less diverse. Even as the proportion of the population ages 65 and older continues to increase, those ages 65 and older make up a larger part of the rural population. | key words: rural, urban, census, metropolitan, non-metropolitan, aging, older, counties

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(Ratcliffe et al., 2016). This recognizes the change in settlement patterns that became evident in the post–World War II era with the development of suburbs, which frequently were not part of an incorporated area. Because the Census designation of urban areas does not follow administrative borders such as city or county lines, statistical data often are not available for rural or urban areas. This problem does not exist for Metropolitan Statistical Areas (Metro), which are made up of whole counties and designated by theWhite House’s Office of Man- agement and Budget (OMB), based on economic integration of surrounding counties and measured Figure 1. U.S. Population by Decennial Census, 1800−2010 US Population by Decennial Census

grown to include about a third of all counties and, after the 2010 Census, about 85 percent of the total population. Changes in a county’s Metro status can be attributed to either pop­ ulation growth or to changes in commuting patterns, which draw the county’s working population into the Core Urbanized Area. Statistical data included below will specify whether it is based on the Census rural designa- tions or OMB’s Metro designations. Two economic trends enabled the momentous shift from a majority rural to a majority urban population: the Industrial Revolution, which cre- ated large numbers of jobs in urban areas; and an astonishing increase in agricultural productivity, which allowed fewer people to produce larger quantities of food for the entire population. Agricultural productivity “In 1870, almost 50 percent of employed persons worked in agriculture and one farmworker could only supply fve people with farm products. By 1980, just 4 percent of the employed were in agri- culture, and each one supplied food for nearly 70 others” (Daly, 2012). By the year 2000, the total number of people engaged in or employed on farms had declined by almost 90 percent from the number employed in 1900, with fewer than 1.6 million people working on farms in 2000 compared to more than 12 million in 1900 (Wyatt and Hecker, 2006). With fewer people required to produce food for a growing population, many of the people born in rural areas were either free to leave or, depending upon their point of view, were re­ quired to leave to fnd employment. This has led to a “graying” of the rural population and, in many rural areas, to a decline in population. Job growth and employment With the number of people required to produce food having declined, rural areas must look to Economic Trends Influencing Population Shift

0 10 20 30 40 50 60 70 80 90 100

Percent Rural

Percent Urban

Source: U.S. Census Bureau, 1993; U.S. Census Bureau, American FactFinder, 2000; U.S. Census Bureau, American FactFinder, 2010. by the commuting patterns of the working popula- tion. Both economic and demographic data are fre- quently collected and analyzed at a county level. Metro areas must contain a Census-desig- nated urbanized area of at least 50,000 people. For Census-designated urban areas of 10,000 to 49,999 people, OMB calls themMicropolitan Statistical Areas (Micro), which also are made up of whole-county areas. All other counties in the United States that do not fall into either category are “Non-core” counties. The Micro and Non- core counties together make up the majority of counties and land area of the United States and are considered Non-metro, or “rural counties.” The Metro population of the country and the number of counties designated as Metro have

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other economic sectors for job growth. Unfor- tunately, since the Great Recession, rural job growth has not recovered and virtually all the new jobs in the United States have been created in Metropolitan areas. Even given that, most of the job growth in Metro areas is not occurring across the board in both large population and small Metro areas, but is mostly occurring in the largest Metro areas. Since the Great Recession, virtually all new jobs in the United States have been created in Metropolitan areas. “[T]he biggest metros [those with popula- tions of more than 1 million residents] generated fully two-thirds of output growth on the eco- nomic front and 73 percent of employment gains between 2010 and 2016—fgures that actually have increased since 2014, when they reached nearly 72 and 74 percent . . . As for the [Non- metro] tier, the trends have been even worse. By the 2014 to 2016 period, rural communi- ties’ contribution to national population growth had turned negative and the ebbing of the ear- lier oil and gas boom saw output and employ- ment growth decline precipitously as a share of national gains” (Hendrickson, Muro, and Galston, 2018). The decline in job growth may contribute to a decline in the Non-metro population in two ways: young people leave the Non-metro areas in search of employment; and even those who remain and live in a Non-metro county com- mute to an Urbanized Area in order to work and, thereby, change the status of the Non- metro county to a Metro county.

females was 48.3 years. By the end of the cen- tury, in 2000, the life expectancy at birth for males was 74.1 years and for females was 79.3 years, an increase of more than 60 percent for both sexes (Arias et al., 2017). At the same time that mortality was declin- ing, leading to increasing average life expec- tancy, the fertility rate also declined (Sutton, Hamilton, and Mathews, 2011). While there has been great variability in the rate over the decades, the trend since the mid-1960s gener- ally has been downward. The fertility rate in the mid-1920s was more than 100 births per 1,000 women, but by 2007, the rate had fallen to 69.5 births per 1,000 women. Since 2007, the fertility rate has fallen fur- ther to 62.5 births per 1,000 women ages 15 to 44, and diverged for Metro and Non-metro areas, with Non-metro areas having a slightly higher fertility rate (Martin et al., 2017; Ely and Hamilton, 2018). The increasing longevity and declining birth rate of the population is reflected in changes to what had been known as the “Population Pyr- amid,” a visual representation of cohorts that began with a very broad base at birth and nar- rowed as the population aged, until the very old, who made up a very small part of the total, were represented by a narrow capstone on the pyra- mid. Recent versions of the Population Pyramid now resemble a rectangle, with less narrowing as the population ages. The Population Pyramids show that the female population outnumbers the male popu- lation more and more as they age. The popula- tion ages 65 and older is made up of 57 percent women, compared to 43 percent men, with the female proportion of the population growing as they age. For the age group older than age 84, women make up 64 percent of the population. While the male Non-metro population ages 65 and older (45 percent) is slightly larger than the male Metro population ages 65 and older (43 percent), by the time they reach an age older than 84, two-thirds of the Non-metro popula-

Other Impacts on U.S. Population: Life Expectancy and Birth Rate

Advances in medicine and public health also have had huge impacts on the U.S. population. At the start of the twentieth century, life expec- tancy at birth for males was 46.3 years and for

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GENERATIONS – Journal of the American Society on Aging

cent) Non-metro counties with a median age more than 20 percent higher than the national median age. There are 80 Non-metro coun- ties that have a median age older than 50, but only nine Metro counties with that median age (based on 2010 Census Data from the Area Health Research File). The Census of 2010 showed that, overall, 13 per- cent of the population was ages 65 and older. The Metro population ages 65 and older contained 81.7 percent of the older adults, while the remain- ing 18.3 percent of elders lived in Non-metro counties (per Area Health Resources Files). However, the population ages 65 and older made up 12.5 percent of the Metro population, while they made up 16 percent of the Non-metro population. (Because of the larger proportion of The poverty rate for the population older than age 60 was higher in Non-metro areas than it was in Metro areas. the Non-metro population that is older than age 65, Medicare payment policies have a greater impact on rural healthcare providers than they do on Metro providers.) Table 1 (see page 13) shows the racial makeup of the population ages 65 and older. While whites make up a large majority of the whole population ages 65 and older, they make up a much larger portion of the Non-metro popula- tion ages 65 and older. But, using the Census Bureau’s regions to further examine the population ages 65 and older shows a great deal of geographic variabil- ity, as follows: √ In the Northeast states (Connecticut, Maine, Massachusetts, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island, Current population: older ages and racial composition

tion of the oldest old is women, which is slightly more than the population as a whole (64.4 per- cent) (data from the Area Health Resources Files [AHRF], based on Census 2010 Tables). A Look at the U.S. Population: Age, Racial Makeup, Health, and Wealth At the start of the twentieth century, half of the population was younger than age 22.9. By 2000, the median age had reached 35.3 (Hobbs and Stoops, 2002). Due to the shift in population from rural to urban areas, the median age in much of Non-metro America is higher than the median age in the Metro areas. Median age Median age is defned as the age of the midpoint of the population, meaning that half the popula- tion is older than the median age and half of the population is younger. In 2000, there were 439 (37.5 percent) Metro counties whose median age was below the national median age of 35.3. At the same time, there were only 375 (19 percent) current Non- metro counties in which the median age was below the national median age of 35.3. The vast majority of Non-metro counties, 1,578 (80 percent), had median ages higher than 35.3 compared to 721 (62 percent) of current Metro counties. By the 2010 Census, the median age of Americans had reached 37.2 years (Howden and Meyer, 2011) and 419 (36 percent) current Metro counties had a median age below the national median, while only 317 (16 percent) current Non-metro counties had a median age below the national median. There were 1,644 (83 percent) Non-metro counties where the median age was above the national median age and 735 (63 percent) Metro counties that had median ages above the national median age. Non-metro counties tend to have much older populations than do Metro counties, with 73 (6 percent) of Metro counties with a median age more than 20 percent higher than the national median age, but 510 (26 per-

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Aging in Rural America

nessee, Texas, Virginia, and West Virginia), blacks make up 11.7 percent of the Non-metro population ages 65 and older. √ In the West (Alaska, Arizona, California, Colorado, Hawaii, Idaho, Montana, Nevada, New Mexico, Oregon, Utah, Washington, and Wyo- ming), Asians make up more than 10 percent and Hispanics more than 13 percent of the Non- metro population 65 and older. Table 2 (see page 14) contains a comparison of Metro and Non-metro populations older than age 64 by race and region. Health and wealth The Non-metro population in general faces greater health problems than does the metro population, and has barriers in accessing health- care. In a recent series of publications, the Cen- ters for Disease Control and Prevention (CDC) examined Metro–Non-metro health disparities (CDC, 2019). Non-metro residents reported higher rates of multiple chronic conditions, with 22.6 percent of Non-metro residents reporting two to three chronic conditions, compared to 18.9 percent of Metro residents and 5.1 percent of Non-metro residents reporting four or more chronic conditions, compared to 4.2 percent of Metro residents (CDC, 2017). In another CDC study, Non-metro residents were found to have higher age-adjusted death rates than Metro residents. The study authors wrote, “Compared with metropolitan areas, non- metropolitan areas have higher age-adjusted death rates and greater percentages of poten- tially excess deaths from the fve leading causes of death, nationally and across public health regions” (Moy et al., 2017). In an analysis of American Community Sur- vey data for this article, the poverty rate for the population older than age 60 was found to be higher in Non-metro areas than it was in Metro areas. The Metro poverty rate for those older than age 60 was 9.5 percent, but for the Non- metro age group, the rate was 10.7 percent. The Health Resources and Services Administra-

Table 1. Racial Makeup of U.S. Population Older than Age 64

Non-metro Metro

U.S.

Total Population

46,108,526

262,630,790 308,739,316

Pop > 64 years Pop > 64 years Pop > 64 years

Total

7,380,656

32,882,750 40,263,406

(% Total Population) White, Non- Hispanic (%Over Age 64 Population)

(16.0%)

(12.5%)

(13.0%)

6,636,759

25,571,517

32,208,276

(89.9%)

(77.8%)

(80.0%)

Black

386,604 (5.2%) 191,936 (2.6%)

3,051,629

3,438,233

(9.3%)

(8.5%)

Hispanic

2,589,671

2,781,607

(7.9%)

(6.9%)

Asian

38,130 (0.5%) 80,776

1,348,494

1,386,624

(4.1%)

(3.4%)

American Indian/Alaska Native

126,284

207,060

(1.1%) 3,485

(0.4%) 27,728

(0.5%)

Native Hawaiian/ Other Pacific Islander

31,213

(0.0%) 46,207 (0.6%)

(0.1%)

(0.1%)

Other

167,427 (0.5%)

213,634

(0.5%)

Source: HRSA, 2019.

and Vermont), more than 98 percent of the popu- lation ages 65 and older is white. √ In the Midwest (Illinois, Iowa, Indiana, Kansas, Michigan, Minnesota, Missouri, Nebra­ ska, North Dakota, Ohio, South Dakota, andWis- consin), whites make up more than 65 percent of the Non-metro population ages 65 and older. √ In the South (Alabama, Arkansas, Dela- ware, District of Columbia, Florida, Georgia, Kentucky, Louisiana, Maryland, Mississippi, North Carolina, Oklahoma, South Carolina, Ten-

Volume 43 . Number 2 | 13

GENERATIONS – Journal of the American Society on Aging

Table 2. Metro and Non-metro Populations Older than age 64, by Race and Region

Northeast Northeast South

South

Midwest Midwest West

West

Non-metro Metro

Non-metro Metro

Non-metro Metro

Non-metro Metro

Total Population

4,684,364

50,632,876

19,752,462

94,797,060

15,211,568

51,715,433

6,460,132

65,485,421

Population over 64

Population over 64

Population over 64

Population over 64

Population over 64

Population over 64

Population over 64

Population over 64

Total

773,478 (16.6%)

7,028,114

3,096,051

11,796,597 2,534,656

6,487,678

976,471 (15.1%)

7,570,361

(% Total Pop)

(13.9%)

(15.7%)

(12.4%)

(16.7%)

(12.5%)

(11.6%)

White, Non- Hispanic (%Over 64 Pop)

759,832

5,691,737

2,580,281

8,954,724 2,465,804 5,576,196

830,842

5,348,860

(98.2%)

(81.0%)

(83.3%)

(75.9%)

(97.3%)

(86%)

(85.1%)

(70.7%)

Black

4,230

636,872

362,094

1,514,878 (12.8%) 224,826

16,602 (0.7%)

601,216 (9.3%) 111,357 (1.7%) 14,459

3,678

298,663

(0.5%)

(9.1%)

(11.7%)

(0.4%) 21,541 (2.2%) 36,342

(3.9%)

Asian

2,474

243,347

7931

6,184

768,964 (10.2%)

(0.3%)

(3.5%) 13,554

(0.3%) 28,602

(1.9%)

(0.2%) 13,903

American In- dian/Alaska Native

1,929

40,758

57,513

(0.2%)

(0.2%)

(0.9%)

(0.3%)

(0.5%)

(0.2%)

(3.7%)

(0.8%) 22,753

Native Hawaii / Other Pacific Islander

69

1,142

375

2,854

259

979

2,782

(0%) 3,241

(0%)

(0.0%) 20,988 (0.7%)

(0%)

(0%)

(0%)

(0.3%) 11,144 (1.1%)

(0.3%) 68,420 (0.9%)

Other

15,231

54,058 (0.5%)

10,834 (0.4%)

29,718 (0.5%)

(0.4%)

(0.2%)

Source: HRSA, 2019.

tion (HRSA) of the U.S. Department of Health and Human Services designates Health Pro- fessional Shortage Areas, areas that lack suffi- cient personnel to provide care to the residents of the area. Access to Healthcare in Rural America The rural United States is a vast area, much of it lightly populated. Many rural areas face shortages of both healthcare facilities and per- sonnel. Although the rural areas of the country contain slightly less than 20 percent of the population, 59 percent of Primary Care Health

Professional Shortage Areas were located in rural areas (Health Resources and Services Administration [HRSA], Bureau of Health Workforce, 2019). Specialists are in even shorter supply in rural areas than are pri- mary care providers. Many rural facilities are supported by dif- ferential payment policies for Medicare and, in many states, Medicaid. Critical Access Hospitals (CAH) are small, rural hospitals that receive cost- based payments fromMedicare for services pro- vided to benefciaries. There were 1,348 CAHs located in rural areas as of July 2018.

14 | Summer 2019

Aging in Rural America

Rural Health Clinics (RHC) must be located in rural, underserved areas. They also receive differ- ential payments fromMedicare. There are more than 4,300 certifed RHCs in the United States. Skilled Nursing Facilities (SNF) provide nursing and therapy care that can only be safely and effectively performed by, or under the super- vision of, professionals or technical personnel. There are more than 15,000 SNFs in the United States, and approximately a third are located in areas defned as rural by the Federal Office of Rural Health Policy (FORHP). FORHP desig- nates all Non-metro counties as rural and uses an additional method of determining rural- ity called the Rural-Urban Commuting Area (RUCA) codes. RUCA codes are based on Census data used to assign a code to each Census Tract. Tracts inside Metro counties with the codes 4 to 10 are considered rural. Continuing Transformation in Rural America—Looking Ahead to the Next Census Since the 2010 Census, the proportion of the population that is ages 65 and older has contin- ued to grow as the Baby Boom Generation ages. According to an analysis of American Com- munity Survey data by the Economic Research Services at the U.S. Department of Agriculture (USDA), between 2010−2011 and 2015−2016, the

Non-metro population declined each year, but then grew slightly through 2016−2017. The pro- portion of the Non-metro population ages 65 and older increased to 19 percent, and the Metro proportion was still lower, with 15 percent of the population older than age 64. Counties with more than 20 percent of their population ages 65 or older are mostly Non-metro, with only about 15 percent of these “older-age counties” in Metro areas (Cromartie, 2018). Much of the Non-metro population growth is occurring in counties the USDA identifes as “either retirement destinations or as hav- ing recreation-based economies. These counties are concentrated in the Upper Great Lakes, the Appalachians and Ozarks, Texas Hill Country, and throughout the Rocky Mountain West. Most of these counties have seen an upturn in popu- lation growth caused by more people moving to them since 2013” (Cromartie, 2018). Only time will tell whether the rural pop­ ulation will stabilize, grow, or shrink in sheer numbers, and as a proportion of the entire population. Steven Hirsch is a program analyst in the Policy/ Research Division of the Federal Office of Rural Health Policy in the Health Resources and Services Administra­ tion, U.S. Department of Health and Human Services.

References Arias, E., et al. 2017. “United States Life Tables, 2014.” National Vital Statistics Reports 66: 4. tinyurl. com/ycphu3f9. Retrieved February 18, 2019. Centers for Disease Control and Prevention (CDC). 2017. “Health, United States, 2017—Data Finder.” tinyurl.com/y63cgbkt. Retrieved December 19, 2018.

Daly, P. A. 2012. “Agricultural Employment: Has the Decline Ended?” The Monthly Labor Review . Washington, DC: U.S. Department of Labor, Bureau of Labor Statistics. tinyurl.com/ y3a5w5rf. Retrieved February 18, 2019.

CDC. 2019. “Morbidity and Mor- tality Weekly Report Rural Health Series.” tinyurl.com/y25m9cey. Retrieved January 30, 2019. Cromartie, J., 2018. “Rural Amer- ica at a Glance, 2018.” Economic Information Bulletin No. (EIB-200) . Washington, DC: United States Department of Agriculture, Eco- nomic Research Service. tinyurl. com/y4enhjaa. Retrieved Novem- ber 9, 2018.

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GENERATIONS – Journal of the American Society on Aging

Ely, D. M., and Hamilton, B. E. 2018. “Trends in Fertility and Mother’s Age at First Birth Among Rural and Metropolitan Counties: United States, 2007–2017.” NCHS Data Brief, No. 323 . Hyattsville, MD: National Center for Health Statistics. tinyurl.com/y3tgwynp. Retrieved February 18, 2019. Health Resources and Services Administration (HRSA), Bureau of Health Workforce. 2019. “Desig- nated Health Professional Short- age Areas Statistics.” tinyurl.com/ y4t27q3q. Retrieved January 30, 2019. HRSA. 2019.“The Area Health Resources Files.” tinyurl.com/y6lr fkj5. Retrieved May 2, 2019. Hendrickson, C., Muro, M., and Galston, W. A. 2018. “Counter- ing the Geography of Discontent: Strategies for Left-behind Places.” The Brookings Institution. tinyurl. com/yborn7zd. Retrieved Febru- ary 18, 2019.

Hobbs, F., and Stoops, N. 2002. “Demographic Trends in the 20th Century: Census 2000 Reports.” Washington, DC: U.S. Census Bureau. Howden, L. M., and Meyer, J. A. 2011. “Age and Sex Composition: 2010.” 2010 Census Briefs . Wash- ington, DC: U.S. Census Bureau. tinyurl.com/zl8qxc6. Retrieved December 26, 2018. Martin, J. A., et al. 2017. “Births: Final Data for 2015.” National Vital Statistics Reports 66: 1. tinyurl. com/ha6gx6o. Retrieved February 18, 2019. Moy, E., et al. 2017. “Leading Causes of Death in Non-metro- politan and Metropolitan Areas— United States, 1999–2014.” Mor- bidity and Mortality Weekly Report Surveillance Summary 66(No. SS-1): 1–8. Ratcliffe, M., et al. 2016. “Defning Rural at the U.S. Census Bureau.” Report Number ACSGEO-1 . Wash- ington, DC: U.S. Census Bureau.

Sutton, P. D., Hamilton, B. E., and Mathews, T. J. 2011. “Recent Decline in Births in the United States, 2007–2009.” Hyattsville, MD: CDC, National Center for Health Statistics. tinyurl.com/ y4ps6w5t. Retrieved November 9, 2018. U.S. Census Bureau. 1993. “Table 4: Population: 1800 to 1990.” tinyurl. com/y2xvm6bp. Retrieved Novem- ber 9, 2018. U.S. Census Bureau, American FactFinder. 2000. “Table: Urban/ Rural and Metropolitan/Nonmet- ropolitan Population: 2000, United States.” tinyurl.com/y2ahf7hd. Retrieved May 7, 2019. U.S. Census Bureau, American FactFinder. 2010. “Table: Urban and Rural Universe: Total Popu- lation.” tinyurl.com/y38ypf7m. Retrieved May 7, 2019. Wyatt, I. D., and Hecker, D. E. 2006. “Occupational Changes Dur- ing the 20 th Century.” Monthly Labor Review . tinyurl.com/ y79zqncs. Retrieved December 19, 2018.

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