As Rural Hospitals Struggle, Some Opt To Close Labor And Delivery Units

By Michelle Andrews 

February 23, 2016--

About 500,000 women give birth each year in rural hospitals, yet access to labor and delivery units has been declining. Comprehensive figures are spotty, but an analysis of 306 rural hospitals in nine states with large rural populations found that 7.2 percent closed their obstetrics units between 2010 and 2014.

A few years ago, when a young woman delivered her baby at Alleghany Memorial Hospital in Sparta, North Carolina, it was in the middle of a Valentine’s Day ice storm and the mountain roads out of town were impassable.

The delivery was routine, but the baby girl had trouble breathing because her lungs weren’t fully developed. Dr. Maureen Murphy, the family physician who delivered her that night, stayed in touch with the neonatal intensive care unit at Wake Forest Baptist Medical Center in Winston-Salem, a 90-minute drive away, to consult on treatment for the infant.

“It was kind of scary for a while,” Murphy remembered. But with Murphy and two other family physicians trained in obstetrics as well as experienced nurses staffing the 25-bed hospital’s labor and delivery unit, the situation was manageable, and both mother and baby were fine.

Things are different now. Alleghany hospital — like a growing number of rural hospitals — has shuttered its labor and delivery unit, and pregnant women have to travel either to Winston-Salem or to Galax, Virginia, about 30 minutes away by car, weather permitting.

“It’s a long drive for prenatal care visits, and if they have a fast labor” it could be problematic, said Murphy, who teaches at the Cabarrus Family Medicine Residency Program in Concord, North Carolina. (Although not essential, women typically see the physician they expect will handle their delivery for prenatal care.)

About 500,000 women give birth each year in rural hospitals, yet access to labor and delivery units has been declining. Comprehensive figures are spotty, but an analysis of 306 rural hospitals in nine states with large rural populations found that 7.2 percent closed their obstetrics units between 2010 and 2014.

“The fact that closures continue happening — over time that means the nearest hospital gets further and further away,” said Katy Kozhimannil, an associate professor at the University of Minnesota School of Public Health, who coauthored the study published in the January issue of Health Services Research.

There are many factors that contribute to the decline in rural hospital obstetrics services. For one thing, obstetrics units are expensive to operate, and a small rural hospital may deliver fewer than 100 babies a year.

 “A labor and delivery unit is functionally no different than an intensive care unit,” said Dr. Neel Shah, an assistant professor of obstetrics, gynecology and reproductive biology at Harvard Medical School.

Staffing levels are high in obstetrics, often one nurse for every patient, and the rooms are cluttered with monitors, infusion pumps and other equipment.

It can be difficult to staff the units as well. Small rural hospitals may not have obstetricians on staff and rely instead on local family physicians, but it can be difficult to get enough to fully provide services for a hospital, too. Nurses with obstetrics experience also can be scarce.

Meanwhile, bringing in the revenue needed to cover the costs involved in maintaining the units can be difficult because insurance payments are often low. Medicaid pays for slightly under half of all births in the United States, but in rural areas the proportion is often higher, said Kozhimannil.

Since Medicaid pays about half as much as private insurance for childbirth, “the financial aspect of keeping a labor and delivery unit open is harder in rural areas,” she said.

Advocates say there are a number of initiatives that could help bolster labor and delivery services in rural areas.

Encouraging medical professionals to move to rural areas is key, they say. A bipartisan bill introduced in Congress last year, for example, would require the federal government to designate maternity care health professional shortage areas.

Such designations exist for primary care, mental health and dental care. The National Health Services Corps awards scholarships and provides loan repayment to primary care providers who commit to serving for at least two years in designated shortage area. Once they get to a community and put down some roots, the hope is they’ll stay.

Expanding the use of midwives and birthing centers could be cost effective since they are generally less expensive than physicians and hospital obstetric units. 

Although birthing centers and home births are on the rise, more than 98 percent of the 4 million babies that were born in 2014 made their arrival at a hospital.

“You can deal with lower volume and still be sustainable,” said Shah.

“Finding strength in numbers, small rural hospitals are increasingly banding together to share resources, said Kozhimannil. For example, since it’s difficult to keep rural staff trained in rare complications, small rural hospitals sometimes pool resources to buy a mobile simulation unit to train people on handling postpartum hemorrhage, the leading cause of maternal mortality.

Kozhimannil sees great opportunity in the ongoing national dialogue about health reform but says much of the research to date has focused on reforming health care in urban settings.

“That’s why it’s crucial to have rural people at the table,” she said.

Please contact Kaiser Health News to send comments or ideas for future topics for the Insuring Your Health column.

Palliative Approach to Care Especially Fitting for Rural Hospitals

Article in Critical Care Nurse discusses how nurses at critical access hospitals can use palliative approach to care for rural residents and families

Newswise, February 1, 2016 — Nurses at critical access hospitals are well positioned to provide high-quality palliative care close to home for millions of Americans in rural communities, according to an article in the February issue of Critical Care Nurse (CCN).

The United States has 1,332 critical access hospitals located in rural communities, providing mostly acute inpatient services, ambulatory care, labor and delivery services, and general surgery.

With fewer than 25 beds each and a mean daily census of 4.2 patients, these hospitals may frequently have a single registered nurse as the only healthcare professional on duty.

The article “Palliative Care in Critical Access Hospitals” uses a case report to illustrate the role that critical access hospitals play in meeting the need for high-quality palliative care in rural settings.

Palliative care provides psychological, spiritual, goal-setting and decision-making support not only to patients with life-threatening illnesses but to their families as well.

The benefits of such care include early initiation of comfort-focused treatment goals, decreased length of stay, continuity of care and reduced cost of care without an increase in mortality.

Unlike hospice care, palliative care is appropriate early in the course of illness, and patients can be simultaneously treated for their condition, including therapies intended to prolong life.

Millions of patients are living with serious, complex and potentially life-threatening conditions, increasing the need for palliative and end-of-life care.

Co-authors Dorothy “Dale” M. Mayer, RN, PhD, and Charlene A. Winters, PhD, APRN, ACNS-BC, are on the faculty of the College of Nursing, Montana State University, Missoula.

“As expert generalists, rural nurses are well positioned to provide support and promote quality of life close to home for patients of all ages and their families,” Mayer said.

“In sparsely populated areas, nurses are not strangers to their patients, often providing care to their neighbors, friends and relatives.”

The healthcare system is increasingly moving away from the consultative model of palliative care, in which clinicians bring in specialists to advise on individual cases.

The authors advocate for a different model, in which frontline staff, including physicians, nurses, social workers and chaplains, incorporate a palliative approach into patient care, especially with patients who have complex health conditions.

This approach is especially suited for rural area and critical access hospitals, in part because of an inherent sense of community between friends and neighbors.

“With limited personnel and resources, healthcare providers can no longer rely on specialized palliative care teams as the only clinicians to provide palliative care,” Winters said.

 “Working together, rural nurses and their urban nursing colleagues can provide palliative care across all healthcare settings to meet the needs of rural residents and their families.”

The American Association of Critical-Care Nurses, which publishes CCN, offers resources and tools to help nurses care for patients and their families at the most difficult times of their lives, including an e-learning course and a free, online self-assessment tool.

For more information on palliative and end-of-life care, please visit www.aacn.org/palliativeedu.

As AACN’s bimonthly clinical practice journal for high acuity, progressive and critical care nurses, CCN is a trusted source for information related to the bedside care of critically and acutely ill patients.

Access the article abstract and full-text PDF by visiting the CCN website at http://ccn.aacnjournals.org/.

About Critical Care Nurse: Critical Care Nurse (CCN), a bimonthly clinical practice journal published by the American Association of Critical-Care Nurses, provides current, relevant and useful information about the bedside care of critically and acutely ill patients.

The journal also offers columns on traditional and emerging issues across the spectrum of critical care, keeping critical care nurses informed on topics that affect their practice in high acuity, progressive and critical care settings. CCN enjoys a circulation of more than 106,000 and can be accessed at http://ccn.aacnjournals.org/.

About the American Association of Critical-Care Nurses: Founded in 1969 and based in Aliso Viejo, California, the American Association of Critical-Care Nurses (AACN) is the largest specialty nursing organization in the world. AACN represents the interests of more than 500,000 acute and critical care nurses and includes more than 225 chapters worldwide.

The organization’s vision is to create a healthcare system driven by the needs of patients and their families in which acute and critical care nurses make their optimal contribution. www.aacn.org; www.facebook.com/aacnface; www.twitter.com/aacnme

Many Aging Farmers don’t plan to retire and lack strategies to keep Family Farms going in the future…Rural Culture at stake

(Reposted January 31, 2016)  Newswise — Farming is less a job than it is a way of life for the Kansas farmers who watch their peers retire from office and factory jobs without intentions of quitting themselves.

They also often don't have plans for the farms after they're gone.

That's what a Kansas State University sociologist has found in a study of farmers in Rush County. 

Although such a work ethic and commitment may be admirable, it leaves the future of family farming and the culture surrounding it up in the air, said Laszlo Kulcsar, a K-State associate professor of sociology and director of the university's Kansas Population Center.

"Farming is really an essential component of the local culture, and many farmers think that local culture simply cannot exist without farming," he said. "At the same time, farming is a core element only as long as it's a family farm or a medium-sized operation. Once the big companies take over, the economic activity remains the same but the culture is going to change."

Kulcsar's study of aging Kansas farmers began by examining 2007 U.S. Census Bureau statistics showing that more than one-third of U.S farmers -- about 550,000 of them -- are 65 years old or older. Kulcsar and two graduate students wanted to see how Kansas farmers fit in. 

They made Rush County their model because of the greater significance of farming on the local economy compared with other Kansas counties, and Rush County's large number of older farmers. Kulcsar said that 30 percent of the county's farmers are 70 or older.

Beyond extended life expectancies, Kulcsar said that several cultural and technological shifts explain why there are so many older farmers in Rush County, as well as elsewhere in Kansas and the country. Thanks to more sophisticated equipment, farm labor is less demanding than it once was. In addition, some farmers are not farmers in the traditional sense but rather retirees who took up farming activities as a pastime.

Another significant cultural change, Kulcsar said, has been in family structure. Many farmers inherited their farms from their parents but now find that their own children are not interested in farming.

The second part of Kulcsar's research involved asking these farmers about their strategies for transitioning their farms if they ever do retire or after death.

"They don't even think about retirement whatsoever," he said. "Their take on farming is one that you'd expect. It's a way of life. It's not just making money, it's a culturally important thing

."

Kulcsar said that from a demographic standpoint, the problem that arises from increased corporate farming is long-term sustainability, for which family farming is better suited.

"It is expensive and difficult to enter the profession as a farmer who didn't inherit a family farm," Kulcsar said. "The land is expensive, the equipment is expensive, and for that reason there really is no other way to enter the family farming business."

He said this poses another problem in that farmers just entering the profession are more likely to adopt technology and innovations that could improve profit margins and help them compete with the economies of scale that corporations have.

"Family farming creates certain values and a work ethic that corporate farming just can't have," Kulcsar said. "The farmers we talked to said that their advantage over corporate farming is that they're going to do the right thing and care about people."

Kulcsar presented the research in August at the annual meeting of the Rural Sociological Society in Madison, Wis. The students participating in the research are Benjamin Bolender and Albert Iaroi, both K-State doctoral students in sociology. 

The project is funded by K-State's Center on Aging.

Kulcsar said that the future of the research could involve extending the study to other farming-dependent counties in Kansas, as well as working with the Center on Aging and with K-State Research and Extension on ways of getting farmers involved in transition plans for their farms.

Broadband could be Boon for Rural Clinics

(Reposted January 31, 2016) --A federal broadband initiative may have implications for the health system, too, NPR reports.

"Millions of Americans who live in rural areas travel long distances to get health care. Or they may go without it. But high-speed Internet connections now make it possible to bring a doctor's expertise to patients in far-off places, if those places are connected.

"As part of its National Broadband Plan, the Federal Communications Commission has pledged $400 million a year to connect nearly 12,000 rural health care providers."

On example is Redwoods Rural Health Center in Redway, Calif. The clinic has 4,000 patients and only one doctor, and is 200 miles from San Francisco.

"Patients come in with skin problems, cancers, diabetes, hepatitis — all diseases that require expertise [the doctor] may not have.

"So she has to send patients to doctors in cities 100 or more miles away. That can be hard on many of them, both physically and financially." Broadband could help connect those patients to specialists without the stress of travel."

Family Farm Managers Earn Less, but Gain ‘Emotional’ Wealth

Newswise, August 27, 2015 — ITHACA, N.Y. – After hours harvesting forage, managing livestock and milking cows, new Cornell University agricultural economic research shows family members who work on the family dairy farm make $22,000 less annually than comparable hired managers, but are handsomely compensated with “socioemotional” wealth.

“While $22,000 seems like a large penalty, there are nonfinancial rewards they experience working for the family business,” said Loren Tauer, professor at Cornell’s Charles H. Dyson School of Applied Economics and Management, who with lead author Jonathan Dressler of MetLife’s Food and Agribusiness Finance, published “Socioemotional Wealth in the Family Farm,” in a forthcoming Agricultural Finance Review.

There are roughly 5,400 dairy farms in New York, large and small. “Family members like to work for the family farm, as it brings prestige and satisfaction by working with siblings, cousins and parents,” explains Tauer. “The socioemotional part is that these family members feel an attachment to the dairy farm. It’s a warm and fuzzy feeling.”

Further, Dressler explained that socioemotional aspects of running a dairy farm “create a sense of pride and belonging, as collectively each family member is contributing an effort toward a common family goal.”

Dressler and Tauer examined dairy farm income in 1999 through 2008 and showed that New York farm manager median salaries varied widely from $41,884 in 1999, to $64,466 in 2004 to $74,986 in 2005, all adjusted for inflation to 2008 dollars. 

While the family farm managers were paid on average about $22,000 less, family members were compensated in other ways, such as with equity in the family business, which includes land values and the value of the operation – all of which have risen over time.

For family farms, Dressler and Tauer estimated a 5 percent current return to equity and asset appreciation of 10 percent, for a total return to equity of 15 percent. 

With “sweat equity,” Tauer explains, children eventually inherit farms or are given an opportunity to purchase farms at a low estimate of the farms’ value. That future ownership opportunity and the chance to work with family members offset reduced annual compensation.

Rural Mainstreet Index Sinks in August

 Cash Rents Expand as Farmland Prices Slump

August Survey Results at a Glance:
• The Rural Mainstreet Index sinks to growth neutral for August.
• Farmland prices decline for the 21st straight month, but cash rents remain strong at $263 per acre.
• On average, bankers expect farmland prices to decline by another 5.8 percent over the next 12 months.
• Housing sales expand at a healthy pace.

Newswise, August 21, 2015 – The Creighton University Rural Mainstreet Index fell for August from July’s tepid reading, according to the monthly survey of bank CEOs in rural areas of a 10-state region dependent on agriculture and/or energy.

Overall: The Rural Mainstreet Index (RMI), which ranges between 0 and 100, sank to growth neutral 50.0 from 53.4 in July.

“This is the first decline in the overall index since March of this year. Weaker conditions among businesses tied directly to agriculture and energy accounted for the downturn in the reading," said Ernie Goss, Jack A. MacAllister Chair in Regional Economics at Creighton University's Heider College of Business.

Farming and ranching: The farmland and ranchland price index for August increased slightly to 32.7 from July’s 31.4. 

“This is the 21st straight month the index has remained below growth neutral. But, as in previous months, there is a great deal of variation across the region in the direction and magnitude of farmland prices,” said Goss.

This month the survey asked bankers to project the expected change in farmland prices over the next year. On average, bankers reported an estimated decline of 5.8 percent over the next year. Last August when the same question was asked, bankers reported an expected 4.8 percent decrease.

“Bank CEOs were also asked to estimate current cash rents for nonpasture cropland. On average, bankers reported $263 per acre, which is up from $258 reported last year at this time. Additionally, bankers reported an increase in the share of farmland financed from 74 percent last August to 77 percent this month,” said Goss.

The August farm equipment-sales index sank to a very weak 14.2 from July’s 17.9, but was up from June’s record low 12.5. “With farm income expected to decline for a second straight year, farmers remain very cautious regarding the purchase of agricultural equipment,” said Goss.

Banking: The August loan-volume index climbed to 73.0 from 72.1 in July. The checking-deposit index rose to 55.0 from July’s 53.4, while the index for certificates of deposit and other savings instruments dropped to 34.0 from July’s 38.6.

Hiring: Despite weaker crop prices and pullbacks from businesses with close ties to agriculture and energy, Rural Mainstreet businesses continue to add workers to their payrolls. The August hiring index increased to a strong 63.3 from 60.3 in July.

 “Rural Mainstreet businesses continue to hire additional workers, while rural Mainstreet communities are growing jobs at a solid annual pace of approximately 1 percent, primarily in businesses not linked to agriculture or energy,” said Goss.

Confidence: The confidence index, which reflects expectations for the economy six months out, slumped to 42.0 from 46.6 in July. “Declines for agricultural commodity and energy prices pushed bankers’ economic outlook lower for the month,” said Goss.

Home and retail sales: The August home-sales index declined to a strong 70.4 from July’s 73.3. The August retail-sales index decreased to 50.0 from 53.4 in July. “Home sales on Rural Mainstreet have been very healthy over the last several months,” said Goss.

Each month, community bank presidents and CEOs in nonurban agriculturally and energy-dependent portions of a 10-state area are surveyed regarding current economic conditions in their communities and their projected economic outlooks six months down the road. 

Bankers from Colorado, Illinois, Iowa, Kansas, Minnesota, Missouri, Nebraska, North Dakota, South Dakota and Wyoming are included. The survey is supported by a grant from Security State Bank in Ansley, Neb.

This survey represents an early snapshot of the economy of rural agriculturally and energy-dependent portions of the nation. 

The Rural Mainstreet Index (RMI) is a unique index covering 10 regional states, focusing on approximately 200 rural communities with an average population of 1,300. It gives the most current real-time analysis of the rural economy. 

Goss and Bill McQuillan, former chairman of the Independent Community Banks of America, created the monthly economic survey in 2005.

Colorado: Colorado’s August Rural Mainstreet Index (RMI) dipped to 51.5 from July’s somewhat stronger 53.2. The farmland and ranchland price index expanded to 38.4 from 12.7 in July. Colorado’s hiring index for August advanced to a healthy 65.5 from July’s 52.9.

Illinois: The August RMI for Illinois declined to 50.0 from 53.6 in July. The farmland-price index dropped to 29.5 from July’s 31.6. The state’s new-hiring index increased to 62.0 from July’s 60.5.

Iowa: The August RMI for Iowa dropped to 53.4 from July’s 56.6. Iowa’s farmland-price index for August rose to 44.0 from July’s 43.9. Iowa’s new-hiring index for August jumped to 67.8 from 65.4 in July.

Kansas: The Kansas RMI for August slid to 49.8 from July’s 52.3. The state’s farmland-price index for August increased to 27.8 from July’s 24.6. The new-hiring index for the state expanded to 61.3 from 57.7 in July.

Minnesota: The August RMI for Minnesota fell to 48.4 from July’s 53.9. Minnesota’s farmland-price index declined to 33.7 from 37.4 in July. The new-hiring index for the state declined to a healthy 58.2.

Missouri: The August RMI for Missouri declined to 43.2 from 47.1 in July. The farmland-price index grew to 29.5 from July’s 13.9. Missouri’s new-hiring index decreased to 51.3 from July’s 53.4.

Nebraska: The Nebraska RMI for August slumped to 48.4 from 50.1 in July. The state’s farmland-price index fell to 19.6 from July’s 21.4. Nebraska’s new-hiring index advanced to 58.0 from 56.4 in July. According to Jon Schmaderer, CEO of Tricounty Bank in Stuart, “The high level of moisture in July-August has substantially reduced the cost of irrigation this season.”

North Dakota: The North Dakota RMI for August decreased to 47.1 from 50.6 in July. The farmland-price index fell to 24.8 from 36.5 in July. North Dakota’s new-hiring index declined to 60.1 from July’s 62.4.

South Dakota: The August RMI for South Dakota slipped to 55.1 from July’s 56.7. The farmland-price index rose to 47.2 from 43.0 in July. South Dakota's new-hiring index climbed to 69.1 from 65.0 in July.

Wyoming: The August RMI for Wyoming sank to 49.2 from last month’s 52.5. The August farmland and ranchland-price index expanded to 47.2 from July’s 27.9. Wyoming’s new-hiring index climbed to 60.9 from July’s 59.0.

Rural American population losses continue

• by Tim Henderson

August 21, 2015 (Pew Charitable Trusts)--Bill Longnecker grew up in rural Nebraska and, after trying life in Kansas City, Missouri, and other urban areas, returned to his home state to start a jewelry store in Red Willow County, population 10,867.

He loves it there.

“All we need is more people,” he said. Every year when high school graduates head off to college, locals present them with a mailbox imprinted with a map of the area. 

“We’re hoping they’ll find their way back,” Longnecker said. Few do.

Population loss is a long-term trend in much of rural America, and it’s gotten more acute since 2010, according to a Stateline analysis. Although 759 rural counties in 42 states lost population between 1994 and 2010, more than 1,300 rural counties in 46 states have lost population since 2010.

As a result, some states with dwindling rural populations, such as Nebraska and Kansas, are trying to lure people with tax incentives, and small, shrinking localities are looking for ways to share services or cut back as the pool of taxpayers shrinks.

They’ve tried shifting schools online in Colorado, and reverting to gravel roads in North Dakota and Michigan. The 251 residents of the village of Brokaw, Wisconsin, have launched an online campaign to raise $2.5 million toward a $3.8 million budget shortfall.

“[Population losses] are immediately a slap to the local funding base for rural counties, because of the loss of property taxes,” said Arthur Scott, who works on rural issues for the National Association of Counties.

“Counties are regionalizing and sharing resources in the face of this rural flight, which is the long-term impact when the younger generation just leaves after college, because there’s no job opportunities that make it fiscally viable for you to return back home,” Scott said.

Enticing College Grads 

Faced with declining rural populations, Kansas decided in 2011 to offer incentives to people who move to a rural county with population losses. Kansas is offering state income tax breaks to people from out of state and will repay a portion of the student loans of Kansans.

Dr. Rachael Cavenee took advantage of the program. She moved to Greeley County in 2013 after attending college in Colorado and graduate school in eastern Kansas. She started an audiology clinic, which allows her time at home with her husband and two children.

Greeley County lost about a quarter of its population between 1994 and 2010, but has gained slightly since 2010, to about 1,300 people. Cavenee said she quickly came to love the area’s friendliness.

“My fear of moving here has evolved into a fear of ever having to move away,” Cavenee said. “This is where you can find genuine, supportive people. This is where we chose to raise our family.”

In a report earlier this year, Kansas estimated that the 330 people who got income-tax breaks in 2014 brought in more than $44 million in economic benefits. That year, 993 people got student-loan subsidies. 

Some analysts are skeptical about the plan’s strategy of paying people to move to rural areas.

The program “may help a few families here and there, which is of course very important for those people and can give positive examples to some communities,” said László Kulcsár, a demographer at Kansas State University.

 “But we have to remember that it was designed to counter long-term depopulation, in which it is terribly ineffective.”

Nebraska started accepting applications this year for enterprise zones that would encourage new businesses in areas with declining population and high rates of poverty and unemployment.

In another effort aimed at rural Kansas, where aging business owners may have trouble cashing out when they retire, the University of Kansas School of Business has a program called RedTire that helps match college graduates to opportunities to buy rural businesses.  

Michelle Reed, who moved to rural McPherson from Orange County, California, this month, said she was struck by the number of help wanted signs, businesses that closed several days a week for lack of employees, and business owners unable to cash out and retire. McPherson is a city of 13,322.

“There are older business owners who would like to sell, but there are no buyers in town,” Reed said. “We need to somehow make it hip to have chickens and farm to table in the heartland, and get the young adults to move east.”

Root Causes

Historically, despite losses in agricultural and mining areas, rural population has grown as suburbia has expanded or retirees sought scenic, low-cost destinations, according to a June report from the U.S. Department of Agriculture (USDA). The department excludes from its definition of rural and small-town areas all commuter areas clustered around cities of 50,000 or more.

Overall, the country’s rural population dipped for the first time between 2010 and 2014, the USDA report said, as the number of people moving to economically hard-hit areas dropped. There were sharp contrasts within individual states. 

An oil boom gave North Dakota the largest rural population gain in the nation at 10 percent, but 16 agricultural counties on the east side of the state lost population.

Coal- and timber-dependent counties have also been hard-hit as those industries founder in the face of less expensive natural gas and as electronic, digital information reduces the need for paper.

High school students in rural Coos County, New Hampshire, a major pulp and paper producer, were asked by researchers if it was easy for somebody their age to get a job in the county (population 31,653). In 2008, two-thirds said it was easy. Three years later, only one in five said so. 

Some of the biggest rural losses are in coal country. The largest population decline from 1994 to 2010 was in West Virginia’s McDowell County, historically the state’s coal capital, which lost 38 percent. It fell another 8 percent since 2010 and the county now has about 20,000 people.

About half the rural counties in Nebraska, North Dakota and Kansas have lost more than 1 in 10 people since 1994.

Some analysts argue that simple math keeps rural college students from going home: Is there a job for me that will pay my student loans, or enough income from a small-town business or farm to support a family? Often the answer is no.

Population decline has been a fact of life in parts of Kansas for 50 years, Kulcsár, the demographer, said. What’s made it worse recently is that there aren’t enough babies to replace people who are moving out and retiring baby boomers are depriving rural areas of a large part of their workforce.

If there’s a chance to lure people back, it may be later in life, after they’ve had children, according to a USDA report released last month. This is especially true for those whose parents still live in their hometowns.

“Conversations about returning home centered on the value of family connections for child raising in a small-town environment,” the report concluded.

About 350,000 people moved out of rural counties between 2010 and 2014. In that time, only 250,000 people were born there. Counties that are more urban had more than 4 million people move in and almost 6 million births.

Effect on Government

Diminished revenue is an ongoing strain on local governments, one that the National Association of Counties thinks should be addressed by counties consolidating services and applying for grants together.

“With regional partnerships, you realize the assets of your neighbors and count on them together,” Scott said. Last year, the group put out a guide to creating regional partnerships, citing examples such as five Minnesota counties that worked to restore a railroad to get crops to market.

School has largely shifted online in Branson, Colorado, where a regional school system has just 52 students remaining in a brick-and-mortar school building, said Lori Green, the school district’s assistant business manager. The system has helped to preserve jobs in a district with shrinking enrollment, Green said. Branson is in Las Animas County, which had one of the biggest rural population losses between 2010 and 2014, with almost one in 10 of its 14,000 residents leaving.

As early as 2010, towns and counties in North Dakota and Michigan were converting paved roads to gravel—and some counties in Ohio were simply letting them erode—to save on maintenance costs, according to a Wall Street Journal report.

Meanwhile, the residents of Brokaw, Wisconsin, which saw its population drop and tax revenue plunge since a paper plant closed in 2012, have raised $756 in their online crowdfunding effort to close the $3.8 million budget gap.

“Without money coming in, you don’t pave the roads, you don’t pick up the trash, you don’t upgrade the sewer system,” said Doug Farquhar, a program director at the National Conference of State Legislatures.