Bringing Health Care to Appalachia: The Long-Run Impact of a Rural Health Care System

Abstract

The U.S. government has supported rural hospitals through direct subsidies and staff recruitment programs. However, little is known about the long-run impact of large-scale changes to rural health care. The authors explore the long-run trajectory of Appalachian counties where a coal mining union introduced a pioneering rural health care program in the 1950s, anchored by a chain of high-quality hospitals. Hospital beds per capita in counties where the union built its hospitals are persistently high through 2006, even when compared to similar counties and accounting for a variety of supply- and demand-side factors. In particular, union counties defied a national hospital consolidation trend starting in the 1980s. Results are consistent with a supply-side explanation where the scale and/or innovation of the union's investment allowed hospital markets to thrive and attract patients from a broad geography.

Keywords

rural health care rural hospitals Appalachian regional health care miners memorial hospitals Hill-Burton Act

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References

Almond

Chay

Greenstone

(2007). “Civil rights, the war on poverty, and Black–White convergence in infant mortality in the rural south and Mississippi.” MIT Department of Economics Working Paper. https://dx.doi.org/10.2139/ssrn.961021

Almond

Hoynes

Schanzenbach

(2011). Inside the war on poverty: The impact of food stamps on birth outcomes. Review of Economics and Statistics, 93(2), 387-403. https://www.jstor.org/stable/23015943

Appalachian Regional Healthcare (2020). About us: Our history. Accessed September 2020. https://www.arh.org/about_us/our_history.aspx

Architectural Forum (1956). Pioneering chain of Ten UMW hospitals. 107(November 1956), 107‐117. https://usmodernist.org/AF/AF-1956-11.pdf

Azariadis

Stachurski

(2005). Poverty traps. In Aghion

Durlauf

S. N.

(Eds.), Handbook of economic growth (1 Vol. 1, pp. 295‐384). Amsterdam: Elsevier.

Baicker

Chandra

(2007). Understanding agglomeration in health care. In Agglomeration Economies; National Bureau of Economic Research Books (1 Vol. 1, pp. 211-236). Chicago: University of Chicago Press. https://doi.org/10.7208/chicago/9780226297927.003.0008

Bailey

Clay

Fishback

Haines

Kantor

Severnini

Wentz

(2016). U.S. county-level natality and mortality data, 1915–2007. Inter-university Consortium for Political and Social Research [distributor]. http://doi.org/10.3886/E100229V4

Bailey

Goodman-Bacon

(2015). The war on poverty's experiment in public medicine: The impact of community health centers on the mortality of older Americans. American Economic Review, 105(3), 1067-1104. https://doi.org/10.1257/aer.20120070

Becker Hospital Review (2015). The modern definition of a community hospital. https://www.beckershospitalreview.com/hospital-management-administration/the-modern-definition-of-a-community-hospital.html

10.

Bitler

Figinski

(2019). Long-run effects of food assistance: Evidence from the food stamp program. https://www.semanticscholar.org/paper/Long-Run-Effects-of-Food-Assistance-%3A-Evidence-from-Bitler-Davis/a554f702faf7f256f66eb8a29091a54c2b4f9694”

11.

Black

Daniel

Sanders

(2002). The impact of economic conditions on participation in disability programs: Evidence from the coal boom and bust. American Economic Review, 92(1), 27-50. https://doi.org/10.1257/000282802760015595

12.

Boyd

Konrad

T. R.

Seipp

(1982). In and out of the mainstream: The Miners’ medical program, 1946–78. Journal of Public Health Policy, 19(4), 432-444. https://doi.org/10.2190/M7RW-U2R0-KFL2-NELY

13.

Catalano

(2000). Investment in a rural residency program: A case study. Journal of Rural Health, 16(3), 224-229. https://doi.org/10.1111/j.1748-0361.2000.tb00461.x

14.

Chung

A. P.

Gaynor

Richards-Shubik

(2017). Subsidies and structure: The lasting impact of the Hill-Burton program on the hospital industry. Review of Economics and Statistics, 99(5), 926-943. https://doi.org/10.1162/REST_a_00654

15.

Cohen

W. J.

Myers

R. J.

(1950). Social security Act amendments of 1950: A summary and legislative history. Social Security Bulletin, 3‐14. https://www.ssa.gov/policy/docs/ssb/v13n10/v13n10p3.pdf.

16.

Currie

Gruber

(1996). Saving babies. Journal of Political Economy, 104(6), 1263-1296. http://www.jstor.org/stable/2138939

17.

Falcettoni

(2019). “The determinants of physicians’ location choice: understanding the rural shortage.” Working Paper. https://www.elenafalcettoni.com/s/Falcettoni_The-Determinants-of-Physicians-Location-Choice.pdf

18.

Figinski

Troland

(2020). Health care and hospital supply—evidence from 1950s coal country. Federal Reserve Finance and Economics Discussion Series (FEDS). https://doi.org/10.17016/FEDS.2020.033

19.

Finkelstein

(2007). The aggregate effects of health insurance: Evidence from the introduction of medicare. Quarterly Journal of Economics, 122(1), 1-37. https://doi.org/10.1162/qjec.122.1.1

20.

Franklin

B. A.

(1964). Appalachian hospitals need $2 million to go on. New York Times, December 20. https://www.nytimes.com/1964/12/20/archives/appalachia-hospitals-need-2-million-to-go-on-us-aid-sought-to-keep.html

21.

Gaynor

Anderson

G. F.

(1995). Uncertain demand, the structure of hospital costs, and the cost of empty hospital beds. Journal of Health Economics, 14(3), 291-317. https://doi.org/10.1016/0167-6296(95)00004-2

22.

Hamilton

C. Horace.

(1962). Health and Health Services. In The Southern Appalachian Region: A Survey (13, pp. 232-232). Lexington, KY: The University of Kentucky Press.

23.

Hoehn-Velasco

(2021). The long-term impact of preventative public health programs. The Economic Journal, 131(634), 797-826. https://doi.org/10.1093/ej/ueaa071

24.

Holmes

G. M.

Kaufman

B. G.

Pink

G. H.

(2017). Predicting financial distress and closure in rural hospitals. The Journal of Rural Health, 33(3), 239‐249.

25.

Hoynes

Schanzenbach

Almond

(2016). Long-run impacts of childhood access to the safety net. American Economic Review, 106(4), 903‐934. https://doi.org/10.1257/aer.20130375

26.

Interior Department

United States

. (1947). A medical survey of the bituminous-coal industry. United States Government Printing Office. https://books.google.com/books/about/A_Medical_Survey_of_the_Bituminous_coal.html?id=3jVP9yQZGkoC

27.

Jaworski

(2017). World war II and the industrialization of the American south. The Journal of Economic History, 77(4), 1048-1082. https://doi.org/10.1017/S0022050717000791

28.

Jaworski

Kitchens

(2019). National policy for regional development: Historical evidence from Appalachian highways. Review of Economics and Statistics, 101(5), 777-790. http://www.mitpressjournals.org/doi/suppl/10.1162/rest_a_00808

29.

Kaufman

B. G.

Thomas

S. R.

Randolph

R. K.

Perry

J. R.

Thompson

K. W.

Holmes

G. M.

Pink

G. H.

(2016). The rising rate of rural hospital closures. The Journal of Rural Health, 32(1), 35‐43. https://doi.org/10.1111/jrh.12128

30.

Kline

Moretti

(2013). Local economic development, agglomeration economies, and the big push: 100 years of evidence from the Tennessee valley authority. Quarterly Journal of Economics, 129(1), 275-331. https://doi.org/10.1093/qje/qjt034

31.

Krajcinovic

(1997). From company doctors to managed care (1 Vol. 1, pp. 108-109). Ithaca and London: Cornell University Press.

32.

Marshall

J. L.

Thomas

Lane

N. M.

Holmes

M. G.

Acury

T. A.

Randolph

Silberman

Holding

Villamil

Thomas

Lane

Latus

Rodgers

Ivery

(2017). Health disparities in Appalachia. Appalachian Regional Commission. https://www.arc.gov/report/health-disparities-in-appalachia/

33.

McNamara

(2007). State-level rural health policy. Journal of Regional Analysis and Policy, 37(1), 1-4. https://doi.org/10.22004/ag.econ.132982

34.

McNamara

P. E.

(2009). Rural hospitals, reimbursement policy, and health care reform. Choices, 24(4), 1-7. https://www.choicesmagazine.org/UserFiles/file/article_103.pdf

35.

Mulcahy

(1993). Health care in the coal fields: The Miners Memorial Hospital Association. The Historian, 55(4), 641‐656. https://doi.org/10.1111/j.1540-6563.1993.tb00916.x

36.

Mulcahy

(1996). A new deal for coal miners: The UMWA welfare and retirement fund and the reorganization of health care in Appalachia. Journal of Appalachian Studies, 2(1), 29‐52. https://www.jstor.org/stable/41446312

37.

Mulcahy

R. P.

(2000). A social contract for the coal fields: The rise and fall of the united mine workers of America welfare and retirement fund (Vol. 1). Knoxville: University of Tennessee Press.

38.

Myers

R. J.

(1961). Further experience of the UMWA welfare and retirement fund. ILR Review, 14(4), 556-562. https://doi.org/10.1177/001979396101400404

39.

National Cancer Institute (2016). Surveillance, epidemiology, and end results program. U.S. population data—1969–2014. Available at: http://seer.cancer.gov/popdata/

40.

North Carolina Rural Health Research Center (2017). Rural health snapshot (2017). https://www.shepscenter.unc.edu/download/14853/

41.

Ploss

(1982). Coal miners’ health care: The first ten years of the medical care program of the united mine workers of American welfare and retirement fund. The Einstein Quarterly Journal of Biology and Medicine, 1(2), 85-93. https://ojs.einsteinmed.org/index.php/EQJBM/article/view/552

42.

Ricketts

(2000). The changing nature of rural health care. Annual Review of Public Health, 21(1), 639-657. https://doi.org/10.1146/annurev.publhealth.21.1.639

43.

Roddy

P. C.

Wallen

Meyers

S. M.

(1986). Cost sharing and use of health services: The united mine workers of America health plan. Medical Care, 24(9), 873-874. https://doi.org/10.1097/00005650-198609000-00009

44.

Rural Health Reform Policy Research Center (2014). The 2014 update of the rural–urban chartbook. https://ruralhealth.und.edu/projects/health-reform-policy-research-center/pdf/2014-rural-urban-chartbook-update.pdf

45.

Smoot

R. C.

(1995). Medical history notes from Appalachia. Appalachian Heritage, 23(4), 21-28. https://doi.org/10.1353/aph.1995.0052

46.

Social Security Administration (1960). Social security bulletin annual statistical supplement. U.S. Department of Health, Education, and Welfare. https://www.ssa.gov/history/pdf/Downey%20PDFs/Social%20Security%20Act%20of%201960%20Vol%202.pdf

47.

Stock Jr

E. W.

Gape

W. C.

(1993). Health care in Appalachia: The united presbyterian church, the united mine workers, and the U.S.A. American Presbyterians, 71(2), 115‐126. https://www.jstor.org/stable/i23332728

48.

Supplitt

Arespacochaga

(2019). 5 Strategies rural hospitals are using to bolster their workforce. American Hospital Association Blog. https://www.aha.org/news/insights-and-analysis/2019-03-05-5-strategies-rural-hospitals-are-using-bolster-their

49.

Trinh

H. Q.

Begun

J. W.

(1999). Strategic adaptation of US rural hospitals during an era of limited financial resources: A longitudinal study, 1983 to 1993. Health Care Management, 2(1), 43-52. https://doi.org/10.1023/A:1019063123037

50.

U.S. Congress

90th Congress

. (1967). Public Law No. 90-103. Appalachian Regional Development Act Amendments of 1967. https://www.congress.gov/bill/90th-congress/senate-bill/602

51.

Ziliak

J. P.

(2012). Appalachian legacy—economic opportunity after the war on poverty (1). Washington, DC: Brookings Institution Press.