LISTENING TOUR 2016 Business Leader Perspectives on the Relationship between Economics and Health in 22 Rural Georgia Counties

Transcription

1 LISTENING TOUR 2016 Business Leader Perspectives on the Relationship between Economics and Health in 22 Rural Georgia Counties Mary Eleanor Wickersham, D.P.A.

2 A Tale of Two Counties Early County Georgia, population 10,491, is a largely agricultural community in southwest Georgia on the Alabama border. Peanut processing, forestry, a paper mill, and a tubing plant are major employers. Like many other rural counties in the state, Early County is poor and aged: 30 percent live below the federal poverty line of $11,670 for an individual (U.S. Census 2014), and 18.5 percent are over the age of 65 (U.S. Census, 2014). Almost a tenth of those under 65 have a disability (U.S. Census, ). The seemingly-low unemployment rate of 5.8 percent, says Chamber of Commerce Director Kyle Kornegay, gives a false picture of economic health, as many able residents have quit looking for work. There is one glimmer of good news, however. Early is one of Georgia s rural counties that has managed, despite long odds and its small population, to retain its hospital and a handful of primary care providers. Despite these healthcare assets, Early s population is considered to be the unhealthiest in the state, ranked 159 th of Georgia s 159 counties in health outcomes (County Health Rankings, 2015). On the opposite end of Georgia is Rabun County, a border county abutting North and South Carolina, population 16,243 (U.S. Census, 2014). It, too, is poor, though less so than Early, with 19.4 percent of the population living below the federal poverty level (U.S. Census 2014). Rabun s population is even more aged than Early s: those 65 and older make up over 25 percent of the population (U.S. Census, 2014), and nearly ten percent of those under 65 report that they are disabled (U.S. Census, ). Rabun s unemployment rate is officially 5.9 percent (Bureau of Labor Statistics, November 2015), but in the eyes of Chamber Executive and Economic Development Director Tony Allred, this number lacks credibility. We have lost most of the middle class jobs here, he explains. We have about 500 businesses here in Rabun, and 400 of them are run by two people. Rabun also has a small, privately-owned hospital with somewhat limited services. Mountain Lakes Medical Center operates an emergency room, mainly offering outpatient services with limited use of inpatient beds but, like other rural hospitals, it has been financially stressed. Allred, who once worked in the business end of the hospital, believes that the service area population is just too small and larger hospitals too close for any long-term sustainability of the facility. In 2013, the hospital opened an urgent care center on Highway 441, providing extended office hours and occupational medicine, helping fulfill one community need. Unlike its counterpart Early County, Rabun fares comparatively well in health outcomes, ranking 45 th in the state of 159 counties (County Health Rankings, 2015). How can counties, alike in many ways that typify rural life, vary so widely in their health outcomes? Substantial research over the last two decades confirms disparities in urban and rural health outcomes and behaviors, with the most serious disparities in health outcomes often occurring in the same rural areas that are most economically stressed. How does the health of a 2

3 community affect economic well-being and, in turn, how does economic well-being influence health outcomes? Two Georgias: Exploring the Relationship between Economics and Health The purpose of this research is to explore the perspectives of county business leaders, represented by the Executives of the Chamber of Commerce and/or Economic Development Directors, in rural counties across Georgia to better understand the challenges and opportunities that exist to improve the health and health care of rural Georgians. This paper examines both widely shared and county-specific health and economic concerns and how business leaders are finding that a healthy economy and a healthy populace are often tandem objectives. Twenty-two Chambers of Commerce and/or Economic Development Directors in rural counties across the state agreed to be interviewed for this report. Two criteria were used in the selection: the counties had to fit the State of Georgia definition of a rural county population under 35,000 and counties selected had to have some degree of health infrastructure. Counties also represent at least two per Regional Commission region, with the exception of Northwest Georgia and Metro Atlanta, where most counties have populations of more than 35,000. Figure 1. Georgia Map with Counties Included in Report Highlighted County Ben Hill Berrien Brantley Burke Butts Chattooga Crisp Early Elbert Emanuel Macon McIntosh Meriwether Rabun Randolph Screven Stephens Telfair Twiggs Washington Wilkes Wilkinson Interviewees Neesa Williams and Jason Dunn Crissy Staley Richard Thornton Ashley Roberts Melinda Atha Sylvia Lee Keziah Monica Simmons Kyle Kornegay Phyllis Brooks Ken Warnock Jimmy Davis Wally Orrel and Mandy Harrison Carolyn McKinley Tony Allred Patricia Goodman Latasha N. Roberts Julie Paysen and Sharon Crenshaw Paula Rogers Anderson Judy Sherling Christy Hinton and Charles Lee John Keen Jonathan Jackson 3

4 Why do rural communities in general struggle with health outcomes? Lack of Preventive Care is Part of the Problem, and Poverty, Education, and Access are Limiting Factors Research indicates that medical care is tied only to about 10 to 15 percent of health outcomes (Braveman and Gottlieb 2014, 20). It is clear that the social determinants of health poverty, education, social environment and culture, and the physical environment play a major role in health outcomes. Chamber and Development officials included in this report widely agree that poverty is the major socio-economic limiting factor to the good health of their residents, describing poverty in their communities as chronic, cyclical, and generational. The U.S. Department of Agriculture s Economic Research Service describes long-standing poverty as persistent poverty and defines it as those counties where 20 percent or more of their populations were living in poverty over the last 30 years (measured by the 1980, 1990 and 2000 decennial censuses and American Community Survey 5-year estimates). Of the counties interviewed for this report, nine of 22 are classified as having persistent poverty in the population, and 14 have persistent child poverty. All have high levels of poverty (Table 1). Table 1. Select Counties and Proportion of Residents Below the Federal Poverty Level in 2013 ($11,490 in 2013) (U.S. Department of Agriculture, Economic Research Service) Ben Hill 31.9 Early 27.4 Screven 27.9 Berrien 24.0 Elbert 23.4 Stephens 20.4 Brantley 22.5 Emanuel 34.1 Telfair 32.8 Burke 32.0 Macon 33.5 Twiggs 22.9 Butts 22.0 McIntosh 23.1 Washington 26.5 Chattooga 28.3 Meriwether 37.2 Wilkes 24.0 Crisp 30.7 Rabun 19.4 Wilkinson 23.6 Randolph 31.7 When it comes to eating or buying medicine, you eat first, says Emanuel Chamber and Development Authority Executive Ken Warnock. Many of those in poverty just don t have the means to be proactive about health. They become reactive. One symptom of reactive thinking is not seeking preventive care, he says. Twiggs Judith Sherling reports that she has learned from the state s Cancer Coalition that her county s Stage 4 breast cancer diagnosis rate is among the highest in the state, a fact she attributes to lack of preventive care. There are no mammography facilities in the county. Before Community Health Care Systems opened a Federally Qualified Health Center (FQHC) in Twiggs County seat Jeffersonville, there was not a medical practitioner located in the county s 363 square miles. Getting to Macon, Dublin, or Warner Robins, the closest medical communities, is difficult for residents, despite a fee-for-service, low-cost transit system. A visit to a doctor or diagnostic facility in another town requires not just an hour off 4

5 from work but sometimes an entire day. Sherling explains that even the FQHC has struggled because of lack of interest in preventive services, at one point considering giving up its small offices inside the local Public Health Department, until the Economic Development leadership located a new office for the FQHC, where the two now share space. Other leaders agree with Sherling about care avoidance. Screven Chamber Executive Latasha Roberts says, We have a lot of residents who simply avoid medical care. They associate doctors with sickness, not health. Lack of prevention may mean failure to diagnosis treatable diseases. Only four counties covered in this report had all-cause cancer rates lower than the state average. Burke and Screven have among the highest rates of prostate cancer in Georgia; Ben Hill Berrien Brantley Burke Butts Chattooga Crisp and while environmental factors could be at work, the geographic diversity of higher cancer mortality rates in rural counties point to a more likely source in late identification due to a lack of preventive care. The close-knit nature of many local communities may also limit diagnosis and treatment of mental illness, which may carry a stigma in some rural communities and result in treatment avoidance. Race may also matter in obtaining preventive services, a factor to consider since 17 of the 22 counties in this report have significant minority populations, primarily Black with smaller proportions of Hispanic residents. Using data, Kaiser Family Foundation notes that Blacks and Hispanics are less likely to have a usual source of care (2014), which may limit access to preventive services or to a relationship in which detrimental health changes might be identified early. Researchers have also shown that being African-American and low income are major significant factors for late-stage [prostate cancer] diagnosis (Xiao, Tan, Goovaerts 2011). Georgia s African-American population is also more likely than Whites to be diabetic, a condition that may go undiagnosed and untreated without preventive services. Even those with insurance are less likely to seek care when co-payments and deductibles are unaffordable. Mandy Harrison, Chamber Director in McIntosh, says that she is covered by her husband s county insurance. We have great insurance, she says, yet the premiums have quadrupled in four years even after individual deductibles went to $4000 each. Most people just avoid going to the doctor when their out-of-pocket costs are so high. Early 5 Elbert Emanuel Macon McIntosh Meriwether Rabun Randolph Screven Stephens Telfair Twiggs Washington Chart 1. All Cancer Mortality Rates for Georgia and Select Counties (National Cancer Institute) Counties Georgia Wilkes Wilkinson

6 Access to care is complicated. Paying for care is a major barrier to access, Chamber leaders agree. The State of Georgia s decision not to expand Medicaid has left some of the state s poorest citizens, those who would be eligible for low-income Medicaid, with little access to preventive coverage through Medicaid and ineligible for insurance subsidies through the Affordable Care Act (ACA). Even those with ACA coverage often find that they cannot afford the deductibles or that physicians will not accept the coverage, because they know the patients cannot pay the out-of-pocket costs. High Medicaid populations in rural areas may mean that primary care providers are overwhelmed, and some do not accept new patients, especially new Medicaid patients because of lower reimbursement. There is good news on this front, as seen in Chart 2, in that uninsured rates have dropped significantly in all 22 counties in the period from (Enroll America). An analysis of 2013 data from Enroll America (prior to full implementation of the ACA) and data on years of potential life lost (a measure of preventable mortality before the age of 75 years), demonstrates that about 11 percent of the preventable mortality rate in these counties can be explained by a lack of health insurance. Education Ben Hill Berrien Chart 2. Uninsured Rates by County; 2013 and 2015 (Enroll America 2015) Brantley Burke Butts Chattooga Crisp Early Poverty is our number one problem in Wilkinson County, says Economic Development Director Jonathan Jackson. Education is our means to address it. Every Chamber or Economic Development Director interviewed mentioned education as a primary limiting factor to both economic development and good health. There s a domino effect, says Carolyn McKinley of the Meriwether County Chamber. Poverty affects education, and education affects everything else. Economic Development and Chamber Directors Neesa Williams of Ben Hill County and Patricia Goodman of Randolph County are two among many leaders interviewed who say education plays a role in poor health outcomes. They describe the lack of awareness of many citizens in their counties in the relationship between prevention and improved outcomes. Data backs up their contention. In the 19 counties for which data is available from County Health Rankings on self-reported poor or fair health, over 38 percent of the variation of health Elbert Emanuel McIntosh Macon Meriwether Rabun Randolph Screven Uninsured 2013 Uninsured 2015 Stephens Telfair Twiggs Washington Wilkes Wilkinson 6

7 outcomes correlates with the high school graduation rate. In other words, the higher the graduation rate, the lower the proportion of citizens who report poor or fair health. Several directors discussed efforts to work with schools on literacy programs and the role of the state-funded Georgia Family Connection in decreasing the drop-out rate. One promising approach is the creation of Mountain Education Charter High School in north Georgia, a system of charter schools designed to help reduce the drop-out rate in the region. Stephens County s Julie Paysen explains that the program has grown from sites in three counties to sites in 12 counties, including schools in Stephens and Rabun. The schools operate at night to allow students to hold down day jobs, while returning to school to finish their high school diplomas. Chamber Director Carolyn McKinley reports that Meriwether County is participating in the Circle of Care program that provides education for adolescents and young adults who are parents. The intent of the program is to improve parenting skills and link participants to supportive services to foster personal success as a route to breaking the cycle of poverty. Aging Populations Without exception, the counties in this report have growing populations of aged persons (Chart 3). In each county in this rural subset, the proportion of 65 and older population increased significantly within four years, from the 2010 census until the 2014 American Community Survey update. An article in the January 18 New York Times, describing rural Oregon, applies perfectly to much of rural Georgia: isolated, rural counties... [are] too far away from those urban centers to catch the economic uplift [of the economic upturn]... so the population grows even older, poorer, and less educated, and opportunities continue to dry up. Some communities have been able to capitalize on their older populations. According to a report issued by the Terry School of Business at the University of Georgia, Georgia is a retiree magnet. Researchers found that it takes only 1.8 in-migrating retirees to generate one job.... The annual economic impact of a typical year s inflow of 15,805 retirees is $941 million and jobs (Selig Center for Economic Growth 2013, 2). The presence of retirees, the report explains, may provide the critical mass necessary to support certain types of business that previously did not exist, reducing outshopping by long-term residents (Selig Center Ben Hill Berrien Brantley Chart 3. Percentage of Population 65 or Older (U.S. Census) Burke Butts Chattooga Crisp Early Elbert Emanuel Macon McIntosh Meriwether Rabun Randolph Screven Stephens Telfair Twiggs Washington Wilkes Wilkinson 7

8 for Economic Growth 2013, 2). Crisp County attracts retirees to Lake Blackshear; Rabun attracts them to the cool north Georgia mountains; and McIntosh has a significant retirement population in the northern part of the county thanks to the county s abundance of marshes and rivers. Wilkes County s 65 and older population is both a measure of its economic trials due to loss of industry and, perhaps less so, efforts to attract new residents to the area s historic community and older homes that need new owners. One plus for these communities is that the residents are generally covered by Medicare; one challenge is that they need and expect good health care close by. With older populations, there is increased likelihood of more chronic diseases and a higher demand for health care services. A group of retired business leaders who live in northern McIntosh County is working to bring a health clinic and grocery to their underserved area, but they admit they face challenges because of the small number of people who live in the area. We need a clinic for all people, because we cannot expect retirees to come here if there is no health care, says Michael Hardy, one of the retirees who is working with others to develop the clinic. They are in the process of meeting with area hospitals, doctors, and FQHCs to see if there is interest in expanding to McIntosh. These are the good news stories, but in many of Georgia s rural towns, the elderly are a growing segment of the population as younger people move away for jobs. All but two of the 22 counties included in this report lost population between 2010 and 2014 (U.S. Census), and those counties with increases showed only minimal growth. There are also high proportions of under- 65 residents with disabilities, for example, 21.6 percent in McIntosh between 2010 and 2014 (U.S. Census 2014). The U.S. Census reports that between 2010 and 2014, 16.5 percent of Crisp s population under 65 was disabled, about the same percentage of those over 65, effectively removing over 30 percent of the county s workforce from the market. Culture and Lifestyle Percentage Change Ben Hill Chart 4. Change in Population by County, (U.S. Census) Berrien Brantley Lifestyle creates major risk factors, agree all of the officials. Monica Simmons of Crisp County says that drug abuse is a problem in her community, a problem shared in most other rural counties. This not only affects the drug users, but the children in these families suffer, she explains. In Stephens County, says Julie Paysen, We have a strong industrial base, but we hear constantly that people can t be hired because they have positive drug screens. Several business 8 Burke Butts Chattooga Crisp Early Elbert Emanuel Macon McIntosh Meriwether Rabun Randolph Screven Stephens Telfair Twiggs Washington Wilkes Wilkinson

9 leaders commented on the high percentage of tobacco use in their counties. Although data is missing in County Health Rankings for some counties, 33.5 percent of Macon County and nearly 32 percent of Ben Hill County adults use tobacco. In some counties, smoking increases with poverty (Coastal Health District 2014). Many of our jobs here in McIntosh, says Wally Orrel, are manual labor and fishing and shrimping, the same types of jobs that have been done here for a hundred years. The workers learned their jobs from their fathers, and they also learned their habits like smoking and eating unhealthy diets. According to County Health Rankings, 29% of McIntosh residents use tobacco in some form and a recent Public Health survey indicates that 39% of men smoke (Coastal Health District 2014). National statistics show that fewer than 19 percent of men and fewer than 15 percent of women smoke (CDC 2014). Among the social determinants widely recognized by business leaders is the southern culture of rural Georgia. Nearly every Chamber director referenced unhealthy lifestyles of citizens, especially the habits of eating that are a way of life in the south. We have 23 restaurants in Early County, says Kyle Kornegay, Chamber of Commerce Director, and not one of them serves healthy food. The sheer number of restaurants in a county with just over 10,000 people reflects the established trend of eating fast and eating out. In McIntosh, says Wally Orrel, there s no place to get fresh, healthy food, and to some degree that includes the grocery store. People are just inclined to eat out and order the daily fried special. Though not included in this subset of rural counties, Talbot County does not even have a grocery store, and in other communities, dollar stores and convenience stores, ubiquitous in even the most rural communities, stock milk and bread and canned items but no fresh food. While some directors point to personal choice in healthy eating, others say that residents simply do not have access to higher-cost healthy foods: 23 percent of the obesity in the 22 counties included in this study can be explained by poverty. People who are doing well economically are more likely to take care of themselves, says Emanuel s Ken Warnock. People who have to work multiple jobs to make ends meet don t have time to take care of themselves, much less exercise. A look at data from County Health Rankings for the 22 counties covered in this report shows that 21 percent of the variation in physical fitness and 23 percent of the variation in the food environment (diet and exercise) are related to poverty, that is, the higher the poverty, the lower the physical fitness and the worse the food environment. Figure 2 provides additional insights into areas with high poverty and low access to supermarkets, both indicators of economic distress. 9

10 Figure 2. Low Access, Low Income and Low Vehicle Access Areas to Supermarkets (U.S.D.A. Economic Research Service) Note that most of these counties are in rural areas with higher poverty, older populations, and high levels of chronic disease. Green: Low income refers to poverty of 20 percent or higher and low access refers to a low-income tract with at least 500 people where 33 percent of the rural population lives more than 10 miles nearest supermarket, supercenter, or large grocery store. Yellow: The vehicle access measure is defined as follows: A low-income tract in which at least one of the following is true: at least 100 households are located more than ½ mile from the nearest supermarket and have no vehicle access; or at least 500 people or 33 percent of the population live more than 20 miles from the nearest supermarket, regardless of vehicle availability. Geographic and Population Density Barriers Chamber executives are divided in their beliefs about transportation as a barrier to access to medical care. Some counties have transit systems, but if there are few medical providers or if costs are unaffordable, preventive care is still difficult to obtain. Others see lack of transportation as a major barrier to access to care. Most of the counties have at least one physician and some have several. Getting to specialists is, however, especially difficult for those with Medicaid coverage. One of our challenges is getting out of town for care like cancer treatment, says Sylvia Lee Keziah of the Chattooga Chamber. Even with transit, it s just not appropriate for people who are sick or elderly. Access to diagnostics is also challenging for some residents. In some counties, there is no place to get an x-ray or have lab diagnostics. Before the Optim Clinic (a chain of about 40 physician-owned and operated clinics, primarily in south Georgia) opened in McIntosh, residents had to go to Brunswick or Richmond Hill (25 to 50 minutes away, depending on the point of origin) if an x-ray was ordered. In Twiggs County, where there is no local ambulance service for residents, even emergency care may be well over an hour away by the time the Macon-based ambulance arrives and returns to the hospital. The main population center in Jeffersonville is 25 miles away from Macon, and other outlying areas are further. Berrien Director Chrissy Staley stays that 10

11 transportation is definitely a factor in Berrien. Many families have no transportation or only a single car that the breadwinner takes to work, so there s no way to get to the doctor. Gas may be unaffordable for some. McIntosh County has a regional transportation network, which is very affordable, says Wally Orrel, but even the $12 to cross the county line into Brunswick may put it out of reach for some residents. Wilkinson Development Authority executive Jonathan Jackson also points out that geography matters in other ways. His county has seven municipalities spread throughout the county, all of which to some degree compete with each other. Telfair and Brantley counties are similar with no predominant population center. In the case of Wilkinson, says Jackson, the county lines sort of disappear when people need to do business or see a doctor. They simply choose the closest place. In Brantley County, with few opportunities for work, most people commute to Ware or Glynn counties and seek health care where they work, says Economic Director Richard Thornton. In Telfair County, Each of our five cities is on a border of our county, explains Chamber Director Paula Anderson, so we are blessed to have hospitals relatively close by in Jeff Davis, Ben Hill, Coffee, and Toombs counties. Telfair County still has a couple of doctors, one of whom is in his 70s, says Anderson, and they have a FQHC. The Telfair Hospital closed in 2008 after efforts to shore it up, including a failed effort with an outside hospital management agreement. The geographic distribution of population has worked against some counties, it seems, because the more geographically dispersed the population is, the less likely the county is to have a hospital or a center of medicine. Smaller populations limit the desirability for a medical practice site. In counties like Brantley, Wilkinson, Telfair, Twiggs and McIntosh, larger hospitals in neighboring counties are less likely to locate medical offices there in part because the population is small and in part because the dispersed population makes it almost impossible to ensure any return on investment, as residents tend to go to the closest provider. Twiggs experience with its FQHC is a good example of the challenges of small and dispersed populations, where loyalty is affected by proximity. This dispersion may also be responsible for some of the divisiveness in small towns, where county and municipal governments tend to argue over matters of common but competitive interest like health, recreation, fire protection, and infrastructure. Egos sometimes get in the way of progress, says one Chamber executive. Believe it or not, some people are still loyal to their old high schools, but funerals will take care of a lot of that, said one Economic Development leader. Geography may also matter where economic success is concerned. We are so fortunate to have our location on I-75, because that has really helped our community survive the economic downturn, says Crisp s Monica Simmons. We think of our county as a transportation hub. The county has between 900 and 1000 motel and hotel rooms, she says, but most of the positions these hotels and motels provide are low wage jobs that may be part-time and not involve 11

12 insurance. Crisp ranks 155 th of Georgia s 159 counties in health outcomes. Health outcomes are often poorer in the counties that are the most heavily agricultural, perhaps due in part to low wages, seasonal work, and lack of insurance. In addition to Crisp at 155 th, Macon ranks 116 th (but 159 th in Health Factors), Burke 143 rd, and Early 159 th in health outcomes (County Health Rankings 2015). One Director suggested that heavy use of chemicals in local agriculture and other industries may have a long-term impact on health of residents. Health and Economics Which comes first: healthy citizens or a healthy economy? Most Chamber and Economic Development directors interviewed for this report agree that their community s health is related to the economy, but there s a bit of the chicken or the egg problem in most Directors minds. Many agree that having good jobs available provides access to insurance and a route out of poverty toward a healthier lifestyle; but in order to attract that employer with decent-paying jobs requires the presence of a skilled and healthy workforce, a good education system, and health care. It goes both ways, says Monica Simmons of Crisp County. When we have business prospects, says Melinda Atha of Butts County, they want to know about our Chart 5. Per Capita Income for Select Counties and State of Georgia (U.S. Census, 2014) Ben Hill Berrien Brantley Burke Butts Chattooga Crisp Early Elbert Emanuel Macon McIntosh Meriwether Rabun Randolph Screven Stephens Telfair Twiggs Washington Wilkes Wilkinson Selected Counties State of Georgia schools, safety in the community, workforce and training, and health care. We are certainly aware, says Washington County s Charles Lee, that anything we do to enhance the workforce will enhance our opportunities to recruit industry and build our economy. Recruitment is challenging, explains Wilkinson County s Jonathan Jackson, because his county simply does not have the amenities larger towns have. We are an impoverished town without much of a middle class, he explains. This makes recruitment difficult

13 Data on government transfer payments to individuals (social security, retirement and disability, insurance benefits, medical benefits, Medicare, public assistance, military, income maintenance benefits, SSI, Earned Income Tax Credit, SNAP, unemployment compensation, veterans benefits, and educational 120% 100% 80% 60% 40% 20% 0% Chart 6. Government Transfer Payments as a Percentage of Per Capita Income (Georgia REAP) Ben Hill Berrien Brantley Burke Butts Chattooga Crisp Early Elbert Emanuel Macon McIntosh Meriwether Rabun Randolph Screven Stephens Telfair Twiggs Washington Wilkes Wilkinson training assistance, among others) help paint a picture of bare-bones living and dependence on government supports in many rural communities when compared to the state s more urban areas. The average proportion of age 16-plus population in the workforce in these 22 counties is just under 50 percent, compared to a statewide average of 62.6 percent. Business and industry, of course, provide jobs and pay taxes that help fund Public Health, environmental protection and regulation, recreation programs, senior programs, hospitals, indigent care, parks, and sidewalks and bike paths that help foster population health. The state as a whole has seen significant declines in state tax revenues, including sales and use taxes since 2001 (Buschman 2015, 2); and rural counties have been hard hit as these losses have been compounded by decreases in property values and loss of tax revenues from closed businesses and industry. Without the levels of tax revenue seen prior to the Great Recession, there are few extras for county residents beyond minimal maintenance of roads and infrastructure, and counties are less willing or able to support health care infrastructure at the very time it is most needed. Twiggs County, for example, does not have an Emergency Medical Service, despite its distance from a hospital, because county commissioners say they cannot afford it. Some counties are struggling with the idea of funding hospital requests for indigent care or other supports, in part because tax revenues are down as businesses have closed and the population has declined and in part because they fear the hospitals are not sustainable. In some communities, there is a feeling that leaders do not want to throw good money after bad, because they fear their hospitals are doomed. Economic development directors and Chamber of Commerce leaders plug away at recruitment of business and industry, but the work is daunting. The stakes for these communities are high as young people leave to seek work elsewhere, leaving the aged and less well-educated behind. Skilled labor is also a challenge in some communities that have low high school graduation rates. There is a belief in some counties where larger employers have survived that 13

14 government, business, and industry can take a leadership role in establishing health and wellness programs for employees. Ben Hill County s wellness programs, say local Chamber leaders, could be the impetus for a more widespread community wellness initiative. Tony Allred of Rabun County points to economic development as a part of the health outcomes solution. If we could get back some of our manufacturing, he says, it would allow us to rebuild the middle class that would help ensure the infrastructure we need to foster good health. Workforce The lack of amenities mentioned by Wilkinson County Chamber and Development Director Jonathan Jackson also plays into the ability to attract the workforce necessary to provide health services. If they don t like to hunt and fish and live in the country, they re probably not coming here, says Ken Warnock of Emanuel County. It s hard to attract physicians. Other Directors complain that the physicians tend to come to their underserved areas, meet their financial obligations to pay back scholarships, and then go on to a city where they can make more money. We were recently able to recruit a physician who has horses and wants to live in the country, says Warnock, but rural Georgia is not for everybody. Warnock, who is aware of the need for physicians, says he has become a regular tour guide, helping the Emanuel County s hospital management company with recruitment. Doctors are in short supply in rural Georgia: the average population-physician ratio in the 22 counties covered in this report is 4,106:1 Chart 7. Physician:Population Ratio (County Health compared to 1,572:1 for Rankings, 2012) the entire state (County Health Rankings 2015, using 2012 data). 0 According to Georgia 2,000 Health News, although 4,000 Georgia grew its total 6,000 physician workforce from 2000 to 2010, the 8,000 10,000 12,000 increase in primary care 14,000 doctors fell short of 16,000 population growth (Miller 2014), and most doctors are choosing urban or suburban practice locations. Counties State of Georgia Ben Hill Berrien Brantley Burke Butts Crisp Early Elbert Emanuel Macon McIntosh Meriwether Rabun Randolph Screven Stephens Telfair Washington Wilkes Wilkinson While most county business executives said that they had sufficient dentists, mental health service is an area that several leaders commented was lacking. People have to drive from Cuthbert to Columbus, about 60 miles away, to get mental health care, explains Patricia

15 Goodman of Randolph County. With worries from all quarters about substance abuse, drug treatment is another area where leaders believe there is a gap in care. Despite efforts to add nurses to the workforce, they fall short in the most rural areas leaving communities with serious shortages. In Washington County, the hospital has on numerous occasions had to go on diversion because there simply were not enough nurses to staff the hospital, despite a quality Licensed Practical Nurse (LPN) program at the local technical school and a Bachelor of Science in Nursing (BSN) program in Milledgeville, a little more than 30 miles away. Randolph County s Patricia Graham says that for several years, Andrew College has been talking about adding a nursing program that would help fill some of their need for nurses. Emanuel County Development Director Ken Warnock says that the hospital authority, Southeastern Tech and Emanuel College are working together on a BSN program that would allow a bridge for technical college trained LPNs. In Crisp County, Darton College has established a branch campus and nurses will be able to earn BSN degrees at home or close to home. Part of the problem in nurse retention in rural communities is that local medical employers often pay less than larger hospitals and clinics within a 40-mile radius, so nurses opt to commute. In addition, when nurses learn that hospitals are at risk, they may jump ship for more dependable jobs. Some Chamber leaders mentioned health occupations classes in their high schools that provide opportunities for students to explore nursing or other medical fields, programs they hope will interest students in the nursing field. There is little data on nurse practitioners, but Georgia s Board for Physician Workforce does track Physician Assistants (PAs). The Board reported in 2014 that there isn t a sufficient supply of Physician Assistants in the state and that they are not well distributed geographically (Miller 2014). The report says that about four of five PAs practice in metro areas of the state with fewer than a third of PAs working in primary care. The medical workforce is acknowledged as being vital to health but is sometimes overlooked as a major economic engine. According to a report from the American Medical Association, on average, a physician in Georgia in 2012 was responsible in direct and indirect economic output for a total of $1,559,494, for jobs, for $874,484 in total wages and benefits, and $57,285 in state and local taxes (American Medical Association 2014, 5). A study published by The National Center for Rural Health Works found that a rural primary care physician practicing in a community with a local hospital creates an estimated 24.2 local jobs and over $1.3 million in income (wages, salaries, and benefits) from the clinic and hospital (Eilrich et al. 2013, 1). Mid-level practitioners, Physician Assistants, and Nurse-Practitioners also provide a huge boost to the local economy. Eilrich et al. found, Given four sample scenarios, a rural NP/PA can create between 4.4 and 18.5 local jobs and $280,476 to $940,892 in wages, salaries, and benefits from the clinic and the hospital (Eilrich, Doeksen, and St. Clair 2014). These figures do not, of course, include the economic benefits from improved health that derive from a healthier and more productive workforce. 15

16 Infrastructure Rural communities with hospitals are extremely concerned about the stability of their local hospitals, as they form the basis for the health care infrastructure and are major employers. We couldn t even think about recruiting industry without a hospital, says Washington County Economic Development Director Charles Lee. I might as well quit if the hospital closed. Barring a miracle, that might happen given the hospital s current financial status. A totally new Hospital Authority is now working to configure a system that will be sustainable for Washington County. Lee is not alone in recognizing the economic value of healthcare infrastructure, particularly hospitals. Patricia Graham of Randolph County says it would be a huge loss if the hospital closed. The threat of industrial accidents in the counties with the most heavy industry Elbert, Berrien, Butts, Stephens, Chattooga, and Washington would put both worker safety and recruitment and expansion of industry at risk. Though not heavily industrialized, John Keen of Wilkes County says that he does not know how we could do without a hospital. Since Wilkes EMS serves neighboring Taliaferro County and transports most of the patients to the hospital in Washington, Georgia, the absence of emergency and diagnostic care would affect two counties. We couldn t even hope to attract industry without it, he says. Early County s hospital continues to function, although like other rural hospitals, it is struggling. The hospital currently employs 248 people. I don t know what we would do if it closed, says Kyle Kornegay. Although there are hospitals in neighboring Miller and Seminole counties, the closest full-service hospital is in Dothan, Alabama, 35 miles west of Blakely. When insurance won t allow for coverage out-of-state, then the person has to go to Albany, 52 miles east, he explains. One challenge for these rural areas is having a sufficient supply of patients to sustain hospital operations. Hometown Health CEO Jimmy Lewis has long said that a service area of 40,000 is required for rural hospital sustainability, but that number has changed since payer mixes have shifted and rural hospitals now have lower proportions of insured and higher proportions of Medicare, Medicaid, and uninsured patients. In a January 29, 2016 interview, Lewis now says that the essential figure is closer to 50,000. Even large geographic areas like Early and the contiguous counties do not have that many residents. Hospitals are important economically, and not just for services they provide. They are generally among a rural county s top ten employers, along with the government and schools. When the hospital in McRae closed in 2008, we lost a lot of jobs just at the worst time possible, says Paula Anderson, Chamber Director in Telfair County. Macon County s shift from a full-service hospital to what is primarily a substance abuse facility has allowed them to keep 16 Figure 2. Counties Contiguous and Close to Early County Shaded Counties Have Hospitals County Population Seminole 8,900 Early 10,542 Miller 5,932 Clay 3,045 Calhoun 6,523 Baker 3,341 Total 38,283

17 about 100 employees, but many were laid off. A study published by the National Center for Rural Health Works indicates that an average critical access hospital (CAH) employs 141 [and] generates $6.8 million in wages, salaries, and benefits (Doeksen et al. 2012, 1). For hospital operations alone, this typical CAH generates an annual impact of 195 jobs and $8.4 million in wages, salaries, and benefits (Doeksen et al. 2012, 1). Health care infrastructure is, of course, affected by the economy as high proportions of indigent care can cripple a hospital. As industries have left many for overseas so have commercial payers. Extreme poverty helps explain why many hospitals in these communities are struggling, since large portions of the population do not have commercial insurance and are covered by Medicaid, Medicare, or are self-pay or indigent. With the passage of the ACA, payments disappeared that had helped shore up hospitals that saw a disproportionate share of indigent patients and those with government coverage. Emergency rooms are losing enterprises in most cases, since many presenting patients are indigent. ERs may also lose out even when patients have insurance coverage, since most insurance companies will not reimburse for nonemergent care, one of the major uses of rural ERs when residents have nowhere else to turn for primary care. One solution to keep at least parts of Macon County s hospital open was to convert it to a substance abuse facility and to close the emergency room. The private company that owns the hospital uses beds at the hospital exclusively for substance abuse treatment, contracting on a case-by-case basis with the State of Georgia s Department of Behavioral Health and Substance Abuse. The bed capacity met an immediate need, because there were so few options in the region for substance abuse treatment (Berry, Personal Interview, January 25, 2015). Macon County residents can, however, still use the hospital for diagnostic services. It has been challenging to change people s patterns of seeking emergency care there, says Macon County Chamber Director/Economic Development Director Gerald Beckham. Although the county saved money by not having to supplement the hospital, there were unintended consequences from the closure. Beckham says that the county has had to enhance emergency medical services to compensate for the loss of the ER. More equipment and personnel had to be added to take people out of town to nearby hospitals. We traded one expensive thing for another. According to other business executives interviewed for this report, some hospitals that have outside management are experimenting with geriatric psychiatric units as a reliable source of revenue, but getting consistent psychiatric coverage is a challenge. Some of those hospitals are supplementing with telepsychiatry to try to provide coverage and keep the beds filled to help keep the hospitals solvent. The majority of Chamber and Development Authority leaders in counties that have hospitals discussed widespread concerns among citizens about hospital quality. One said that a common expression he heard was, They ll kill you over there. Another described the hospital as a band-aid station. What happens, explains one Chamber Executive, is that people with insurance go out of town, leaving high proportions of uninsured and those with Medicaid and 17

18 Medicare at our local hospital. If we don t figure out how to change our hospital s reputation, it will end up closing. There are also concerns about the quality of care in hospital emergency rooms, some commenting that citizens often bypass their local hospitals for regional hospitals. Some Chamber leaders suggested more aggressive hospital public relations campaigns; others thought that association with an urban medical center would help change the ruined reputations of some of the smaller facilities. That latter idea has some credence, since two of the hospitals, Randolph and Berrien, both run by larger hospitals, do not appear to have struggled with reputation issues. We often see the attitude that everything is better in a bigger town, says Chrissy Staley of Berrien. We have to get past that and support what we have here. People in our community need to be educated about what it means to lose a hospital, says Elbert Chamber Director Phyllis Brooks. Management has been the issue in some communities. In Washington County, mismanagement included paying the administrator $40,000 per month as a contractor, with the check sent to his car dealership (Robbins and Teegardin 2016), and millions in questionably spent dollars going to Duke University consultants and interns while the hospital had difficulty making payroll. In Burke County, where the hospital was long run by a group of local physicians, a request to the county for subsidies when the hospital began to lose money was denied, so the physicians terminated their contract with the Hospital Authority, leaving the Hospital Authority to regroup. As Burke Chamber executive Ashley Roberts points out, Augusta s urban hospitals are only about 35 minutes away from Waynesboro, putting added pressure on the hospital. An agreement between Phoebe Putney and Dorminy Hospital in Ben Hill County was abruptly terminated, leaving them in much the same position as Burke, until an outside management company contract was signed. Purchase or management by a larger hospital, sometimes seen as a solution by local leaders, may be impossible as these hospitals are often reluctant to take on losing operations or find that the hospitals are so deep in debt that making ends meet would be impossible without the local taxpayers assuming liability for debt that would allow them to get a fresh start. Commissioners have been hesitant to take that leap or to ensure ongoing subsidies for hospitals that are losing money. A few Chamber leaders said that there was no need for a hospital in their communities, as they are a drain on the taxpayers and have little chance of staying open. Several opined that a hospital with a handful of inpatient beds, some routine outpatient surgery options, robust diagnostic operations, along with an appropriate number of swing beds, would work for their communities. Chattooga County s hospital has been closed for years, and area hospitals now compete for their county s patients, says Sylvia Lee Keziah. Floyd Medical has opened an urgent care center that has extended hours, and that has helped meet some of the need in Chattooga. Leadership In most of the counties covered in this report, Chamber directors admitted that no one is in charge of health and health care planning for their communities. Some Chamber and 18

19 Development Directors believe that it is the hospital s or Hospital Authority s responsibility. Others see it as the job of Public Health or the Board of Health, and still others consider it up to the County Commission. While some of the executives praised the role of Public Health in their communities, some commented that funding had been so seriously cut that Public Health staff are now spread too thin to be effective or to take leadership roles in their communities. In one community in which residents are dependent on outlying hospitals, the Chamber leader commented that receiving hospitals should take a role. The larger hospitals want our patients, but they offer us nothing in return. They could help with community education or put some services here, he says. None of the Chambers has a health committee, but in many of the communities, someone who works at the hospital serves on the Chamber board and in some cases, the Chamber or Economic Development executive serves on the Hospital Authority or on an advisory committee. Where this is true, there appears to be increased awareness of hospital challenges and of the business community s role in ensuring health and health care for residents. Translating this awareness into action is another matter, as there is little consciousness of health outcomes or the relative health of one county s population compared to others. Health outcomes are often viewed as a matter of personal, not public responsibility, although many acknowledge the socioeconomic factors that are a driver of poor health. Several Chamber and Economic Development leaders mentioned the existing Family Connection collaboratives that now function in every county as having potential to focus on health. These organizations, funded in part by the state, often choose a focus area like teen alcohol abuse or teen pregnancy, since their primary focus is children and families, not population health. All but one of the counties included in this report has a Chamber of Commerce, but in many counties, they, too, are struggling as businesses close and Chamber dues dry up. Brantley County has a government-funded Development Authority, says Director Richard Thornton, but has no Chamber at present. Patricia Goodman says that Leadership Randolph training does include a session for potential leaders on health care, the class visiting the hospital and the Public Health Department. It is an eye-opener for most of the class, she says, since most have little knowledge of health care infrastructure. Goodman adds that their State Representative Gerald Greene is working to ensure that the hospital stays open, but if funding does not change, they may have to close. Our county is the sum of its parts, says Macon County s Gerald Beckham. We have to get jobs to improve things here, so the county needs to come together to see the relationship between economics and health. In the past, many counties relied on the federal and state governments to give us money; they wanted somebody else to pay for it. Now, those funds have gone away, and we realize it is up to us. 19

20 Ideas for Righting and Right-Sizing the System: Seeking Solutions for the Rural Health Care Crisis Assets Chamber and Economic Development leaders have not given up on health care and improving health. There are positive activities taking place in some counties. Washington County s Archway Partnership with the University of Georgia has focused on both health and economic development. According to Economic Development Director Charles Lee, the county has engaged with the University s Information Technology Outreach Services to create an interactive map of the county s resources. According to an Archway news release, The Internet application uses ArcGIS technology to generate easy-to-access maps showing available industrial sites, local health care facilities, and recreation areas including points of interest for visitors interested in self-guided walking tours. Viewers can click on each location for a pop-up that gives additional information (Nielson 2015). Lee says that this is a tremendous tool for industry recruitment. The technology provides ready information for prospects, answering frequently asked questions about industrial sites, schools, and health care, and it can help local leaders identify areas that need to be strengthened to enhance the community. The Archway Partnership has also worked with the community to raise money to fund housing for medical students for training in rural Georgia in the hope that they will decide to return to work there. Washington County is the state s only county in which Archway has had a health care focus. Most of the business leaders interviewed are aware of the presence of a clinic that accepts sliding scale payments in the counties with a FQHC, even if they are not familiar with the terminology. Eighteen of the 22 counties covered by this report have FQHCs, which are widely considered by business leaders as tremendous assets. Only Screven County reports a free clinic, opened recently by St. Camilla Catholic Church on a part-time basis with volunteers. Screven does not have a FQHC. (See FQHC map following the reference section.) The affordable access our FQHC provides is a tremendous help to our residents, says Chattooga s Sylvia Lee Keziah. In both Telfair and Twiggs, the Development Authority was instrumental in attracting or retaining the FQHC. Patricia Goodman in Randolph County and Chrissy Staley in Berrien see their hospitals relations with larger hospitals as positive, both from a financial viewpoint and a reputation viewpoint. There s just no negative perception of the hospital here, says Goodman, and I think part of that is the Phoebe connection. Berrien County s school telemedicine program is a tremendous success, reports Chrissy Staley. I think this program keeps children in school, ensures that they receive needed care, and identifies problems early. Monica Simmons says that Crisp County s Community Council provides opportunities for civic and government leaders to get together to talk about issues. We know what s going on 20

21 with each other including the hospital, she says, so this could be a platform for more discussion on health. The location of the nursing program was a joint effort of school and community and civic organizations. Health and wellness are a part of Ben Hill County s comprehensive plan, shared for this report by Economic Development Director Jason Dunn. Having a focus on better health and fitness in the plan may raise consciousness of health outcomes. The document also prioritizes marketing the local hospital as a first choice health care provider (South Georgia Regional Commission 2016). Awareness of the need for stability in health care is also recognized in the report. Some directors have aspirations that could lead to improved health and health care in their communities. Jonathan Jackson in Wilkinson County says that he dreams of having the former Calhoun High School turned into a community health and social services center, sort of a one-stop-shopping mall for physicians, therapy, wellness, social supports like Department of Family and Children Services, and adult and health education. In addition to funding for renovation and attracting the workforce, he says, the key would be transportation, which is currently inadequate. Wally Orrel points to northern McIntosh County, where business leaders are willing to donate the property and perhaps do more to get a clinic to locate there. We can t attract retirees without health care, says Martin Miller, one of the developers involved. The group is talking to FQHCs and area hospitals to ascertain interest in a clinic in an underserved area. Conclusion Economics and health are intertwined in rural Georgia. As populations dwindle, the proportion of aged residents and those with chronic diseases, disabilities, and low educational levels remain in place, exacerbating economic decline as industries are less attracted to communities without a healthy, educated workforce. This results in fewer people with insurance and fewer providers willing to set up practices in communities, which in turn reduces opportunities for preventive care. As tax revenues decline, counties are less able to ensure environmental health and public health or to contribute to indigent care services or public transportation. Sidewalks and parks that foster physical activity are less likely to be funded, when basic road maintenance is a bigger priority. Poorer communities are less likely to have good grocery stores, so there is less access to healthy, 21

22 fresh foods. Pharmacies may be in neighboring communities, miles away from residents homes. Even getting to the grocery store can be challenging, since transit is not always available or is unaffordable for the poor. The cycle continues, in some places becoming a downward spiral as counties lose population. There are bright spots, however, especially in those counties that recognize the relationship between health and economics. Chambers are poised to assume a leadership role in health care. After all, many look to industries and businesses to take charge of their employees health, and those organizations look to the Chamber for guidance. Current efforts to understand the community s assets, increase graduation rates, cooperate on ventures to increase the health care workforce, and support clinic development through community initiatives and telemedicine in schools are steps in a positive direction. It is clear that the rural health infrastructure is unlikely to return to its pre-2000 vigor. Demographic trends show nearly all of the state s growth in metropolitan areas, with most rural growth not from in-migration, but from births. Figuring out how to right-size the system is critical. Some counties are facing hard dilemmas: close the hospital or create a new type of healthcare facility that meets different needs. There was wide support in this subset of leaders for smaller hospitals with fewer beds but retaining vital diagnostic services, emergency rooms or urgent care centers, and in larger counties offering basic endoscopy and retaining some swing beds to help meet the needs of the elderly. Geography also matters, especially in those counties where the population is most widely dispersed and there is no center of health. Public transportation has become more important, as local resources are less available and specialty care requires a drive of 30 miles or more. Figuring out how to break down barriers between counties in making that work will be critical. McIntosh Economic Development Director Wally Orrel believes that one of his county s barriers to improved health is the lack of communication among the citizens. The two McIntosh communities are ten miles apart, and there is no radio, only a weekly newspaper that not everyone reads. We need to figure out how to come together to address this problem, he says. Not every community has good internet services: the digital divide is real in rural Georgia. Surprisingly, in some rural counties, many of those without computers are the 18 to 24 year old set who cannot afford computers or internet connections (Coastal Health District 2014). A longtime desire in Meriwether has been the use of telemedicine for triage in the jail and for telemedicine in the schools, says Carolyn McKinley, but the county just doesn t have the infrastructure to handle broadband services. The most critical first step toward improving the health of Georgia s rural residents is local leadership. When nearly all of the Chamber and Economic Development Directors admit that no one is in charge of planning for health care, it is perhaps time to take a fresh look at ways to coordinate efforts to achieve change. Learning from others who have demonstrated 22

23 success and inviting the support of expert guidance could be instrumental, but without local collaboration and commitment, any such efforts will be futile. It s up to us, says Gerald Beckham of Macon County, acknowledging the essential nature of locally-driven planning and decision-making. The options are frightening for some communities, as their hospitals threaten to close and the last doctor retires, but there is hope among business leaders and there are platforms from which change can be launched. For too long, health has been considered an individual problem, not a community problem. Data from County Health Rankings that puts some of these rural counties near the bottom in the state is eye-opening for many business leaders, who are as a Healthcare Georgia Foundation publication describes it, beginning to understand the need to Partner Up! For Public Health as they begin to Connect... the Dots between Community Health and Economic Vitality (Hayslett 2012). 23

24 References American Medical Association The Economic Impact of Physicians in Georgia. Prepared by IMS Health (March). Berry, Frank. Personal Interview, January 25, Braveman, Paula, and Gottlieb, Laura The Social Determinants of Health: It s Time to Consider the Causes. Public Health Reports 129 (Supplement 2). Buschman, Robert Georgia s Incredible Shrinking Sales Tax Base. Georgia State University Fiscal Research Center. October 6. Incredible-Shrinking-Sales-Tax-Base_October-2015.pdf. Coastal Health District Community Health Needs Assessment. Doeksen, Gerald, Eilrich, Fred, and St. Clair, Cheryl The Economic Impact of a Critical Access Hospital on a Rural Community. National Center for Rural Health Works. (September). Eilrich, Fred, Doeksen, Gerald, and St. Clair, Cheryl The Economic Impact of a Rural Primary Care Physician. National Center for Rural Health Works. (October). Eilrich, Fred, Doeksen, Gerald, and St. Clair, Cheryl The Economic Impact of a Rural Nurse Practitioner or Physician Assistant. National Center for Rural Health Works. (August). Enroll America Changing Uninsured Rates by County. Georgia Board for Physician Workforce Georgia Physician and Physician Assistant Professions Data Book, 2010/ Georgia Regional Economic Analysis Project (GA-REAP), Data from the U.S. Department of Commerce, Bureau of Economic Analysis Transfer Payments Tables, Georgia Southern Regional Commission on Behalf of the Ben Hill County City of Fitzgerald Update to the Comprehensive Plan. ensive%20plans/2016/ben%20hill_co_fitzgerald_ci_%20joint%20comp% pdf. Hardy, Michael. Personal Interview, January 22, Hayslett, Charles Partner Up! For Public Health: Connecting the Dots between Community Health, Economic Vitality. HealthVoices. Healthcare Georgia Foundation. Johnson, Kirk Rural Oregon s Lost Prosperity Gives Standoff a Distressed Backdrop. The New York Times (January 18). Kaiser Family Foundation The Georgia Health Care Landscape. (September 30). 24

25 Lewis, Jimmy. Personal Interview, January 29, Miller, Andy Doctor Shortage Remains Acute in Rural Areas. Georgia Health News (January 2). Miller, Martin. Personal Interview, January 27, National Cancer Institute State Cancer Profiles. 5&3&2&0. Neilsen, Roger Institute Develops Interactive Map to Aid Washington County Economic Development. (December 17). Robbins, Danny, and Teegardin, Carrie Rural Hospital s Bet on Car Dealer Goes Bust. The Atlanta Journal-Constitution (January 23). Selig Center for Economic Growth, Terry College of Business, University of Georgia. Evaluating Retiree-Based Economic Development in Georgia: Golden Rules. Research Commissioned by the OneGeorgia Rural Policy Center. (August). U.S. Bureau of Labor Statistics Local Area Unemployment Statistics Map. (November.) U.S. Census Building Permits. U.S. Centers for Disease Control and Prevention Current Cigarette Smoking among Adults. nal. U.S. Centers for Disease Control and Prevention Diabetes Data and Statistics. U.S. Department of Agriculture. Food Deserts in Georgia. Food access research atlas: Georgia Map indicating food desert areas. Low income and Low access to food within 1 to 10 miles. U.S. Department of Agriculture, Economic Research Service. Geography of Poverty. U.S. Department of Agriculture, Economic Research Service. Percentage of Total Population in Poverty,

26 U.S. Department of Commerce, Bureau of Economic Analysis. Local Area Personal Income: Wickersham, Mary Eleanor Two Georgias: Rural-Urban Disparities in Health Behaviors and Outcomes. Healthcare Georgia Foundation (August). Xiao, Hong, Tan, Fei, Goovaerts, Pierre Racial and Geographic Disparities in Late-State Prostate Cancer Diagnosis in Florida. Journal of Health Care for the Poor and Underserved 22(40):

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