Hospitals Are Leaving Rural America. Rural Americans Are Staying Put.

Kendra Colburn spent a decade uninsured. During those years, she worked as a carpenter near her hometown in rural Vermont, earning just enough that she didn’t qualify for low-income health care, but not enough to afford health insurance on her own. While uninsured, she suffered two major work injuries that landed her in the emergency room—once, a nail shot through three of her fingers, and another time, a piece of wood kicked back on the table saw and sliced her arm. When she was unable to pay the emergency room costs, her credit took a hit for years.

Today, Colburn works on her brother’s farm and is covered by Medicaid. As a manual laborer, Colburn has developed nerve damage, which flares up in her hands and wrists with overuse. “I cut back my hours to deal with it. I can’t afford to not be able to use my hands,” she says. “That’s how I make all of my money.”

As a child who grew up in a farming community, Colburn says she observed that pain is just a part of being a farmer. “It’s taken for granted that your body hurts every day, that your back always hurts.” That’s true for workers employed in some of the most dangerous jobs: Many manual laborers with high rates of injury and repetitive stress injuries are also more likely to be uninsured. In fact, a 2015 study found that 65 percent of commercial farmers identified health insurance costs as the most serious threat to their farms.

Alana Knudson, co-director of the Walsh Center for Rural Health at NORC at the University of Chicago, prefers to discuss rural health care in terms of strengths, but she does recognize the real barriers demonstrated by statistics. “Overall, we know that people who live in rural communities are likely to have lower incomes than their urban counterparts,” she says. Rural residents are also more likely to have multiple chronic conditions and lower educational attainment, and they’re more likely to face barriers in accessing transportation to medical care.

But there are also less tangible barriers. Colburn says that many people she knows don’t feel comfortable navigating the complicated web of professional medical interventions when experiencing health issues. And the Medicaid system can often lack efficiency. Colburn says her state’s website often doesn’t work, and she still hasn’t figured out how to find a primary care doctor who takes her insurance. Once, a computer glitch resulted in her being removed from her insurance plan, and she was charged hundreds of dollars in out-of-pocket expenses. Even though it was an error on Medicaid’s part, Colburn was still responsible for the bill. “Generally when we’re talking about rural health care issues, we’re talking about access, as if once you get access that actually means something. But when you get access, it still can be a nightmare,” she says.

77 percent of rural U.S. counties are considered Primary Care Health Professional Shortage Areas

Faced with whether to seek medical attention or “make do,” Colburn says many people simply don’t go. She notes that farmers especially have a hard time leaving their farm obligations to take care of themselves. They also spend significant time outdoors, and it’s difficult to imagine a hospital stay. Colburn says, “I have treated myself or not gone a million times.” One spring, she stepped on a potato fork and punctured her foot. Instead of going to the doctor, she spoke with a community herbalist, used an herbal tincture, and soaked her foot in salt water.

“I know for a fact that I need a root canal,” Colburn says, “It used to hurt and now it doesn’t hurt, so I just deal with it.” She pauses. “I know a lot of people who just get their teeth pulled. And the dental piece is important because what your teeth look like has [a] direct impact on what opportunities you have.”

This reality is echoed by rural journalist Sarah Smarsh. “In the past year, the Affordable Care Act, or ‘ObamaCare’, has changed many lives for the better—mine included,” she wrote in an essay for Aeon. “But its omission of dental coverage, a result of political compromise, is a dangerous, absurd compartmentalization of health care, as though teeth are apart from and less important than the rest of the body.”

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The fabric of rural America is shifting, in large part due to changes in agriculture. Knudson grew up in North Dakota and says she’s seen that change firsthand. “Our neighbors are farming our land and they seed over 10,000 acres. A lot of the small farms are not there anymore.”

Many children of farmers choose not to take over the farm. Land is then sold or leased to larger farms. Small businesses that once depended on a critical mass of farm families as customers also go out of business. The effects of this rural migration are particularly severe on rural elderly with complex medical needs—and no younger generation remaining in the area to care for them.

Last year, a photographer and I drove across Kansas and Iowa to report on the hidden crisis of farmer suicide. We visited Onaga, Kansas, a small town with a newly renovated hospital. Just blocks from the hospital’s beautiful lobby and squeaky-clean floors were empty streets and boarded up storefronts. One doctor said the hospital had a hard time attracting medical professionals to practice there. The therapist had left months ago, she said, and they were struggling to fill the position.

An online search for “benefits for rural medical professionals” turns up a slew of sites about attracting medical talent to rural communities. Rural medical establishments are advised to advertise the lower cost of living and ability to buy acreage, less traffic, a quieter life, student loan forgiveness in certain underserved areas, “the potential to become the ‘town hero,’” more time spent with patients, and increased proficiency due to physicians seeing “a broader scope of illness.”

Still, rural communities are facing the closure of hospitals and clinics. In 2016, The National Rural Health Association (NRHA) announced that 673 rural hospitals were at risk to close. Of those, 210 were at “extreme risk” of closure. The NRHA warns that “Medical deserts are forming across the nation, significantly adding to the health care workforce shortage in rural communities. Seventy-seven percent of rural U.S. counties are already considered Primary Care Health Professional Shortage Areas.”

Knudson says the health care industry is undergoing a significant transformation in terms of how medical care is being reimbursed. “Our reimbursement system is moving from a volume to value,” she says. ”Historically hospitals have been reimbursed by the number of hospitalizations they provided—you have 10 hospitalizations and you get reimbursed for 10 stays. Our country has really shifted as much as possible to outpatient to make health care more affordable.”

That means a decrease in admissions, more outpatient procedures, and less reimbursable care for hospitals. Additionally, Knudson says many of the rural hospitals closing are in states that have not expanded Medicaid, which has led to a higher number of uninsured patients. “When people are uninsured, it’s difficult to collect payment for that hospitalization.”

Hospital closures can be devastating to rural communities, creating gaps in access to the detriment of residents. “Many of these hospital closures are happening in areas with the highest concentration of heart disease and diabetes, and in some of the poorest communities in the country,” says Maggie Elehwany of the NRHA. “When that hospital closes, it’s like putting a nail in the coffin of that community. You can’t attract businesses or families with kids or keep retirees. So we’re fighting not only for rural hospitals, but also for the economies of these rural communities as well.”

Rural communities are known for being innovative, self-sufficient, and organizing quickly in an emergency

In June 2017, Missouri Congressman Sam Graves introduced the Save Rural Hospitals Act (H.R. 2957). The bill doesn’t increase reimbursements, but it does offer stability for “the closure crisis” by eliminating cuts and Medicare Sequestration for rural hospitals. It also establishes a new Medicare payment designation, called the Community Outpatient Hospital, that would guarantee rural access to emergency care and give hospitals the choice to offer outpatient care. The bill was co-sponsored by 21 representatives (14 Republicans and 7 Democrats), but it is still waiting for a vote.

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Rural residents can’t afford to wait, so they are using the assets they have. Rural communities are known for being innovative, self-sufficient, and used to organizing quickly in an emergency. Families may have been rooted in one area for generations, which manifests in a deep knowing of their neighbors, as well as each other’s talents and stressors. And rural communities are often filled with people who want to help one another.

One story Alana Knudson tells me goes like this: One winter, in a northern rural community, an elderly man was treated for chronic urinary tract infections. He was treated and advised by medical staff to flush his kidneys as much as possible by drinking water. But he soon returned with another infection. When a community health worker visited his home, she discovered the man lived in the back of a shed, did not have an indoor toilet, and had to haul his own potable water.

At last, the urinary tract infections made sense. Knudson says, “It was not easy for this elderly man to traverse the snow and the cold in the dark to access the outdoor restroom, so he limited his fluid intake which contributed to reoccurring UTIs.”

To serve the health care needs of the nearly 60 million Americans who live in rural communities, Knudson says “it takes an entire team.” Ideally, Knudson says community health workers are part of that team. As public health workers who are also trusted members of the community, community health workers are particularly equipped to provide valuable connections between health or social services and the community. Primary care providers, pharmacists, social workers, health departments, and even agriculture extensions are critical members of the rural health care team. Knudson says, “A lot of different entities come together and complement each other. We can’t afford the luxury of duplication, so we really work together.”

“People come together to support others,” she says. “In my home community in North Dakota, we had a neighbor who had a heart attack during harvest, and all of us got together and finished the harvest for him. If you needed the help, you could count on your neighbors doing that.”

This frame is important, Knudson says, as much of the media attention about rural communities has been negative. As a result, she says, “There is such dystopia about rural America. We’re hearing from some rural communities that potential businesses are saying ‘we’re not interested in investing in rural America.’”



Raj Chetty on His Groundbreaking Study on Racism and Inequality

A great deal of what we know about inequality in America comes from Stanford economist Raj Chetty’s work. He’s shown us how much place matters in determining upward mobility, the long-lasting effects of experiencing poverty during childhood, and that inequality has connections to everything from inventions to mortality.

Now, in a groundbreaking new study by a team of researchers at Harvard, Stanford, and the Census Bureau, he’s changing the conversation yet again. This latest study finds that even when children grow up next to each other with parents who earn similar incomes, black boys fare worse than white boys in 99 percent of the country. And, perhaps even more staggering, those gaps only worsen in neighborhoods with low poverty rates and good schools.

I spoke with Chetty to unpack this new study and what it means for our understanding of racial inequality in America.

Rebecca Vallas: So the racial income and wealth gap has long been documented, but your study sheds new light on what’s driving income inequality across racial groups. What did you find with your colleagues?

Raj Chetty: What’s new about the study is that it takes a perspective across generations. So most prior work on racial inequality in the United States has looked at people with a snapshot at a point in time—comparing adults who were, let’s say, 40 years old who were black versus white versus Hispanic and looking at how their incomes and other outcomes differ. But what we do here is use data that span across generations where we can link kids to their parents. And in this case we’re able to use anonymized data covering about 20 million kids and their parents and look at how these disparities evolve across generations.

The key finding that emerges from this analysis is that there are very large differences by race, especially when it comes to kids’ chance of climbing and staying at the top of the income ladder. Most strikingly, even among kids who grow up in high-income families, if you’re black, you have a much lower chance of remaining in the next generation at the top of the income distribution or even in the middle of the income distribution than if you’re white. Black kids have almost an equal chance of ending up at the bottom as they do of staying at the top if they start out in a high-income family.

The reason that’s so important is that it tells us these disparities are not just arising from something that’s happening today. Trying to climb the income ladder for black Americans is almost like you’re on a treadmill. You climb up in one generation only then to fall behind again and have to climb up once more, and it’s that feature, that cycle that has to be broken to combat these disparities in the long run.

This is not about immutable factors like differences in ability.

RV: Your study also found that racial inequality can’t be explained by differences in cognitive ability, which maybe sounds common sense to a lot of folks listening, but is actually pretty important as an empirical finding considering a lot of the narratives that still persist out there about what explains poverty in America.

RC: That’s right. We really don’t think differences in ability explain the gaps that we’re documenting, and there are two simple reasons for that. The first is the pattern that I just described of downward mobility across generations. It’s really only there for black boys. Black women do just about as well as white women once you control for their parental income. And that suggests first of all, if you look at most prior theories of differences in cognitive ability, The Bell Curve book for example, it does not present evidence that you’d expect these differences to vary by gender. Furthermore, if you look at test score data, which is the basis for most prior theories about differences in ability, the fact that black kids when they’re in school tend to score lower on standardized tests than white kids, that actually is true for both black boys and for black girls to the same extent. In contrast when you look at earnings there are dramatic gender differences.

And so that suggests that these tests are actually not really capturing in a very accurate way differences in ability as they matter for long-term outcomes, which casts doubt on that whole body of evidence. So, based on that type of reasoning, we really think this is not about differences in ability. One final piece of evidence that echoes that is if you look at kids who move to different areas, areas where we see better outcomes for black kids, you see that they do much better themselves, which again demonstrates that environment seems to be important. This is not about immutable factors like differences in ability.

RV: You mentioned gender differences. One of the most interesting pieces of the study—to me in particular—was that when it comes to women, it seems to be a very different story.

RC: Yeah, that’s exactly right. I think we were quite surprised by that. So there is earlier evidence showing that gaps in wages, for example, are smaller for women between black and white relative to black and white men. What we were struck by is if you just control for parental income so you look at two children, say growing up in a family making $50,000 a year, if you look at their daughters they have essentially the same outcomes in terms of earning, wage rates, employment rates, their chance of going to college. Lots of different outcomes you can look at.

If you look at boys, it’s a completely different picture. If you compare black boys to white boys you see enormous gaps in earnings and employment rates, perhaps most starkly in the context of incarceration. One in five black men born to a low-income family is incarcerated on a given day, which is just an astonishingly high rate. You don’t see anything like that for both black and white women.

Thinking about socioeconomic class and neighborhood is not a substitute for thinking about race

Now, one thing I want to emphasize here is that in some of the public discussion following the paper, people have been a little bit surprised. “Are you saying there is no issue here for women? That doesn’t really sound right.” I want to emphasize that that is not what we’re saying. First of all, if you just look in the raw data, there is still a significant difference in the earnings of black women and white women, and the reason for that is black women still grow up in much lower-income families than white women. So it’s only once you control for parental income that their outcomes look much more similar. The second important point to note is that black women, white women, and black men all have relatively similar levels of earnings, that it’s really white men who have considerably higher levels of earnings. The reason we focus on black men is when we look at certain outcomes like the probability that they have a job or their odds of being incarcerated or their chances of completing high school, they do look like an outlier relative to all the other groups. Black men are significantly less likely to be employed than black women, they are significantly more likely to be incarcerated, they’re significantly less likely to complete high school. And so it does seem like there are a special set of challenges confronting black men. That’s not to say that there’s no issue for black women or that gender equity is not an issue, that’s just not the focus of this study.

RV: The gaps that you found in your research only worsen in neighborhoods with low poverty rates and good schools. Why is that?

RC: Both black kids and white kids do much better in places that have better schools, that have low poverty rates, that you might think of intuitively as “good neighborhoods.” So we’re not challenging that intuition at all. However, what you see in the data is that white kids gain more from being in these lower-poverty areas and from attending better schools than black kids do. And as a result the gaps between white kids and black kids are larger in those areas. So the takeaway from that is not that schools are not important or that having lower-poverty, lower-crime areas are not important; all of those things would help black kids and white kids as we’ve shown in our prior work.

What this study is showing is it is not adequate by itself to close black-white disparities. You need to do more than that. You need to perhaps integrate black kids into these better schools so that they can take advantages of the resources they offer to the same extent that white kids do.

To put it differently, thinking about socioeconomic class and neighborhood is not a substitute for thinking about race. We need to think about how to narrow racial disparities separately.

This interview was conducted for Off-Kilter and aired as part of a complete episode on March 23. It was edited for length and clarity.



A Gun Violence Expert Explains the Link Between Inequality and Gun Deaths

Support for gun safety laws is at an all-time high. Heading into Saturday’s March for Our Lives, more Americans than ever supported new laws to reduce gun violence—including nearly 70 percent of adults and half of all Republicans. But gun safety measures, while critical, are only the tip of the iceberg in addressing gun violence in the country.

In both the United States and globally, gun violence is strongly correlated with both poverty and inequality. A recent World Bank study found that inequality helped predict the difference in murder rates between states in the United States—as well as between countries. Suicides, which make up the majority of gun deaths in the country, skyrocket in times of economic distress. The Great Recession alone was linked to more than 10,000 suicides, according to one study.

At a time when the Trump administration is undertaking an all-out assault on health care, food assistance, and the broader safety net, I reached out to Mark S. Kaplan, a professor of social welfare at the University of California, Los Angeles, to discuss the link between inequality and gun violence.

Jeremy Slevin: It sounds like from your research, the primary way we can quickly address the gun violence epidemic in this country is through gun policy—reducing the amount of guns that are available in circulation. Is that fair to say?

Mark Kaplan: Limiting access to guns is a form of harm reduction. What guns do to a society that is inherently violent—and we are a violent society—is that it lethalizes the violence. So if we are able to tamp down that violence by reducing people’s access to guns, that might be a first good step in the direction we’re talking about.

JS: Could you talk a little bit about your research on how inequality correlates with levels of gun violence?

Gun deaths are only the tip of the iceberg

MK: For one, we know that the numerous studies that have looked at the intersectionality of race and class and gun violence have clearly shown that there is some relationship between issues of racial segregation and issues of deprivation—social and material deprivation. The reduction of guns is not going to alleviate those problems. But there is a very troubling and very strong association, and gun deaths are only the tip of the iceberg. Often we don’t talk about the other 90 percent of that iceberg—people who have to be hospitalized, the financial cost, members of those families, the pain, the post-traumatic stress associated with it. So it’s a much bigger problem than gun death.

JS: Is it fair to say that to address the gun violence issue, you need to tackle both the issue of guns, but also tackle the issues of poverty and inequality?

MK: There isn’t one epidemic of gun violence—there are multiple epidemics of gun violence. Suicide doesn’t come up as often, but that represents two-thirds of gun deaths in this country. And that’s a problem that is different from the interpersonal violence. But both are particularly sensitive to the issue of gun availability.

Let me give you an example. California is rated as an A+ by the Brady scorecard, which rates states by the number of gun laws they have on the books. Nationally, 51 percent of all suicides are gun-related. In some states, it runs even higher, all the way to 80, 90 percent. In California, it’s 30 percent, on average. So it means that with fewer guns, there’s a window of opportunity to intervene and possibly rescue people who are suicidal. But with the presence of a gun, the opportunities to intervene diminish dramatically.

JS: Has there been any research, either by you or other scholars, on how suicides are linked to economic factors?

MK: I did recently complete a project, funded by the NIH, looking at the impact of the Great Recession on suicides. And indeed, there is a relationship! There’s some evidence that with the Great Recession we saw a rise in unemployment, we saw a rise in foreclosure rates, we also saw a rise in the rate of poverty—which may have contributed even more than the other two measures in economic distress. That rise in poverty contributed to an uptick in the suicide rate.

There are data that seem to suggest, both coming from the United States and more so from Europe, that many European countries such as Greece went through a very hard time. The EU imposed very restrictive, draconian measures that were attached to the loans they got, and that caused a cutback in welfare and health care and all sorts of other things. And in countries that traditionally had lower suicide rates such as Greece and Italy during the Great Recession, rates of suicide went up. But we know in this country too that the long-term research looking at periods of unemployment and following up five years or more show that for each percentage-point rise in unemployment, there’s also a rise in the suicide rate.

JS: And of course, in the United States, it’s very easy to get a gun, which seems to be the most fatal form of suicide. Of all suicide attempts, those attempted with a firearm are unfortunately more likely to be fatal.

MK: Yes, that’s referred to as the “case fatality rate.” With the use of guns, it’s nearly 95 percent.

We’re dropping the safety net, meaning that people are going to get hurt.

JS: What would you recommend as policy solutions that get at both the firearm access and the social justice issues of gun violence?

MK: I think that we need to approach this in a more holistic way, a more comprehensive way. The gun issue is perhaps the first step. It’s how we tamp down the lethalization, which I brought up at the beginning. That’s something that researchers have looked at globally—the presence of guns. The first thing we need to do is lower the rate, the prevalence of gun availability, access to guns. California is a great example. Some of the most restrictive gun laws have produced very positive results, fewer gun deaths in the state. They say the winds blow from the west to the east, so hopefully that will happen.

And then we can begin to tackle some of these social inequities and inequalities, and some of the structures that promote inequality. Violence is a more difficult social problem to tackle. It represents more than just the loss of lives: The economic toll on society is huge. How do we redress the various measures of inequality? The distribution of wealth and income, the issue of racially segregated communities, the under-resourced and underfunded social welfare infrastructure that seems to be taking a hit in the current administration—those are issues that also need to be addressed. We are lowering the safety net right now. In other words, under the current government … we’re requiring work for health care, so we’re dropping the safety net, meaning that people are going to get hurt.

This interview has been lightly edited for length and clarity.




Tennessee Wants to Use Funding Meant for Poor Families to Kick People Off Medicaid

Nashville Public Radio reported over the weekend that the Tennessee legislature is finalizing legislation that would add work requirements So-called 'work requirements' function as strict time limits on public assistance for unemployed and underemployed individuals. Earlier this year, President Trump opened the door to work requirements in Medicaid by allowing states to take health insurance away from most working-age individuals who are not currently working or participating in qualifying 'work related activities' for a minimum number of hours, even though not having health insurance can make it harder to find and keep a job. to the state’s Medicaid program, kicking at least 3,700 Tennessee workers off their health care.

The state’s Republican leaders appear to have no qualms about taking health insurance away from Tennesseans who can’t find work or get enough hours at their job—even though taking away someone’s health insurance isn’t going to help them find work any faster, and can actually make it harder to find and keep a job. Instead, debate around the legislation has reportedly centered on how to pay for the new policy. Lawmakers’ own estimates put the price tag for enforcing the new work rules at $10,000 per person disenrolled from Medicaid—which advocates note could be more than the new policy saves.

This is where Tennessee’s proposal gets really evil. Unwilling to foot the bill for their new policy out of the state’s general budget, Republican lawmakers have decided to pay for it with funds from the state’s Temporary Assistance for Needy Families (TANF) program—which provides meager cash assistance to very poor families with children.

While news reports, such as the Nashville Public Radio story noted above, make it sound as though Tennessee’s TANF program is flush with unused cash due to a “booming economy and historically low unemployment,” the real story is much more dire.

Nearly one-quarter of Tennessee children live below the federal poverty line, making it one of the worst states in the nation when it comes to child poverty. But fewer than 1 in 4 poor Tennessee families with children get help from the state’s TANF program, which is one of the stingiest in the country. A Tennessee family of three lucky enough to get temporary assistance can expect to receive a maximum of $185 per month—or a little over $6 a day.

Fewer than 1 in 4 poor Tennessee families with children get help from TANF

Why is Tennessee failing so horrifically to help so many of its poorest children? In part, this failure is the legacy of 1996 “welfare reform,” which converted the nation’s main source of assistance for poor families—then called Aid to Families with Dependent Children—into TANF, a flat-funded block grant with very little accountability for how the money is spent.

Many states use TANF as a slush fund to close budget gaps, with just 1 in every 4 TANF dollars going to cash assistance for struggling families with kids. But Tennessee has made an Olympic sport out of diverting TANF funds away from poor families in need of help, squirreling away more than $400 million in unspent funds in recent years rather than using the money to help struggling families with kids avoid hunger and homelessness.

Now the state’s lawmakers want to use those unspent funds to bankroll the disenrollment of thousands of struggling Tennesseans from Medicaid.

The bill is expected to clear Tennessee’s conservative Senate in the coming days and has the support of Gov. Bill Haslam (R), who is expected to sign it into law. If passed, both the state’s proposed work rules and their proposed pay-for will require the approval of federal health officials. If the state’s scheme gets a thumbs up from the Trump administration, other states will likely follow suit. Kentucky, Indiana, and Arkansas have all received permission from the Trump administration to enact work requirements for Medicaid, following Trump’s widely criticized invitation to states earlier this year, and more than a dozen states are actively seeking similar approval. Many—if not all—of these states are looking for ways to pay for the costly bureaucracy required to implement this type of policy.

One would be hard-pressed to cook up a more twisted irony than taking money intended to help poor families with children avoid hunger and hardship and using it instead to take health insurance away from, in some cases, the very same struggling workers and families. But there’s a deeper rot at the core of Tennessee’s plan that cuts across conservative proposals to slash not just health care but food assistance, housing, and more—both in Congress and in the states. And that’s an ideology-fueled willingness to spend whatever it takes to take aid away from struggling workers and families—even when bureaucratic disentitlement costs more than it saves.



How Food Stamps Are Keeping Small Farms In Business

On a weekend morning, the farmers market stretches out like a long caterpillar. Customers mill about, pushing strollers and walking dogs. A band is playing something folksy. Vendors stand behind tables that are literally spilling over with winter greens and root vegetables. It’s a picture-perfect image that connotes abundance and community—if you have the cash for it.

The local food movement has been criticized for catering to middle- and upper-class Americans, and for leaving behind the low-income in all of the hype for Community Supported Agriculture (CSA) and “know your farmer” initiatives touted in glossy food magazines. But in the last decade, food justice activists have sought to correct this, connecting low-income consumers with cooking classes, gardening workshops, children’s programming, and locally grown and culturally appropriate foods.

Enter Double Up Food Bucks, a program that doubles Supplemental Nutrition Assistance Program (SNAP, commonly known as food stamps) benefits for recipients shopping at participating farmers markets or grocery stores, up to $20 per visit. Launched by the nonprofit Fair Food Network, Double Up Food Bucks began at five Detroit farmers markets in 2009. Today, 20 states have launched programs modeled after the original, including my home state of Arizona.

“Double Up is a win-win-win,” says Adrienne Udarbe, executive director of Pinnacle Prevention, the nonprofit that manages Arizona’s statewide Double Up initiative. “SNAP recipients have access to more fruits and vegetables, local farmers make more money, and more dollars stay in the local economy.“

In 2016, nationwide SNAP spending dropped to its lowest point since 2010

Pinnacle Prevention operates 23 Double Up sites across Arizona under the Fair Food Network national umbrella, including a mobile market with 80 stops on its route. Each of them has seen an uptick in SNAP spending, and Udarbe says local produce vendors have indicated an increase in sales since the program started.

Since Pinnacle Prevention’s Double Up program began in 2016, Udarbe says SNAP spending at participating farmers markets has increased by between 67 and 290 percent. Additionally, 84 percent of SNAP customers shopping at Pinnacle Prevention’s Double Up sites responded that they “buy and eat a greater variety of fruits and vegetables as a result of Double Up Food Bucks.” This increase in spending is significant, especially since in 2016, nationwide SNAP spending dropped to its lowest point since 2010.

The handful of Double Up programs in Arizona that are not managed by Pinnacle Prevention have also reported ballooning SNAP spending after their programs began. The Community Food Bank of Southern Arizona (CFBSA), one of Arizona’s earliest adapters of the Double Up concept, reported $9,000 in SNAP spending at its Tucson farmers markets in 2015. But in 2016, after receiving federal funding to implement Double Up, program manager Audra Christophel says SNAP spending at CFBSA markets increased to $37,000. And in 2017, the total SNAP spending exceeded $43,000—nearly half of which was spent on Arizona-grown fruits and vegetables.

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In September 2018, the federal Farm Bill will expire. This means legislators are working now to craft a nearly $900 billion piece of legislation to steer food and agriculture programs over the next five years, including crop insurance, farmer loans, SNAP, and the Food Insecurity Nutrition Incentive (FINI) grants program that funds Pinnacle Prevention’s Double Up program. Udarbe says including FINI in the 2018 Farm Bill is important for the SNAP customers and farmers who count on similar produce incentive programs across the country.

But the recent unveiling of the USDA America’s Harvest Box, part of a theoretical overhaul to the SNAP program that would include deep cuts, shows that the Trump administration may have a different plan in mind. America’s Harvest Box—a Blue Apron-style box for SNAP recipients—would contain pre-determined rations of U.S.-produced breads, shelf-stable milk, pastas, and canned goods.

The box program was immediately met with widespread criticism from individuals and organizations working in the fields of nutrition and food security. In February, when a USDA official discussed the concept of America’s Harvest Box during a National Anti-Hunger Policy Conference, Politico reported that “boos and mocking laughter erupted” from a crowd of 1,200 anti-hunger advocates, and “at least 20 people walked out in protest.”

Udarbe says, “The Harvest Box idea contradicts everything we have been doing over the past decade to move in a direction that best supports food-insecure families and farmers.” Indeed, America’s Harvest Box would remove the element of choice and would not provide fresh fruits or vegetables. It would also cut back on the economic opportunities for local produce farmers across the United States, who have come to count on the Double Up program for sales.

Median farm income is projected to be negative $1,316 in 2018

The far-reaching benefits of Double Up, combined with increased pressure by the federal government for states to cough up funding for such programs, are at the foundation of SB 1245, a new bill introduced by State Sen. Kate Brophy McGee (R).

If passed, SB 1245 would allocate $400,000 from the Arizona state general fund to be used as a match for Double Up Food Bucks. Udarbe and Christophel each say that federal grant applications will be more competitive if they can show a match from the state. “While match requirements aren’t new to USDA grants,” says Udarbe, it helps if applicants can show “evidence of buy-in and support from local leaders.”

And though SB 1245 was introduced before the unveiling of America’s Harvest Box by the USDA, it’s hard not to contrast the two strategies—they’re literally at opposite ends of the continuum. “I passionately, passionately believe in this bill,” said McGee during public hearing for the bill. “If we are going to be spending food stamp dollars, this is where we need to be spending them.”

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As a former vegetable farmer and SNAP recipient, I’ve been on both sides of the table—I actually qualified for SNAP when I was growing food for my community, a cruel irony replicated among the millions of food insecure food workers in America. Farmers are often low-income (in fact, median farm income is projected to be negative $1,316 in 2018), a fact that highlights the role of programs like Double Up in providing economic benefits for direct-market farmers.

“Funding for this program truly is the world to local farmers who sell directly at farmers markets in terms of being able to not only feed their families, but keep lights on and keep a roof over their heads,” says Udarbe.

This sentiment is echoed by Dave Brady, a vegetable producer from Pinal County in Arizona, who testified in support of SB 1245. “I was basically at the point where farmers markets just weren’t working for me,” he says. “But the one thing that made sense to me was Double Up SNAP program. It just makes it possible for me to get my volumes up to a level that’s practical, that I can actual make a decent living at it.”

Because of Double Up, Brady has started experimenting with a box program for seniors in his community who are SNAP recipients. A far cry from America’s Harvest Box, Brady’s boxes are comprised of fresh fruits and vegetables and customized to meet the needs of the seniors.

“When seniors participate in Double Up, I can help them stretch their food dollars and supply them with enough locally grown produce for an entire month,” he says.

In the months ahead, votes by federal and state lawmakers may determine the future of the Double Up program—and the lives of the consumers and farmers like Brady who depend on it.