Rural areas across America have missed the population and economic gains of the cities and suburbs. The average age in Appalachia has gone up, a result of young people leaving for work or a different culture. They might boomerang back when they’re older and want to start a family, but few people flow into the region to replace them.
Persuading young people to return, and new people to visit and stay, depends on creating a stable culture and a viable economy. To move toward those goals, expanding health care access and attracting immigrants could improve the status quo if local and state leaders can recognize the opportunity.
Expanding health access can take several forms. One direct way is to make it easier for foreign doctors to move here who have the skills Appalachia needs. Doctors who focus on lung and respiratory care, for example, are sorely needed in coal country, as Sam Peak pointed out in Reason magazine. Coal mining, high smoking rates, and asbestos exposure from polluted waterways mean the region needs to bring in more lung doctors. If Congress removed barriers to foreign doctors coming to the region and fast-tracked their visa applications in exchange for working in medically underserved areas, the people of Appalachia could see their health improve and gain some economic growth, and their youth could have more chances to work in health care.
For locals who already have medical experience, loosening restrictions to make it easier for them to work could also be a solution. With a national shortage of primary care doctors, some states have favored deregulation so nurse practitioners and physician assistants can work without needing doctoral oversight, but Appalachia lags behind the country in letting them work independently.
While Western states and New England allow NPs “full practice” latitude, where they don’t need to be overseen by a primary care doctor, only Maryland does so among Appalachian states. Those restrictions make it harder for remote health care to expand access to rural areas and for smaller, cheaper health care facilities to open.
While NPs and PAs cannot do everything a doctor can, making it easier for them to practice has great potential.
The lack of health-care facilities and weak economic growth in rural Appalachia also make health insurance markets more complicated. As the Daily Yonder reported, rural counties with fewer insurers before the Affordable Care Act passed also had fewer individual policies bought from the federal government’s health-insurance market. Policies that use market incentives to improve health care outcomes, then, might not affect rural areas very much. There’s not much of a market in the first place to change.
There are heavy costs if local and state politicians don’t take the lack of doctors and health care workers in Appalachia seriously. The opioid crisis has cost the United States at least $130 billion since 1999, according to a study out of Penn State University. From health care costs to criminal justice costs, the researchers estimate an ongoing yearly tab of at least $6 billion. That figure doesn’t include the 400,000 people who have died nationally from an opioid drug overdose since 1999. The effect of those lives lost and money spent has hit Appalachia harder than most regions, and may be exacerbating long-term rural decline.
One concern, though, is that locals and politicians might hope for a return to a fictional “golden age” of the past when towns were growing and everyone could find a job. The United States faces a crisis in rural America: Using data from the U.S. Commerce Department, Iowa State University economics professor David Swenson predicts that most rural areas will decline. Not every town or county can be “saved.” Accepting reality is important so local leaders focus on how to create positive change.
The heyday of many parts of Appalachia, however, is instructive. It was a time when many migrants, either from the American South or from southern and eastern Europe came to the region. Attracting more immigrants could reverse the population decline and spark economic growth. Cities outside the region such as Allentown, Pennsylvania and Dayton, Ohio have stopped their population and economic declines by attracting immigrants, for instance.
The economy shouldn’t dictate every aspect of life or political choice, but not every mining town or farm community can be restored to its peak. Propping up some declining industries can also cause problems of its own. As the Trump administration escalates its trade war with China and increases tariffs, farmers suffering from tariffs imposed by China have received billions of dollars in subsidies from the government. Tweaking the economy can have future, unintended consequences that undermine long-term stability for local economies.
That being said, many places could still thrive. Charles F. McElwee argued in City Journal that
Places like Greater Hazleton unquestionably need help. Opportunity, prosperity, and a healthy quality of life should extend beyond the confines of cities’ costly urban rentals and metro suburbs’ exurban townhouses. Perhaps the real problem isn’t declining mobility, but that the social and economic conditions of so many communities—the result, in part, of policy choices—force residents to consider leaving, even when they might prefer to stay.
The responsibility falls on local leaders and citizens to find a way to save their towns and communities. Political decisions, the changing economy, or fate determined by geography might have caused their decline, but locals know the place best and have the most riding on creating positive change. Some places, such as McDowell County, have tourist potential. Others can attract retirees and cater to older populations. What matters is bringing together employers, civic leaders, and people with a vested interest in tackling local problems. Then, they can figure out local priorities and build communities that keep promising young people around and attract new outsiders.
Anthony Hennen is a co-founder of expatalachians and managing editor at the James G. Martin Center for Academic Renewal in Raleigh, North Carolina.