IOLA, Kansas - Surrounded by corn fields and cattle, the people of southeast Kansas seem far from the Washington debate on reforming U.S. healthcare but many care deeply about the issue and hope that change can come.
For many of the 60 million people living in rural America, inadequate and unaffordable healthcare is an immediate and growing problem.
"Reform is a big deal here. We're on the edge," said Brian Wolfe, an Iola family doctor. Half his patients rely on government aid for the poor and elderly and some who need care don't seek it because they can't pay.
President Barack Obama hopes to get reform passed this year before congressional Democrats become embroiled in next year's midterm elections. He is pushing both houses of Congress to at least pass initial versions before the August recess.
Rural residents are heavily represented among the 46 million Americans lacking health insurance. Many are too poor to pay for a doctor's visit and too far from cities to reach emergency rooms and free clinics.
Additionally, rural resident are disproportionately losing jobs and insurance or their seeing benefits cut as employers fire workers and cut costs in the continuing recession.
When rural residents do seek care, many find long lines for a shrinking number of primary care physicians and specialists.
"The numbers of people struggling to get the kind of care they need is growing," said Dan Hawkins, senior vice president for the National Association of Community Health Centers, which operates 5,400 non-profit rural clinics serving more than nine million rural Americans with help from federal grants.
Such struggles are cited by Democrats and the White House as arguments for the massive overhaul of the $2.5 trillion healthcare industry. But the plan, which could cost $1 trillion in its first 10 years, has run into trouble.
Lawmakers are looking at both higher taxes and savings in the federal Medicare and Medicaid programs to finance the overhaul. The nonpartisan Congressional Budget Office says Congress has not yet found a way to pay for the plan.
One of the most controversial aspects of Obama's reform efforts is a "public option" government-run insurance program that would compete with private insurers and help provide benefits for the uninsured.
A study released on Tuesday by the Center for Rural Affairs argued that rural areas need a public option. People living in rural regions tend to be older. They suffer from more chronic health problems, but have less access to private employer-based insurance because so many are self-employed or work for small businesses.
"Rural people have much to gain from inclusion of a public health insurance plan option in health care reform legislation, possibly more than any other group in the nation," said Jon Bailey, director of analysis at the Center for Rural Affairs.
But many Republicans and some conservative Democrats say including a public option is too costly.
Fiscally conservative Democrats worry that higher taxes in the bill proposed by House Democrats will harm the economy. If these 50-70 Democrats ally with Republican opponents of the bill, it could scuttle the legislation.
In any case, the bills under consideration would not change the fact that rural areas simply do not have enough doctors. Critics say reform should focus more on increasing incentives for doctors to serve rural Americans.
"It does not do someone any good to have an insurance card when there is no medical professional to administer care," said Congressman Jerry Moran, a Kansas Republican.
NO DENTISTS OR HOSPITALS
Many small towns like Iola, with its population of 5,500, have no dentists or hospitals and only one or two doctors.
A government-supported community health center that operates five clinics in southeast Kansas for those who can't pay and don't have insurance has seen a dramatic jump in patients in the last two years. Some travel up to 100 miles for an appointment, said Krista Postai of the Community Health Center of Southeast Kansas.
The situation has worsened since December, when a nearby automotive supplier plant closed with the loss of 600 jobs.
"We're seeing people who have not seen a doctor in three, four and five years," Postai said. "We've seen people in end stages of cancer who have never been seen by a physician because they just keep putting it off."
Adding doctors should be a top priority for reform, along with a public option. "If people have an option maybe we'll see them sooner," she said.
In the former coal mining community of Frontenac, population 2,900, solo practitioner Dr. Michael Simmons argued for a different approach.
Simmons said offering financial incentives to doctors who cut costs and improve health outcomes for their patients was the most efficient way to improve the system.
"Healthcare reform needs to be developed in fashion that is beneficial for those providing services and those receiving services," Simmons said.
For 64-year-old Mary Black, who drives 30 miles to a community health clinic because she lacks insurance, the key elements of reform are more doctors, more access to affordable insurance and more government services for the poor.
"My kids and grandkids are going to be inheriting this system," said Black, who suffers from asthma. "I don't know what the answer is. I really don't. But I know we need help."
(Editing by Alan Elsner)