May 2, 2025
Dear Interested Readers,
The First 100 Days of a Bad Dream
I apologize for the excessive attention I have given to the blatant dangers ahead inherent in our reckless president’s personality disorder and destructive ambitions. His policies threaten the nation’s health, and although we have endured the first 103 days, there are still about 1357 days of rolling risk and damage to endure. Who knows what our system of healthcare and our once enviable medical research community will look like come January 21, 2029?
In further defense of my fixation on the inadequacies and the possibly unlawful behavior of the president is the question, “What is more appropriate for a letter entitled ‘Healthcare Musings’ than a continuing effort to remind us of the losses we are currently suffering, the damage yet to be done, and the need to work to find ways to mitigate the damage to the social determinants of health that occurs with each new executive order that moves us closer to an autocracy or perhaps more accurately a kleptocracy?”
On Wednesday, the New York Times columnist Jamelle Bouie published a comparison between the first 100 days of President Trump and President Roosevelt entitled The New Deal Is a Stinging Rebuke to Trump and Trumpism. One difference that Boule did not mention is that Roosevelt got Congress to pass fifteen laws to begin to lift the country out of a terrible economic depression, and Trump has signed no significant laws. Trump has set a record with 142 executive orders.
There were dramatic differences between the real problems that faced Roosevelt and the imagined “threats” that Trump has inflated as justification for many of his actions. Boule uses the last few paragraphs to put our current situation into perspective and offer us a continuing warning wrapped in a little hope. Ironically, Trump’s chaotic methods and the incompetence of his bootlicking underlings are the sources of our greatest hope. Boule writes:
Roosevelt could orchestrate the transformative program of his 100 days because he tied his plan to American government as it existed, even as he worked to remake it. Trump has pursued his by treating the American government as he wants it to be. It is very difficult to close the gap between those two things, and it will become all the more difficult as the bottom falls out of Trump’s standing with the public.
Do not take this as succor. Do not think it means that the United States is in the clear. American democracy is still as fragile and as vulnerable as it has ever been, and Trump is still motivated to make his vision a reality. He may even lash out as it becomes clear that he has lost whatever initiative he had to begin with. This makes his first 100 days less a triumph for him than a warning to the rest of us. The unthinkable, an American dictatorship, is possible.
But Trump may not have the skills to effect the permanent transformation of his despotic dreams. Despite the chaos of the moment, it is possible that freedom-loving Americans have gotten the luck of the draw. Our most serious would-be tyrant is also among our least capable presidents, and he has surrounded himself with people as fundamentally flawed as he is.
On Inauguration Day, Donald Trump seemed to be on top of the world. One hundred days later, he’s all but a lame duck. He can rage and he can bluster — and he will do a lot more damage — but the fact of the matter is that he can be beaten. Now the task is to deliver him his defeat.
As the next 1357 days roll by, I will continue to speculate on the damage that is being done to American healthcare. Our healthcare, like our democracy, was not perfect before Trump. We have been a work in progress for the last 250 years. Real progress toward the realization of a better society and a healthier nation has been made since Roosevelt’s first one hundred days, but real problems persist, and some were even getting worse before Trump, Musk, and Robert Kennedy took a chainsaw to medical research. One example of an area where we had been losing ground before Trump and where things could get much worse fast, as his attacks on federal agencies and programs continue, is our system of care in rural and small-town America. Ironically, many of these at-risk Americans are MAGA enthusiasts. How weird is that?
The Challenges That Face Rural Health and Plausible Solutions
No aspect of care delivery has been more challenged than the care of Americans, especially women and children, who live in small-town/ rural America. One of the major downsides of fee-for-service payment mechanisms in commercial insurance, Medicare, and Medicaid is damage done to low-volume but critical services in rural environments. I became more aware of these challenges in 2011 when I joined the board of Guthrie Health, which provides care to the rural and small-town residents of north central Pennsylvania and south central New York.
My experience with the healthcare issues of rural and small-town Americans became even more personal and focused when my wife and I moved full-time to a small town in rural New Hampshire in late 2014. Part of our decision process when choosing the location of our retirement home was our desire to be close to essential services, including a hospital. We now live about a mile from New London Hospital, a “critical access hospital,” that is, part of the Dartmouth Health network.
Fortunately for us, we won’t be having more children because the New London Hospital, like many other rural/ small-town hospitals, closed its OB and pediatric services for financial reasons in 2002. If we needed Ob or pediatric services, they are available 30 miles to the north or 30 miles to the south. Those distances become functionally much greater, and travel times get much longer in bad weather.
The impact of the closure of OB and pediatric services in rural America has been huge. It may surprise you to learn that twenty percent of Americans (over 65 million) live in rural and small-town America. As you might know, a larger percentage of the people in rural and small-town America than in urban environments are served by government programs like Medicare, Medicaid, fuel and food supports, and many of these areas are in “red states” of the Midwest and South. Suffice it to say, rural and small-town America is older, poorer, and more vulnerable than urban and suburban America. Ironically, because every state, no matter how small or poorly populated, gets two senators, which gives them filibuster power in the Senate, these poorer and less populated areas have a disproportionate influence on political processes, including the electoral college and the election of the president.
Against that background, I was quite surprised last Saturday to find an article on the front page of The Boston Globe about the problems of timely access to obstetric care in New Hampshire. The article had a long title, “As N.H. maternity units close, care can be hard to get to: Since 2002, nearly half of New Hampshire hospitals have closed their labor and delivery units, forcing some women in labor to travel more than a hour to give birth,” and was written by Amanda Gokee, a Globe staff writer.
The story contains the experience of several mothers who were forced to deliver at home or on the highway, because of the great distance to a hospital with a delivery service. Several solutions to this problem are being tried, including well-trained midlevel clinicians and better training for emergency personnel. After a couple of stories about women who were impacted by a lack of timely care, she writes:
Since 2002, 11 of the 26 labor and delivery units in the state have closed, creating what the state has deemed “maternity deserts’’ in parts of rural New Hampshire. To help fill the gaps, the state is training emergency first responders who say they are increasingly coming to the aid of women in labor.
“This is a service that people desperately need, that people will literally die if they don’t have,’’ said Daisy J. Goodman, a nurse-midwife at Dartmouth Health who works with the North Country Maternity Network, a group that seeks to create and support maternal health infrastructure in northern New Hampshire.
So what created this problem?
Many of the hospitals that have closed their labor and delivery units faced financial pressure to do so, according to the latest report from the New Hampshire Department of Health and Human Services. The units can be expensive to maintain, requiring costly malpractice insurance, 24-hour staffing, and specialists, such as someone who can provide a C-section.
The units that closed had fewer births and more mothers who were insured by Medicaid, which traditionally doesn’t reimburse as well as private insurance, Goodman said.
New London Hospital had been operating at a loss for three years when it closed its birthing unit as a way to control costs, a hospital spokesperson told the Concord Monitor in 2002. In 2008, when Weeks Memorial Hospital in Lancaster closed its birthing unit, it pointed to escalating costs and fewer births, something the state’s report also said was driving the closures of labor and delivery units.
Ah, yes! Finance, specifically fee-for-service finance, was a driving factor in the closure of maternity, pediatrics, and mental health services. Ironically, my local hospital has a thriving orthopedic practice. In small-town America, we fix knees and hips, but we don’t deliver babies. It is a complex problem. Ms. Gokee gives us some data:
Statewide, the birth rate has declined 33 percent, dropping from 12.67 births per 1,000 people in 1995 to 8.51 per 1,000 people in 2023, the latest data available. In the state’s most-populous county, Hillsborough, the rate is still at 10 births per 1,000, while it’s the lowest in more-rural parts of the state like Carroll County, where the rate has dipped to 6.6 births per 1,000.
Before the closures, about 7 percent of the state’s population lived more than half an hour away from a hospital with labor and delivery services; now, about 19 percent do, according to Sanam Roder-DeWan, a primary care physician at Dartmouth Health who works with the North Country Maternity Network.
Nationally, a typical drive to the nearest hospital takes about 16 minutes, according to the March of Dimes. After eight New Hampshire maternity wards closed, the median driving time in New Hampshire doubled, rising from 18 minutes to 39, a 2021 report from the Urban Institute found.
In northern New Hampshire, it can take up to two hours to make the drive to the nearest hospital with an OB service. That’s in good weather.
…for about 14,000 people, the drive to the nearest hospital with such services is over an hour. For people who live in Pittsburg, N.H., it can take nearly two hours to drive to Littleton, N.H., where there is a hospital with a labor and delivery unit.
“If you’re in labor, that’s a huge distance,’’ said Goodman. “In the winter, it’s an almost insurmountable distance. It’s life-threatening to drive in a car in certain kinds of snowstorms up there.’’
After a few more horror stories, Ms. Gokee expands the scope of her examination to neighboring states.
Neighboring states are seeing access to maternal care diminish, too. In Maine, 42 percent of community hospitals have closed their birthing units because of financial challenges… Essex County in Vermont has been designated a maternal health desert by the March of Dimes, a nonprofit that works on maternal health. The county has no birthing hospitals, birth centers, or obstetric providers…
…The farther people have to travel for care, the less likely they are to receive the recommended number of prenatal care visits, and the more likely they are to give birth enroute to the hospital or to have an unplanned home birth, the most recent report from the New Hampshire Department of Health and Human Services found…
After some more stories,
Giving birth in an unintended location can come with increased risk, particularly if there are unforeseen complications…
…the closures are a devastating loss for the communities that are left behind…the longer a hospital has been closed, the harder it is to bring care back to the community after the workforce has moved away.
Is it a problem with no practical solution, or should we look at it through a different lens? We build highways, string electrical lines, and even try to provide high-speed Internet service to rural America. Could we do better if we changed the finance system to better support the care of the population? Finance alone is not the only problem. We would need to recruit, train, and financially incentivize clinicians who are willing to work in rural environments. The problems are complex, so I decided to ask my “bot thought buddy” at ChatGPT for its/her/his opinion. I asked:
Please discuss the impact of fee-for-service financing on ob-gyn, pediatric, and other medical services in rural areas of America.
[The bot gave me a much broader and more detailed analysis than I expected.]
ChatGPT said:
Sure — let’s dig into this carefully:
The Impact of Fee-for-Service Financing on OB-GYN, Pediatric, and Other Medical Services in Rural America
The fee-for-service (FFS) model — where providers are paid for each individual service or procedure — has long shaped American healthcare. In rural areas, though, it creates a unique set of challenges, especially for critical fields like obstetrics-gynecology (OB-GYN), pediatrics, and primary care.
Here’s how:
- Economic Instability for Providers
- Volume-Driven Income: FFS relies on patient volume to generate income. Rural areas simply don’t have the patient numbers to sustain steady, predictable revenue for many practices, especially specialties like OB-GYN and pediatrics.
- Low Birth Rates: In rural counties, fewer births mean it’s financially difficult for hospitals to maintain labor and delivery units under a FFS structure. As a result, more than 50% of rural counties no longer have hospital-based OB services.
- Pediatric Practice Challenges: Children tend to have fewer complex health needs than adults. Under FFS, pediatricians in rural areas may have even lower billing totals, making it hard to keep practices afloat.
- Service Consolidation and Closures
- OB Unit Closures: The economics have forced many small hospitals to shut down their OB units, pushing rural women to drive hours for prenatal and delivery care — sometimes with tragic outcomes in emergencies.
- Pediatrics Merging into Family Medicine: In many rural communities, there are no standalone pediatricians anymore. Family physicians have absorbed much of the child health care, often stretching their already broad practices even thinner.
- Outmigration: Specialist shortages push families to travel to larger towns or cities for routine pediatric, prenatal, and gynecologic care, increasing costs and health risks.
- Poorer Health Outcomes
- Delayed or No Care: When services aren’t locally available, people delay seeking care. This leads to higher rates of premature births, unmanaged chronic illnesses in children, and worsening maternal health outcomes.
- Emergency Overreliance: With no local OB or pediatric coverage, rural ERs are often left handling complicated cases they aren’t equipped for — especially risky for obstetric emergencies.
- Provider Burnout and Workforce Shortages
- Undercompensation: Rural providers under FFS get paid less for doing essential but low-volume work. They often spend longer on social determinants issues, patient education, and coordination — none of which are adequately reimbursed.
- Workforce Drain: Newly trained OB-GYNs, pediatricians, and even family physicians face student debt loads that discourage them from working in low-volume, underpaying rural areas.
So, what’s being tried to fix this?
- Global Budgets: Some rural hospitals are experimenting with lump-sum funding instead of billing per service (e.g., the Pennsylvania Rural Health Model).
- Value-Based Care: Payment systems are starting to reward quality and outcomes rather than quantity — like perinatal bundles that pay providers to ensure healthy pregnancies overall, not just each visit.
- Subsidies and Incentives: Federal and state programs are offering loan repayment, housing, and bonus incentives to encourage providers to work in rural settings.
- Telemedicine: Especially post-COVID, remote care options are being expanded for prenatal checkups and pediatric visits to make care accessible without overwhelming rural systems.
Summary
Fee-for-service financing has amplified the struggles of rural healthcare delivery by favoring high-volume, procedure-heavy, urban settings. For rural OB-GYNs, pediatricians, and other providers, it means fewer services, declining health outcomes, greater travel burdens for patients, and increasing financial instability for providers.
Transitioning to funding models that emphasize population health, stability, and access over raw service volume is critical if rural healthcare is going to survive — and thrive — over the next decade.
That was a much-appreciated analysis, and then came another surprise. The Bot wanted to do more for me. It asked:
Would you like me to also create a short table summarizing solutions rural systems are trying, or show how different payment models could better support rural healthcare? It might be a helpful quick reference!
I said yes!
ChatGPT said:
Here’s a quick reference table summarizing the problems with fee-for-service in rural healthcare and the solutions currently being explored:
| Challenge | Impact | Emerging Solutions |
| Low patient volumes | Financial instability for OB-GYNs, pediatricians, hospitals | Global Budgets: Fixed annual payments to rural hospitals regardless of volume (e.g., Pennsylvania Rural Health Model) |
| Closure of OB units and pediatric services | Longer travel times, higher risks during emergencies | Regional Networks: Coordinating prenatal and pediatric care across multiple counties to share resources |
| Delayed or skipped care | Worse maternal, child, and chronic disease outcomes | Telehealth Expansion: Remote prenatal care, pediatric visits, mental health services |
| Provider burnout and exodus | Fewer rural doctors, overwhelmed remaining providers | Incentive Programs: Loan forgiveness, higher rural pay rates, housing and relocation assistance |
| Underfunding of preventive care | Missed opportunities to lower long-term costs | Value-Based Payment Models: Rewards for outcomes like healthy pregnancies, timely vaccinations, chronic disease management |
| Difficulty attracting young physicians | Workforce shortages deepen over time | Rural Training Tracks: Medical education programs based in rural hospitals and clinics to “grow their own” future providers |
Quick Key Terms:
- Global Budgets: Hospitals get one lump-sum payment per year to provide care, promoting stability.
- Value-Based Care: Payments tied to patient health outcomes, not number of procedures.
- Telemedicine: Virtual care that reduces the burden of travel for rural patients.
- Workforce Incentives: Financial and lifestyle support to encourage rural practice.
That was great, and the surprises kept coming! My Bot buddy next asked:
Would you also like a short “future forecast” — what rural healthcare might look like by 2030 if these solutions catch on more widely? It could give you a big-picture view!
Once again, I said “yes” even though I seriously doubted, based on its current actions, that the Trump administration would ever focus on improving the care received by its supporters in rural America.
ChatGPT said:
Here’s a future forecast for rural healthcare by 2030 if the emerging solutions to today’s problems are widely implemented:
Rural Healthcare 2030: A Big-Picture Forecast
| Area | What Could Change by 2030 |
| Hospital Funding | Rural hospitals operate under global budgets. Financial stability improves, reducing closures and keeping core services like labor and delivery open. |
| Primary and Specialty Care Access | Expanded telehealth connects patients with OB-GYNs, pediatricians, and mental health providers without long travel. Some routine visits (like prenatal check-ins) happen via video. |
| OB-GYN and Maternity Services | Fewer OB unit closures thanks to bundled payments and regional maternity care models. “Perinatal hubs” allow coordinated prenatal, delivery, and postpartum care across multiple small communities. |
| Pediatric Care | Family medicine providers team up with regional pediatricians through teleconsults. More mobile clinics and school-based health centers provide routine child health services locally. |
| Workforce Stability | Loan repayment, better pay, flexible scheduling, and professional support attract young doctors and nurse practitioners into rural health careers. Local training programs (“grow your own”) become common. |
| Health Outcomes | Improved maternal mortality rates, better early childhood vaccination rates, and better chronic disease control among adults. Gaps between rural and urban health outcomes start to narrow. |
| Community Health Focus | Broader integration of social determinants of health (like housing, nutrition, and transportation) into rural healthcare, funded partly through value-based care models. |
| Emergency and Specialty Care | Stronger regional partnerships ensure rural patients can quickly transfer to higher-level care when needed — but basic urgent and emergency services remain available locally. |
The Bot then spontaneously predicted what would happen if things just drift along as they have been.
If Solutions Aren’t Implemented?
- Continued hospital closures, especially OB services.
- Worsening workforce shortages.
- Higher maternal and infant mortality in rural areas.
- Greater reliance on emergency departments for basic care.
- Deepening health inequities between urban and rural America.
It was as if I had opened Pandora’s box. The Bot would not quit. It continued without asking for permission.
Key Drivers to Watch Between 2025-2030
- Federal and state funding reforms (especially how Medicare/Medicaid pay rural hospitals).
- Adoption of telehealth infrastructure and broadband expansion.
- Success of rural medical education programs and incentive models.
- Public-private partnerships to sustain critical access hospitals and community clinics.
Bottom line:
➡️ If reforms like global budgets, telehealth expansion, and rural workforce incentives succeed, rural America could see a resilient, locally-driven, more equitable healthcare system by 2030.
➡️ If not, the rural healthcare crisis will likely deepen, with serious human and economic costs.
Would you like me to also sketch out a simple 5-point action plan rural communities could start working on right now to help drive toward the better 2030 scenario? It could be useful if you’re thinking about solutions from a local or policy perspective! ✅
The Bot was on a roll. It wanted to do more. Why would I say “no.”
ChatGPT said:
Here’s a simple 5-point action plan that rural communities, healthcare leaders, and policymakers could start working on right now to help push toward a stronger, more sustainable rural healthcare system by 2030:
5-Point Rural Healthcare Action Plan (2025-2030)
| Action Step | Goal | Example Activities |
| 1. Advocate for Stable Hospital Funding (Global Budgets) | Secure predictable funding to keep hospitals open and protect key services like OB and ER care. | – Push state Medicaid agencies and federal lawmakers to pilot or expand rural global budget models.
– Build alliances with hospital associations and patient groups. |
| 2. Invest in Telehealth and Broadband Expansion | Bring specialty care and preventive services into rural homes and clinics. | – Apply for federal rural broadband grants.
– Equip clinics and schools with telehealth technology. – Train providers and patients on telehealth tools. |
| 3. Grow the Rural Healthcare Workforce Locally | Build a pipeline of doctors, nurses, and other health professionals who are committed to staying. | – Develop partnerships with medical schools to create rural training tracks.
– Launch local scholarship and loan forgiveness programs tied to rural service. |
| 4. Address Social Determinants of Health Upfront | Prevent illness and reduce system strain by improving food security, housing, transportation, and education. | – Create rural community health coalitions.
– Partner with nonprofits to expand food banks, housing programs, and mobile health outreach. – Advocate for transportation services to medical appointments. |
| 5. Strengthen Regional Care Coordination | Make it easier for patients to navigate care across distances and facilities. | – Build regional networks that link local clinics, telehealth hubs, and higher-level hospitals.
– Create shared patient records and care transition teams. – Fund mobile clinics and rotating specialists. |
Without asking permission, or just to ice the cake, the Bot launched into coaching:
Pro Tip for Rural Leaders:
Success usually depends on strong local leadership — hospital CEOs, county health officers, school superintendents, local governments, and patient advocates teaming up to present a unified front when applying for grants, lobbying for policy changes, or building new programs.
If communities start now, by 2030 they could:
- Cut maternal deaths and infant mortality.
- Keep small hospitals alive and thriving.
- Improve life expectancy.
- Grow a rural healthcare workforce that sticks around.
- Rebuild trust in rural health systems.
The generosity of the Bot continued, but its advice was becoming redundant, so I will keep the rest of the conversation for another day, perhaps. The Bot was persistent. It asked if I wanted it to create a story about a small town that decided to solve its healthcare access problems. It then offered to extract learnings from its example and then create a poster that told the story. The work was impressive, but didn’t add any new ideas. This exercise had to end at some time.
My takeaways from the experience were that the Bot is getting more articulate, and perhaps there is reason to worry that it won’t be long before AI takes over. At the moment, if I had to choose the Bot or Trump as the source of healthcare policy, I think that I would pick the Bot. I did not ask the Bot what Trump should have done for the health of the nation during his first 100 days. Perhaps that was a missed opportunity.
This morning, after I “finished” this letter, I made my breakfast and sat down to read the New York Times while I enjoyed my own cooking. I am a man who enjoys a routine that varies little from day to day. I usually begin my reading with the Opinion section of the paper. More than once, what I find after “finishing” the letter is a piece that i wish I had read and included in my message to you. It happened again today. The first thing I saw was a “guest essay” entitled “What Medicaid Cuts Would Do to My Rural Hospital,” written by the CEO of a small Colorado hospital, Kevin Stansbury. Mr. Stanbury’s hospital sits on Interstate 70. It is 80 miles from the next hospital. His piece talks about the vulnerability of obstetric and pediatric care to expected cuts in Medicaid. He also points out that with these cuts, the hospital may be forced to close. Trauma care for travelers involved in accidents on the Interstate is also at risk.
The need for emergency trauma care in rural areas is something I can understand from personal experience. In 1952, my favorite uncle and his family were traveling from their home in Southern California to visit us in Oklahoma. They were crossing the desert at night because, in those days, cars were not usually air-conditioned. They had a flat tire near the Arizona and New Mexico line. While my uncle was changing the tire, they were hit by a big truck. Its driver had fallen asleep. The nearest hospital was 70 miles away. My aunt died in the ambulance that eventually came. My uncle did recover after a long hospital stay. I tell you the story to underline the fact that even though you may live in a city with multiple academic health systems, there could come a day when you, too, might be a victim of the consequences of our failure to adequately support our rural and small-town hospitals. I urge you to read the article.
The Spring Flowers Are Coming In
My signal that Spring is here is the appearance of the yellow blooms of forsythia bushes all over town and the red buds on the maple trees that ring the lake. After the yellow forsythia buds and the red buds on the maples pass in a few days, they will be replaced by greenery. It amazes me that for some plants the flowers come first, for many others like the Rose of Sharon, the flowers won’t come until mid or late summer.
A few years ago my wife had a “Star Magnolia” planted as part of a visual blind for our hot tub and outdoor shower. The Star Magnolia, like forsythia, flowers first, and adds its leaves later. Today’s header shows the little magnolia. The buds are out, but I fear they won’t last long. The flowers on the bush do convince me that with each passing day Spring is a little more certain.
I hope that Spring is well underway wherever you are!
Be well,
Gene
