The state of the State

By ANGIE WATSON

Pregnant women in Metropolis, Harrisburg, Eldorado and Cairo can expect a 50- to 80-mile drive to the nearest obstetrician for prenatal care. They can expect to repeat the long drive when they are ready to deliver because local emergency room physicians will not deliver babies. If they are poor, they may not have transportation to get regular prenatal care.

Rep. David Phelps (D-118, Eldorado), who represents these women in a district that sprawls through all or part of 10 counties at the southern tip of Illinois, is one of several legislators grappling with this shortage of obstetricians. Eighteen counties in southern Illinois lack obstetricians. Phelps' district includes eight of those; it also has two fewer hospitals than four years ago.

Progress in gaining legislative support for rural health needs has been slow. But Phelps and other downstate legislators say that the impetus of reports from the Chicago and Cook County Health Summit and the Lt. Governor's Rural Health Task Force offers an opportunity to forge a statewide health initiative.

Rural health care proponents think the time is right for change. "I think we might be closer than we've ever been," said Al Grant, director of the Center for Rural Health at the Illinois Department of Public Health (IDPH). "There is a focus now on the rural. We need to capture that and make changes.'' The IDPH has designated 67 of the 102 counties in Illinois as rural. About half of them are considered federal health manpower shortage areas, meaning they have a doctor-to-patient ratio of 1 -to-3,500 or 1-to-3,000 if the infant mortality rate is at least 20 deaths per 1,000 live births or at least 20 percent of the population has an income at or below the poverty level.

The Rural Health Task Force report released April 9 recommends 40 steps to address rural problems. The report's top four recommendations urge:

• An unspecified cap on damages in malpractice suits for noneconomic damages such as pain and suffering. High awards drive rising malpractice insurance costs, critics say. (Costly malpractice insurance has caused many hospitals and obstetricians to stop delivering babies.)

• Four community-based demonstration projects which could take the form of building community health centers and training clinic lab technicians and emergency medical technicians for unserved areas. The estimated cost is $100,000 per project.

• Increased use of a federal program. The Rural Health Clinic Act, that offers higher reimbursements to clinics from Medicaid for treatment for the poor and from Medicare for treatment for the elderly. These clinics could use nurse practitioners and physician assistants at least half of the time the clinic is open.

• Expanded scholarships to health professionals other than doctors to encourage them to serve in rural areas. Presently, most state and federal assistance is targeted at helping young physicians pay tuition in exchange for service in rural areas.

The task force offered no recommendations on ambulance services for underserved regions or alternatives to counter obstetric shortages. Nola Gramm, a member of the task force representing the Illinois Farm Bureau, said that members felt those issues needed more study and that the topics are very much "alive."

The start-up costs for some of the suggestions are modest because they use facilities and programs already in place. In the long run, rural areas may need state help to subsidize clinic operations or physician

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malpractice insurance, said Ray Robertson, assistant dean for regional medical programs at Southern Illlinois University School of Medicine in Springfield. He quickly points out that this would not be a "bail out" for rural areas.

Finding state funds for rural health needs will not be easy, but Phelps said that combining Cook County and rural interests into a statewide health care plan would justify money from general revenue funds. The parallels between Cook County and rural areas are striking:

• Both suffer from a lack of prenatal and postnatal health services.

• Both have underserved areas that would benefit from scholarships to attract health professionals.

• Both lack accessible primary health care provided by general practioners, obstetricians and mental health specialists.

Yet, a wish list is all that Cook County and rural Illinois have right now. It is up to the legislature to provide the leadership to carry out the recommendations, but key to any program's success is local involvement. Health care professionals may provide ideas, but people are more likely to use local health services if they plan those services, according to Gramm.

Local support for community health services has not been strong in some rural areas because many believe that bigger is better. The Illinois Farm Bureau surveyed 6,000 families in rural counties and found that 81 percent went outside their communities for health care. Forty-two percent said they traveled up to 80 miles to use what they perceived were better services than those available locally. Robertson said changing a community's perception of its local health services will fall to community leaders. "The community leadership must get behind it," he said. "That's what nobody can do from Springfield or Chicago."

What lawmakers can do in Springfield is try to fuse rural and Cook County efforts to improve health care. Gov. James R. Thompson decreed in his state of the state address that he would accept nothing less:

"This Governor represents the whole state. He's not committing dollar one of state dollars to any health care delivery system in Cook County — however good, however needed — until we take care of the health care delivery needs of the whole state of Illinois from Chicago to Southern Illinois and everything in between. "

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