James E. Rohrer, Ph.D., Professor and Chair, Department of Health Services, Research and Management, Texas Tech University Health Sciences Center, Lubbock, Texas

What do rural communities want and need in regard to health policy? Sometimes we seem to be saying "poor me" quite a bit: infant mortality is high, teen pregnancy is a problem, we face an epidemic of pediatric diabetes, elderly people need access to specialists, we don't have enough primary care physicians, and our hospitals are in danger of bankruptcy-which could send the local economy into a tailspin. These are real problems in rural areas, but the question I have to ask is this: are we really in worse shape than the cities? Inner cities, even in rural regions, can claim many of the same problems that rural communities complain about. And frankly, more needy people are located in the cities, suggesting that they deserve a lot of assistance. In fact, many rural communities have good health statistics, despite shortages of medical resources and moderate economic development.

What then should we be asking for in regard to health policy? Let me offer a few ideas, just off the top of my head:

• Rural areas should be given the flexibility to combine governmental funding streams in ways that will meet local needs. For example, some people are on Medicaid, some are on Medicare, and some are on both. But rural beneficiaries don't make as many medical visits, partly because of the shortage of physicians. Why can't we use those savings to buy medications in bulk, thus making sure that those who need medicine receive it at no cost?
• Regulatory requirements often have been designed for large populations, but the rules should become flexible in under-served areas. For example, many communities are too small to support a physician, but since people still need medical care why not be flexible about who may prescribe and dispense medicine?
• Some rural communities are very poor and deserve just as much per capita assistance as poor urban communities. This includes money for housing, food, transportation, and education as well as health care.

Whether those specific suggestions are feasible is not the point. Rather, I would say that not all rural communities are in need of extra public assistance. Some could get by with regulatory relief. More importantly, I would ask that we demonstrate a lot of pride in our rural communities. If rural areas were not better places to live than the inner city, then a lot more rural people would move to town. Not everybody moves. Therefore, we do indeed have better quality of life and should be proud of it.

On the other hand, we may not want to brag about it too much. After all, if all the city people moved out into the country, they would spoil it for those who got there first.