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Sue Lani Madsen: Title X news release technically accurate and cynically misleading

Sue Lani Madsen, an architect and rancher, writes a weekly column. (Jesse Tinsley / The Spokesman-Review)
Sue Lani Madsen, an architect and rancher, writes a weekly column. (Jesse Tinsley / The Spokesman-Review)

“Unless overturned, this flawed decision will hurt Washington women, especially low-income women in rural Washington,” read the news release from Attorney General Bob Ferguson.

Pairing low-income and rural is classic fearmongering, a tactic used by both sides on hot political topics. It creates a mental picture of redneck poverty and remoteness intended to garner sympathy. And it’s almost always misleading.

Ferguson was referring to the recent decision by a three-judge panel of the 9th Circuit U.S. Court of Appeals upholding a federal rule prohibiting health care clinics funded with Title X federal dollars from making referrals to clinics that are not full-service primary care providers. Most health care clinics meeting that description are operated by Planned Parenthood, and to no one’s surprise they sued.

It’s easy to be confused by the terms urban and rural because there are at least 15 federal definitions. Each Cabinet department, agencies within a department and even programs within the same agency may use different criteria. Some individual federal programs allow overruling objective metrics with local knowledge about conditions affecting access to whatever services or problems the program is addressing.

For the U.S. Census Bureau, anything that’s not urban is rural. That generalization sweeps dense but unincorporated suburban areas into rural classifications and grossly overcounts the rural population. On the other hand, the Office of Management and Budget counts an entire county as urban if it has at least one citified area with a population of at least 50,000. Among the more absurd results, the Grand Canyon is counted as an urban area.

The U.S. Health Resources and Services Administration has more specific criteria for health care programs, administered by the Federal Office of Rural Health Policy. They rely on a system of Rural-Urban Commuting Area (RUCA) codes, attempting to balance the overcounts and undercounts of other agencies.

The diversity of definitions of rural allows any statement citing the impact on rural areas to simultaneously be technically accurate and cynically misleading. Emphasizing “rural” is a common Planned Parenthood talking point, implying they’re the only health care provider available to women in rural communities even if they are not full-service providers.

But how true is it? Planned Parenthood operates 33 clinics in Washington. Eight of the 33 are located in small-town ZIP codes recognized as rural by the RUCA rating system. Seven of the eight (Centralia, Ellensburg, Moses Lake, Port Angeles, Pullman, Shelton and Sunnyside) barely meet the criteria for rural, scoring either 4 or 4.1 out of 10 points possible. 4 is the cutoff for rural program eligibility. The eighth rural Planned Parenthood clinic is located in Friday Harbor, which scores a 10 with its very small population and ferry-dependent island isolation. All eight of the rural towns with a Planned Parenthood clinic also have a hospital with primary care providers available to all residents.

Planned Parenthood serves less than 3% of the 281 ZIP codes in Washington classified as rural, and less than 2% of the total general population. They’re not a big player in the state in rural health care. Yet the talking point persists because it begs for sympathy.

The most critical of female specific health care services is the one most lacking in rural areas. The exorbitant cost of medical malpractice insurance for family practice physicians has pushed the majority of rural critical-access hospitals out of the baby business. A physician cannot provide prenatal care without a hospital for the delivery. Lack of prenatal care makes it difficult to recruit young couples planning a family to rural jobs, inhibiting economic growth.

What rural Washington needs is support for comprehensive, full-service health care. It’s particularly critical for the low-income women in rural Washington whom Ferguson purports to be concerned about, the women who can’t afford time off work and the cost of travel for regular prenatal care an hour or more away. Tangible support for couples planning families would be a better place to focus attention than suing over rules described by the appeals court as “reasonable.”

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