SUCCESSFUL RURAL HEALTH PROGRAMS IN PERSISTENT POVERTY COUNTIES IN THE SOUTHEAST UNITED STATES By SUSAN WHEATLEY MORFIT A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY UNIVERSITY OF FLORIDA 2008 1 © 2008 Susan Wheatley Morfit 2 To my beloved Parents who watch over me, and to my husband who loves and nourishes me. 3 ACKNOWLEDGMENTS I thank Leslie Lieberman, my friend and mentor. She has been an inspiration to me since the moment I met her in 1990. We have worked together, laughed together, and cried together. Her enthusiasm and encouragement have been unwavering. Leslie offered me the opportunity and experience to work on collaborative interdisciplinary research projects, where applied anthropology came to life. Many others have guided and supported me through the process of the dissertation. Foremost, members of my committee have generously provided valuable insight and guidance. Dr. Michael Reid, professor at the College of Public Health at University of South Florida and the Office of Rural Health Policy staff were invaluable in aiding my understanding of the political process of health policy at the federal level. Dr. Robert Brehl, a global health systems expert and dear friend, listened when I was confused, offered editorial suggestions when my logic failed me, and championed my work when I needed it the most. Most of all, I thank my husband, Van. Ultimately, this dissertation is a product of my loving husband’s support, guidance, and encouragement. He has endured years of my graduate studies, absences while I was in the field, read all of the early drafts. And for the last stages of the dissertation, he has cooked, cleaned, and taken care of me so that I may finish my degree. And then there are my beloved Irish Wolfhounds . Brenainn, Cearbhall, and Campbell. 4 TABLE OF CONTENTS page ACKNOWLEDGMENTS ...............................................................................................................4 LIST OF TABLES .........................................................................................................................10 LIST OF FIGURES .......................................................................................................................13 ABSTRACT ...................................................................................................................................16 CHAPTER 1 OVERVIEW ...........................................................................................................................17 Introduction .............................................................................................................................17 Statement of the Problem ........................................................................................................17 Theoretical Framework ...........................................................................................................17 Methods ..................................................................................................................................22 Original Ethnographic Policy Project, 1993-1994: Successful Rural Health Programs in Persistent Poverty Counties in the Southeast United States ....................22 Contract research and the PLI research team ...........................................................23 Development of case studies ....................................................................................23 Fieldwork methods ...................................................................................................26 Dissolution of the research team ..............................................................................27 Supplemental Research on Migrant Farmworkers, 1994-1999 .......................................27 Migrant Farmworker Health Centers ...............................................................................27 Archival Research, 2002-2007 ........................................................................................29 Addendum Data, 2008 .....................................................................................................30 Case Study Organization ........................................................................................................30 2 THE RURAL SOUTH: A PROFILE DERIVED FROM FEDERAL POLICIES .................34 Introduction .............................................................................................................................34 Race and Ethnicity and U.S. Policy of Enumeration ..............................................................34 Sociodemographic and Socioeconomic Characteristics of the South .....................................39 Poverty .............................................................................................................................39 Per Capita Income ...........................................................................................................41 Unemployment Rates ......................................................................................................42 Educational Attainment ...................................................................................................42 Access to Health Insurance .............................................................................................43 Health Outcomes 2003-2005 ..................................................................................................44 Mortality Rates, all Causes ..............................................................................................44 Heart Disease Mortality Rates .........................................................................................44 Cancer Mortality Rates ....................................................................................................45 Cerebrovascular Mortality Rates .....................................................................................45 5 Suicide Rates ...................................................................................................................45 Diabetes Mortality Rates .................................................................................................46 3 FEDERAL POLICIES, EXECUTIVE AGENCIES, AND PROGRAMS .............................51 Introduction .............................................................................................................................51 National Forces and the Health Policy Process ......................................................................52 National Legislative Structure .........................................................................................52 Genesis of health initiatives: Illustration from the executive office ........................53 Changing the rules: special interest groups transmuting health care policy ............53 Participatory democracy and policy process ............................................................54 Transmuting health laws through the judicial system ..............................................56 Health Care Policy Implementation: The Department of Health and Human Services ........................................................................................................................57 United States Health Care Payment Structure ........................................................................57 National Policies, National Health Care Programs, and National Health Care Funding .......60 Center for Medicare and Medicaid Services ...................................................................60 Medicare ...................................................................................................................61 Medicaid ...................................................................................................................62 State Children’s Health Insurance Program (SCHIP) .....................................................63 Health Resources and Services Administration (HRSA) ................................................65 The Office of Rural Health Policy (ORHP) .............................................................65 Bureau of Primary Health Care (BPHC) ..................................................................67 Maternal and Child Health Bureau (MCHB) ...........................................................69 In Summary ............................................................................................................................71 4 BEBÉ SANO ..........................................................................................................................76 Introduction .............................................................................................................................76 Sociodemographic and Socioeconomic Indicators .................................................................78 Selected Catchment Area Sociodemographic Indicators, 1990 ......................................79 Selected Catchment Area Socioeconomic Indicators, 1990 ............................................80 Poverty rate ..............................................................................................................80 Per capita income .....................................................................................................81 Unemployment rate ..................................................................................................81 Educational