When Care Is an Hour Away: The Reality of Aging in Rural America

In this episode, Dr. Pooja A. Patel and Dr. Sydney Marshman delve into the critical issue of healthcare access in rural communities, emphasizing how geographical location significantly impacts the quality of care individuals receive as they age. They discuss the disparities in access to primary care, specialty services, and the challenges faced by families in rural areas when seeking medical attention. Dr. Marshman shares her experiences as an occupational therapist working with older adults in Iowa, highlighting the importance of home assessments and therapy services that cater to the unique needs of rural populations. The conversation also touches on the complexities of healthcare funding, the role of telehealth, and the implications of recent legislative changes on rural healthcare systems.

Key Takeaways

• Access to care is not equal across different regions.
• Rural residents often face significant travel distances for healthcare services.
• Engagement with local communities and legislators is crucial for improving healthcare access.

Chapters

• 00:00 Introduction to Rural Healthcare Access
• 01:50 Understanding the Disparities in Care
• 07:57 Challenges in Expanding Services
• 12:04 The Role of Data and Interoperability
• 20:02 Managed Care vs. Traditional Medicare
• 26:03 Rural Health Transformation Program
• 29:56 Impact of Medicaid Cuts on Rural Healthcare
• 35:04 The Importance of Telehealth
• 39:00 Call to Action: Community Engagement

Learn more

• About Sydney: https://www.linkedin.com/in/sydney-marshman/
• About Sydney's Company: Happy at Home Consulting
• CMS: Rural Health Transformation (RHT) Program 
• Iowa HHS: Iowa's RHT Plan 
• Talk of Iowa: What a $209M federal boost means for rural hospitals and what's still at risk in these communities

Transcript

Pooja A. Patel (00:00)
Where you live still determines how well you're allowed to or able to age. And we don't talk about it enough. My hot take this week, let's stop pretending that access to care is equal. How far is your primary care doctor? How far is your dentist, your pharmacy? How about your grocery store? If you live in a city, the five minute neighborhood is usually pretty real.

Anything you could possibly need or want can be found within five minutes, whether you're walking, taking public transportation, or driving. And if that's all you know, you have no idea how far some families drive just for lab work or a follow-up appointment, or unfortunately, just to be told that there's unfortunately nothing they can do.

Pooja A. Patel (00:40)
Welcome to the Aging Together podcast. I'm your host, Dr. Pooja Ashok Patel, a double board certified occupational therapist and gerontologist with additional certifications in dementia and fall prevention. This season, we are unfiltered.

In this podcast, I interview guests who are experts in their fields or caregivers who are sharing their lived experiences.

Pooja A. Patel (00:58)
We're kicking off the season tackling rural access issues and health and elder care. We're talking about what access to care actually means, especially for rural communities.

and we're questioning what families are expected to do when that access simply doesn't exist. To help us tackle this topic, I'm joined by Dr. Sydney Marshman, founder and occupational therapist with Happy at Home Consulting based in Des Moines, Iowa, servicing many rural towns and counties across Iowa. Happy at Home Consulting provides therapy at home to older adults with her team of physical, occupational, and speech therapists. In addition to traditional rehab services,

Sydney continues to increase access to home assessments throughout the state. Happy at Home Consulting presently provides the evidence-based programs HARP through collaboration with community partners. She works alongside builders and interior designers to craft beautiful functional spaces. Sydney is the president of the Iowa Occupational Therapy Association and advocates for accessible housing through her involvement with multiple state coalitions.

She received her Doctorate of Occupational Therapy from Drake University. And in her free time, Sydney enjoys spending time with her husband and lovely two little boys. Sydney, so glad to have you back on the show.

Sydney Marshman (02:12)
Thanks for having me, really excited to be here.

Pooja A. Patel (02:15)
What's your hot take? Let's start.

Sydney Marshman (02:16)
You know, I have been thinking about this for a while since you asked me to be here, and I was kind of feeling like an imposter late yesterday because I realized that I actually don't have lived experience living in a rural space. Isn't that hilarious? Like I was having. Yeah, I was just having this like, ⁓ I actually haven't ever lived in.

Pooja A. Patel (02:32)
I actually...

Sydney Marshman (02:40)
rural parts of Iowa. Like we have lived out, we've lived in a bedroom community, we've lived out like outside of town, but not necessarily in a spot or in a location that is similar to the people that I serve in rural Iowa, which is out there.

Pooja A. Patel (02:55)
Yeah, I think I was trying to think about if I have and I haven't really, except I had one when I was doing travel therapy my first year out of school. I was in one very rural town in Northern Texas where I couldn't find any housing nearby. So I was commuting from the farthest North Dallas I could up to this town.

Sydney Marshman (03:14)
Mm-hmm.

Pooja A. Patel (03:20)
which is now on the map apparently because of a reality TV show, but it's called Paris, Texas and I was driving an hour and 45 minutes each way to get there and back with no traffic, single lane roads because everything I passed along the way was like population 500, population 200, population 700 and so there was no like

Sydney Marshman (03:25)
Yes.

my gosh.

Mm-hmm.

Mm-hmm.

Pooja A. Patel (03:47)
hotels or Airbnbs or anything that I could find closer housing to. Although I did later find out that Paris itself is a fairly bigger town, when I first looked, I couldn't find anything. And so I think that's probably as rural as I got. And the hospital that I was at was a regional level four trauma center, which I didn't even know level fours existed because I had

Sydney Marshman (04:00)
Right?

Right.

Pooja A. Patel (04:12)
I've only worked at level ones and twos. And it was so interesting. mean, the, not even just like limited access, because like even a car accident had to be airlifted to the closest level two trauma, I want to say, which was like an airlift to, think it was Lubbock. ⁓ And so that's probably as close as I got to like being rural.

Sydney Marshman (04:29)
Yeah. Yep.

Mm-hmm. Yeah. It's wild. And I think, too, when you were talking about that you are a travel therapist there of, we pay our travel medical professionals very handsomely. And it's, yes, for that reason. And that it is hard to find housing. It's hard to convince people to come practice in rural parts of the country. There's a lot of hidden costs.

Pooja A. Patel (04:46)
for that reason.

Sydney Marshman (05:00)
in hiring medical professionals.

Pooja A. Patel (05:02)
Well, yeah, and I think that makes it that much harder than for people to even have access to different specialty providers or different ancillary services like we're often referred to because there's just not a supply of it.

Sydney Marshman (05:17)
Yeah, I mean, think specialty providers, when I think of specialty providers anyway, I think of the folks that you maybe see like once a year, just checking in, making sure everything's going okay, that sort of specialty provider. I don't consider people like an OB or an OB-GYN a specialty provider, but there are so many places in Iowa that don't have

consistent access to OB. So I think it's great question of who do they have access to? And that's typically going to be a primary care provider. And that person might even be a travel professional themselves. They could be there for a short time on only a short contract. They may have access to therapy.

They probably have access to nursing, public health. They have access to a lot of medical professionals, but it's not necessarily the specialty providers or anyone who's really specialized or home their skill in a specific area.

Pooja A. Patel (06:14)
How hard was it for you to be able to expand your services? Because you started out of Des Moines, right? That's where you started, but then you've slowly expanded it across a few different parts of the state.

Sydney Marshman (06:23)
Great. Yeah.

Yes, so we cover, we partner with an area agency on aging. So we cover their 17 county territory. That was a time conversation. I had been in talks with their team for a very long time, I wanna say years, before we were contracted and partnered with one another because it was always about the dollars and the finances of how do we make this work?

What funding stream can we use? How can we get people access? Because going out into rural parts of Iowa, I mean, it can take your whole day. It can take an entire day to see one person. And when we talk about these, again, specialty programs that are really fine-tuned to home modifications, to adaptive equipment, I could easily be driving three hours in one direction for one person.

Pooja A. Patel (07:02)
Yeah.

Yeah, and that's a lot. That just means you can't service as many people either, right? Because if it's taking you three hours to just get there and do an assessment or do whatever you need to do and then three hours back, realistically, you're only seeing one patient a day.

Sydney Marshman (07:33)
Yeah, I mean, I kind of want to negate that a little bit because I think there's a lot of room to expand of what does that look like? Because if we can really gather referrals in the same geographic area to then be seen by that specialist or by the OT or whoever it is, you can see a good number of people even with the constraint of travel time, of the additional cost of travel, all of those pieces.

But again, it means that the rest of the team, the rest of the staff need to be really diligent in how they are navigating their referrals and putting together that list, so to speak.

Pooja A. Patel (08:09)
And how hard is that? Is there like a buy-in process where you have to like essentially partner with maybe local primary care doctors or local, I know you mentioned the area agencies.

Sydney Marshman (08:21)
It's tricky, right? Like it's tricky to think about the folks who are on the front lines. Like I think about primary care providers. I think about the information referral specialists or information assistance specialists. I feel bad even asking to say, please consider this as a resource because they are drowning in requests, referrals, things to do.

I don't think that there's even enough brain power or time in the day to say, let me work on who for my patient caseload, who for my panel would be a good fit for this fall prevention program when you're seeing 20 people a day because the family medicine and internal medicine clinic closed. So now, you know what I mean? Like, it's just, it's overwhelming.

what we're asking our rural providers to do who live and work in these areas. So then to come in and say, also, would you see about how you could, you know, fill my program in addition to just navigating your day to day.

Pooja A. Patel (09:19)
Yeah. Do you feel like there's a role for them? I don't know, because then that just adds more to your plate as a small business to have like a person dedicated to then supporting that primary care provider channel potential referrals. You know what I mean? Like if you want to take the load off of them and take that on, but then you're having to hire somebody to be able to fill that.

gap need.

Sydney Marshman (09:44)
Right. So I think what we're the answer that you're really looking for is data and interoperability. So there is a realm in which when we talk about value based care and cost management of client care, I think that there is a realm to say if this person meets these three, four five data points that they are an automatic referral. Like I think there's a way to make that happen behind the scenes.

But there's a couple barriers to that, right? The barrier might be that it's not set up in their EMR. It might be an additional cost to be set up in their EMR. I've even heard of therapists not billing for the caregiver training code because it's not accessible in their EMR because they have to pay to get it added. They have to pay to get CPT code added to their EMR. That's just wild to me.

Pooja A. Patel (10:35)
Yeah.

Sydney Marshman (10:35)
But I think that there's a lot of behind the scenes work that can be done to fill out some of those and refer people into preventative programming, like a fall prevention program. But then once we've collected that data and we're making it more automated, how do we send those referrals within our HIPAA compliance space? And how do we then collect data to support the work that they're doing? So if they're being incentivized on...

reducing emergency room visits or reducing falls in the home or whatever it may be, how do we then support their data collection and how do we do it in a way that it's not overwhelming to the patient or the person that we're seeing?

Pooja A. Patel (11:14)
I think you mentioned a couple of points, like the data interoperability.

I think it's so important but very tricky because there are so many different EMR systems. I remember when I was working full time at the hospital, we rolled out a pilot program to look at which, essentially we created an internal algorithm that based on a bunch of data points that would identify which patients were at an increased risk for readmission.

Sydney Marshman (11:22)
Mm-hmm.

Yeah.

Pooja A. Patel (11:42)
And based

on that, it would flag the patient in the system so that us as providers, we were all assigned roles within that pilot to address specific parts of that readmission risk. And for OT, our role was cognition and self-care. And so we would do that, and then we would provide information based on that.

Sydney Marshman (11:46)
Mm-hmm.

Yeah.

Pooja A. Patel (12:06)
I left before we saw the results of the pilot, but we did end up rolling it out to larger part of the hospital because there was some positive outcomes of that. How do you do that when the system is so siloed across an entire state? And what does that mean for state level data systems or data infrastructure? But how do you then?

Sydney Marshman (12:25)
Mm-hmm.

Pooja A. Patel (12:27)
address the whole data privacy and data security aspect of it and patient privacy access side of it. There's so much nuance that goes into that on top of just access.

Sydney Marshman (12:30)
Yes.

Hmm.

Yes, right, right. Yeah, I think there's a lot of question marks there. And I think that the more we, because we're getting to a point that we're siloing less while we're equally siloing more. And that's confusing. I will try to explain it. We are seeing a greater uptick in major medical groups being more consistent across our state.

Pooja A. Patel (12:49)
Yeah.

Mm-hmm.

Sydney Marshman (13:00)
that

we only have a few players within medical groups. We're seeing fewer private practices when it comes to things like primary care. We're seeing larger networks of primary and specialty care. So in some ways, we're a little bit less siloed, which is both good and bad. But in other ways, we're becoming a little bit more siloed because we're also introducing

things like managed care organizations, and now your Medicare and your Medicaid benefits are managed by a private carrier. And that private carrier will do its due diligence to keep costs down, to contain costs associated with chronic care or chronic disease management. And that data becomes very private to them.

Pooja A. Patel (13:41)
Let's talk about that a little bit because that and this shift to value-based care outcomes is so interconnected, but I feel from an OT lens, in my mind, it's almost contradictory.

Sydney Marshman (13:49)
Hmm.

Ooh, it's contradictory. The shift to value-based care, and then what was the other one?

Pooja A. Patel (14:02)
what you just said about like data and managed care. Yeah, managed care essentially. I mean, I think as OTs, we as a collective are not fans of managed care in a lot of regards, I think, but specifically when it comes to Medicare. ⁓

Sydney Marshman (14:04)
of managed care of data.

Yeah.

Ooh,

okay, so I want to like play devil's advocate for a minute. I actually do think that OTs are huge proponents of managed care. I just don't think we know it yet. Okay, because OTs are the ideal person centered holistic care profession, right? We know that...

Pooja A. Patel (14:27)
Why do you say that?

Sydney Marshman (14:40)
one person with one diagnosis, Parkinson's, for example, does not look like anybody else with Parkinson's. There's a lot of similarities, but like one solution that works for one person is not going to work for someone else. And in a typical, in a typical like reimbursement strategy, we're going to see that there are some standardizations that if you have Parkinson's disease, maybe that means that you can get a U-step walker.

have to have that disease before you can get said product, right? I think that managed care has the opportunity, I'm gonna say opportunity with like a italic bold underlined, they have the opportunity to provide more client-centered care if they wanted to. Because I think that there's a realm to say that instead of the use step, maybe we actually just need urban poles.

And this person is not going to put the use up in the garage and never use it and waste our money doing so. I think if we provided these urban polls, which are what, like 125, they're going to get out and about more. They're going to be more physically active. They're going to reduce their risk of falls. They're going to socialize. I think that there's opportunities they're knocking that really align with OT. But they're just not quite perfected yet.

Pooja A. Patel (15:53)
Why do you think that is? Because obviously, I'm under the impression that, especially in large, at least here in Chicago, generally when I speak with my coworkers and care managers and stuff, we're usually advising our clients and our patients to go the traditional Medicare route.

Sydney Marshman (16:04)
Mm-hmm.

Mm-hmm.

yes,

yes, I'm not knocking that. I do believe that everyone should go the traditional Medicare route, but.

Pooja A. Patel (16:19)
Yeah.

Right. And

then you're saying that there's an opportunity under managed care for us to be able to be more present and be better utilized. Why do you think that that's not the norm, I guess?

Sydney Marshman (16:30)
Mm-hmm.

I mean, I think it's just going to take more work. think it takes a lot more work and more, I mean, you and I have had this conversation. It takes more people power to be more client centered. It doesn't mean that we're using, yes, it means we're using data, but it doesn't mean that we're using the same process that provides the same outcome for everyone.

just because that's the process required. It means that we're seeing things like the program for all inclusive care of the elderly, the PACE program. I am a huge proponent of the PACE program. It's for those of you who don't know, it's a Medicare program. So it's covered by Medicare.

Pooja A. Patel (17:06)
Mm-hmm.

Sydney Marshman (17:11)
It means you're not getting rid of your Medicare benefits. You're not going into a managed care or Medicare Advantage plan, but you are enrolling in the program and that does have some stipulations around it. But PACE programs, they receive federal funding and state funding to care for people at home. And we see that people power at play. We see that our PACE programs are required to meet as an interdisciplinary team weekly.

if not more often than weekly, to discuss the care of their members and to suggest ways to invest in their members for better outcomes long term.

Pooja A. Patel (17:46)
I think I do like that you use the PACE program as the example. I feel that the programmatic options are so good because of that accountability.

Sydney Marshman (17:56)
Mm-hmm.

Pooja A. Patel (17:57)
Right. Like

Sydney Marshman (17:58)
Yes.

Pooja A. Patel (17:58)
when you did when you were enrolled in the CAPABLE program, it was sort of the same thing. Right. Like there's an accountability there for this holistic client centered care that requires certain touch points and ensures that this person is getting what they need. The PACE program. Similar like there there's touch points. There's making sure that people have what they need. Your HARP program. Right. Like I feel like these programs are what really helps.

Sydney Marshman (18:02)
Mm-hmm.

Hmm.

Pooja A. Patel (18:25)
support outcomes, think, and support that holistic opportunity that you were talking about. I feel like, though, because you can talk about that, how difficult is it to enroll in these programs and then be able to actually run them specifically in rural areas?

Sydney Marshman (18:28)
Mm-hmm.

Right. Well, I mean, that was one of the reasons that it took so long from the initial conversations to then getting up and rolling is because we were initially talking about capable. When we think about capable and having six visits with four nursing visits with this equipment slash handyman budget and we're covering 17 counties, that is unreasonable. That is extremely unreasonable. And one of the reasons that we switched from the capable program into the heart program.

Pooja A. Patel (18:51)
Hmm.

Yeah.

Sydney Marshman (19:11)
is HARP is the Home Hazard Removal Program. There we go. Is it actually, it gives a little bit more flexibility to the clinician. It doesn't give a hard six, hard four, but it also eliminates the nursing component. And the reason that that has just worked a little bit better in Iowa is that when we were running CAPABLE, we were seeing a lot of folks who already had nursing involved.

⁓ They didn't always necessarily have OT. They might have had OT during like a home health plan of care, but generally they don't have ongoing OT. But most did have nursing. They did have some sort of home health nurse that was coming out routinely, whether that was through like a home community-based services waiver or some sort of program that they were also involved in. So the nursing was a little bit of a duplication.

of services, so that was another reason we went into the HARP program. Capable, it was also a little bit of a longer start to finish, and I can't remember what the fidelity measure is. I think it's four months, if I'm remembering correctly, where HARP, we can get things situated typically within four weeks.

So we're also being a little bit more responsive. We don't maybe have as much as a heavy education base that Capable does. Capable provides a lot of great resources to people, but at the same time, I think that with HARP, we've been able to be more responsive and it also fits with the rural travel restrictions as well.

Pooja A. Patel (20:37)
the rural travel restrictions.

Sydney Marshman (20:39)
Just

the idea of driving three hours one day, one way to go, you know, that it's just, it's tricky. And then when we look at the programs, so yes, programs are a great way to provide that holistic plan of care, but at the same time, programs often usually require clinicians to be credentialed with that program to go through that training process. So then when we're thinking about who, what, when, where, why, how hard is it to find

Pooja A. Patel (20:42)
⁓ yeah.

Sydney Marshman (21:05)
an OT, a PT, or whoever to run this program who's going to serve this small town in Iowa, then also can we invest the potentially thousands of dollars in training for that individual that that needs to be renewed the next year. Like there is just a significant cost of entry to some of the programming pieces.

Some more than others. So, HARP has been much more financially feasible for our organizations to participate in. The training aspect is just a little bit easier to access financially. It's available online. It doesn't necessarily require an in-person checkout. does have a live checkout. But other than that, it's just been easier to offer and to expand and grow.

Pooja A. Patel (21:50)
That's good to know. I know one of the touch points that you wanted to talk about was the Rural Health Transformation Program. Can you tell us what that is and what that means for you and just rural areas in general?

Sydney Marshman (22:06)
Yeah, I really wanted to bring that up as more of a you should do your own research at your own pace. But what I really understand the rural health transformation dollars have been allocated to specific states that applied. Iowa was one of those states. So we are in the process. We've passed the point. OK, so let's follow the money for a second. The federal one big beautiful bill is where these dollars came from.

that then opened it up to states to apply for those dollars. Now the states have been allocated dollars and now the states are going through their own application for organizations to apply. Okay, you with me? The application process is already closed. The organizations have already submitted their applications and that's currently being reviewed. But there's a few different focal points in Iowa anyway.

of what those dollars are supposed to be used for. And in our state, we're really looking into how do we continue to support this hub and spoke model, which is such a, sorry, kind of chuckle because it's like, I don't know, such like a highlight word lately of, yeah, it's just crazy. It's like, if you know hub and spoke model, you're in the know. But anyway.

Pooja A. Patel (23:18)
I don't think I'm in the know, Sydney!

Sydney Marshman (23:19)
Oh, okay. Well, apparently I'm in the know. So the idea

is that, our spokes are going into the rural communities and they lead back to like a center of excellence. So whether that's a specific specialty area like memory care or cancer care is a really hot topic in Iowa. We're number two for cancer diagnoses in the entire United States. So cancer is a very hot topic. And how are we providing

Pooja A. Patel (23:29)
Okay.

Sydney Marshman (23:47)
more early diagnoses so people can get further treatment for whatever their condition is. And a lot of the applications that people, that organizations have put into the state are around that improving access for rural Iowans, whether that's through better technology. I know a lot of the rural access hospitals have submitted for MRI machines.

because right now MRI machines to some counties, to some hospitals come via semi truck that they just roll up on, you you have your MRI every Tuesday, your MRI machine, and that's when people get seen. Is it? Yes. I know you're like, your mouth just drops open. Literally, yes. Yes, the MRI machine, comes on a truck. It's like a mobile MRI.

Pooja A. Patel (24:33)
can't imagine how heavy that is.

Sydney Marshman (24:35)
I know, we should look it up later.

Pooja A. Patel (24:37)
And then

how they plug it up, or are the patients going into the MRI on the semi-truck bed? And there's enough energy to support that in the back of a semi-truck.

Sydney Marshman (24:43)
Yes, I believe so.

Well, yeah, I'm

sure it's like, don't know the technology, obviously. I'm not an MRI technologist, but I'm sure hooked into the hospital system.

Pooja A. Patel (24:51)
No.

Okay. I'm just, that's just so interesting. I mean, there's so many services that are mobile at this point, but that's not one that I would think would be sustainable or feasible or realistic.

Sydney Marshman (24:57)
Let me see if I can do a quick search for you. ⁓

Yes.

Well, and that's one of the things.

Yeah, when we talk about sustainability, it's costly. It's costly to have an MRI on a semi truck. It's costly to have an MRI machine in your hospital. And that's not even considering, you know, the other adjacent costs like having the right medical professional who could run your MRI machine, having the people who can read your MRIs. I mean, there's just there's some logistics there.

Pooja A. Patel (25:37)
Yeah, that's very interesting. think one of, as you're looking that up, I think one of the parts of, because we're talking about where this rural health transformation program came from, it's also important to highlight that this same bill that's helping,

us get this money for rural areas is also cutting into a lot of Medicaid cuts and policies that impact rural areas just the same. And have you seen any changes that have already started to occur because of that.

Sydney Marshman (26:09)
Yes, yes.

To be honest, no, I haven't seen changes that have started, but it's also January of 2026. I think that we will see a trickle down effect. think that, well, I suppose they won't come out and say it, but we have seen already family medicine practices closing. And is that related to the revenue projections?

Pooja A. Patel (26:35)
Yeah, pulled up some numbers here just so we can look at the data. But essentially,

Sydney Marshman (26:35)
probably.

Pooja A. Patel (26:41)
The modeling estimates that 1.8 million rural residents are expected to lose Medicaid and reduce rural hospital Medicaid payments by about $50.4 billion over the next 10 years. And that is going to impact how many hospitals can stay open.

Sydney Marshman (26:57)
Yes.

Pooja A. Patel (27:03)
right, because they are not going be able to sustain it. And Because Medicaid covers over 16 million rural residents and a high share of rural births and nursing home care,

The laws projected Medicaid reductions are expected to significantly increase financial pressure on rural facilities, especially in states with large rural Medicaid populations.

Sydney Marshman (27:15)
Mm-hmm.

Yeah, and I think, I mean, I think this just all wraps into together. So I was at a meeting for healthcare executives in Iowa and I wrote this down and I just pulled it back up. I kind of forgot I had it. And their keynote was talking about how in our state, we have approximately each critical access hospital has approximately 40 to 80 % of people on Medicare.

and 25 % of the state is on Medicaid. So we're looking at on the low end of over half of your payer mix being federal and or state funded. I mean, I shouldn't even say state funds because Medicaid still comes from federal. It's just administered by the state. We're looking at a really high percentage of federally funded.

Pooja A. Patel (28:10)
Yeah.

Sydney Marshman (28:16)
insurance case mix. So when we cut things like Medicaid, when we add in administrative costs for work requirements, those things all trickle down to the people, yes, in urban health care centers too, but most importantly, our ability to access health care in rural places. Because when people in rural places don't have access to health care,

They overwhelm the urban populations as well.

Pooja A. Patel (28:43)
Yep. And that's when we see even more people, the travel issue becomes backwards then because these rural residents are now having to travel three, four, five hours just to get to a doctor's appointment.

Sydney Marshman (28:49)
Mm-hmm.

Yes. And I would say in Iowa, we're pretty, I don't want to say lucky, but we do have a lot of urban areas in Iowa that are dispersed throughout. So I wouldn't say that generally we're going to be traveling three, four hours for like a general physician visit. I think the clinic closure I was telling you about, they're rerouting patients to a primary care physician an hour and an hour and 15 minutes, an hour, 20 minutes.

Pooja A. Patel (29:15)
Sure.

Sydney Marshman (29:25)
So I can't say, yes, that's better than three hours, but I can't imagine when you're feeling miserable, like death warmed over, getting in the car to drive an hour and 20 minutes one way to see the doctor. And maybe you can't even drive that long. Maybe you need a care partner to drive you. And then that means that they're taking work off. And then that means, what do you do with the kids? And then what do you do with grandma who also like relies on you to have lunch delivered?

in rural places, you know, like there are just so many trickle down effects that I don't think we've really considered when we're making these regulations. But it seems that.

Pooja A. Patel (29:56)
Yeah.

Well, and

another related thing is the availability of telehealth. Right? Because.

Sydney Marshman (30:07)
but telehealth, yes,

will be voted on in 11 days, hopefully.

Pooja A. Patel (30:10)
Hopefully and that's what we're advocating for so if you're listening and you're a provider or a professional who can advocate for this make sure you're contacting your legislators, but it's a concern that if it doesn't pass if those telehealth waivers do not get extended that these rural health resident rural residents who might need to travel an hour hour and 15 minutes could instead

Sydney Marshman (30:22)
Mm-hmm.

Pooja A. Patel (30:38)
access telehealth services within minutes from their own comfort of their bed and not have to worry about their kids or their caretaker or their grandma, they would have a much better health outcome than having to get on the road for an hour.

Sydney Marshman (30:49)
Yes. Yes. But yeah, I think it's just hard. think it's hard when we talk about health care and we have legislatively tied health care into budget pieces, which makes sense because, of course, we just talked about we have very high payer mixes of federally provided insurance coverage.

Pooja A. Patel (30:50)
So, and that's all part of it.

Sydney Marshman (31:11)
So it makes sense that yes, we do need to tie that into the budget and things like that, but it just access and human health care. Can you really put a dollar on it? Can you really see the full picture in the lives that you're impacting when you vote yay or nay?

Pooja A. Patel (31:34)
Yeah, I mean, and like you said, there's so many cascading issues that there's no real tangible way. I mean, I'm sure the actuaries and the data financial people are looking at the projections and all of that and doing the math on it. But does that incorporate all this other stuff, like we said, right? The loss of work, the loss of or hiring of a babysitter or a caretaker or?

cost of travel Depending on how far they have to go. So no, I don't think that there's a way to really quantify all of that into one big projection and All of this to say I think ultimately Yes, there are more programs that are being rolled out to hopefully try and support and fund rural care and access to care

I think ultimately that those populations are still going to be the one who have the most difficult time and access to care.

Sydney, I love talking to you. We can probably go on forever with this, but if you had one takeaway other than the fact that we want people to go call their legislators on this, what would you leave our audience with?

Sydney Marshman (32:45)
I think my one ask is that people get engaged, whether that's engaged with your neighbors to talk about what's happening in their lives and how some of these changes impact them and the people that they love, whether that's knowing who your legislators are, whether that's emailing them and asking for specific support on specific issues.

or that's getting engaged with some sort of nonprofit that supports the things that you believe in and supports the changes that you hope to see. I think that at this point, we all want to stick our heads in the sand and say, don't want to hear anything more. I don't want to see anything more. I've had enough. just don't even want to look at what's happening because I can't do anything about it. And I think we all need to be encouraged to do the exact opposite.

which is open your eyes a little bit wider, turn your head left to right, and actually see and visualize what's happening in our communities and how we can be supportive of that rather than saying, I don't want to know. I don't want to find out. I don't want to talk about politics.

Pooja A. Patel (33:51)
Yeah, the worst of it all, right? I agree. Thanks so much for sharing that. I'm a big advocate for we can't change the world. You can't even change your country. you probably can't. Most people can't even change their state. But you can definitely make a difference in your neighborhood, in your community, and in your local area if you just get involved and support your local neighbors and communities. So thank you for that.

Sydney Marshman (34:16)
Yeah, thanks for having me. It so much fun.

Pooja A. Patel (34:18)
Absolutely.

Always, always a pleasure. Thank you so much, Sydney. And we hope to talk with you again. Thanks so much.