William Lietzau (Defense Department photo)

William Lietzau, a Marine colonel who currently serves as deputy legal counsel to the National Security Council, is poised to become the Pentagon’s new deputy assistant secretary for detainee affairs in the next several weeks. Lietzau, an international law expert described even by his critics as a brilliant and energetic attorney, previously served as a special adviser to Jim Haynes, the top Pentagon lawyer during Donald H. Rumsfeld’s tenure, when Rumsfeld and Haynes codified torture and indefinite detention as hallmarks of Bush-era terrorism policy. The position, which is not subject to Senate confirmation, came open late last year, after Phil Carter, the previous deputy assistant secretary for detainee affairs and a favorite of civil libertarians, abruptly resigned.

As the next deputy assistant secretary, Lietzau will be at the center of the Obama administration’s decisions about trying the remaining Guantanamo detainees in reformed military commissions or in federal courts. He will also be central to the construction of a post-Guantanamo terrorism-detention policy in an administration that claims to be more committed to the rule of law than its predecessor. Lietzau is said to have gained the confidence of senior administration officials over the past year, particularly as he helped revise the military commissions to include greater process protections for defendants — even though civil libertarian groups still consider those rules to be unfair.

Two senior military lawyers who fought with Haynes over military commissions and interrogations in the Bush administration said they were surprised to hear of Lietzau’s impending appointment to the Obama Pentagon. Retired Rear Adm. Don Guter, who served as the Navy’s Judge Advocate General from 2000 to 2002, described Lietzau as a close Haynes confidante but not an outspokenly opinionated figure. “If he disagreed with Jim Haynes you’d never know about it,” Guter said. “Because of his close association with Haynes I’d be more comfortable if I saw something public [indicating] he’d made a break with those policies.”

Retired Army Maj. Gen. Thomas J. Romig also described Lietzau as closely tied to Haynes, whose role in instituting extreme interrogations at Guantanamo Bay against the wishes of military lawyers cost him Senate confirmation for a federal judgeship. Romig, the Army’s Judge Advocate General during Bush’s first term, said that although he did not know specifically what positions Lietzau took on detainee interrogations or if Haynes even consulted him on the issue, “at that time, he was certainly in the bosom of the administration that was running interrogation programs that at the very least were quite troubling, and in many minds were a violation of the laws of war and the Geneva Conventions.” Lietzau’s expertise in international law — he was part of the Clinton administration’s delegation to the 1998 Rome conference that wrote the treaty establishing the International Criminal Court — should have allowed him to know “what was right and wrong with [Bush's] interrogation policies,” Romig said.

While Lietzau was close to Haynes, he also became close to retired Marine Gen. Jim Jones, now Obama’s national security adviser. The two officers met in Europe a few years after Lietzau had left the commissions, when Jones commanded U.S. military forces on the continent and Lietzau was his staff judge advocate. Lietzau joined the National Security Council last spring at Jones’ request.

Lietzau has many advocates in the legal and policy communities. John Bellinger, the former National Security Council and State Department legal adviser during the Bush administration, sparred frequently over detainee treatment with Haynes and David Addington, Dick Cheney’s attorney, who took far more extreme positions. But Bellinger, now a partner with the law firm of Arnold & Porter, considered Lietzau a first-rate appointee. “I think Lietzau is an excellent choice who knows the issues and is pragmatic and non-ideological,” he said. “I have never seen him to approach terrorism issues or international justice issues in an ideological way.

Similarly, Eugene Fidell, a Yale Law professor and president of the National Institute of Military Justice, called Lietzau’s appointment “creative,” despite any substantive policy disagreements they had. “The last thing I want is someone to come into the job without the respect of the military bench and bar, which he would have,” Fidell said, “and having to start from scratch in understanding the legal environment.”

Rosa Brooks, a Pentagon policy official who criticized the military commissions during the Bush years, added that while she couldn’t confirm Lietzau’s appointment, “I am a fan of Bill Lietzau’s. He’s smart, an honest broker, and has both intellectual and moral integrity.”

Lietzau was the first prosecutor for the military commissions established in 2001 — an official Pentagon release called him “instrumental” to the military commissions’ “preparations” — and served in that role until 2003. Yet during that time, the commissions did not bring charges against a single detainee, a fact that raised eyebrows among his colleagues. “I have to believe in his position Lietzau was being used by Jim Haynes as a sounding board or adviser on all international law issues,” Romig said, “because he was not doing much as chief prosecutor.

In a valedictory May 2003 press briefing, Lietzau described his role as “really the process portion of setting up military commissions.” That process, established by Rumsfeld, his deputy Paul Wolfowitz and Haynes, departed significantly from the military’s courts-martial system, restricting a defendant’s right to a public trial and allowing for hearsay to be admissible, although Lietzau pushed for defendants to retain the presumption of innocence. At the briefing, a reporter asked Lietzau if the commissions provided a defendant with a defense comparable to the normal military justice system, and he replied that the commission’s rules “were drafted to accommodate that kind of flexibility that would be needed.” But five years after their creation, a 5-4 majority of the Supreme Court ruled that the commissions were unconstitutional, improperly established by the administration and providing defendants with insufficient due process rights. In 2006, Congress passed a law authorizing a new version of the commissions although the Supreme Court in 2008 found problems with the process rights of the new commissions as well.

One senator who voted against the 2006 Military Commissions Act was Barack Obama. Last May at the National Archives, in one of Obama’s most important national security speeches as president, Obama criticized “the flawed commissions of the last seven years” and said his embrace of a reformed version of the commissions would bring them “in line with the rule of law.” Some in the administration believe Lietzau is, however ironically, the man for the job. A senior administration official who would not speak on the record because Lietzau’s appointment has not been announced said that the colonel “believes the rule of law is a fundamental part of our effort in the fight against al-Qaeda” and that Lietzau’s long experience with both the military commissions and international law provides the administration with “value added as we work with Congress” on a “durable” legal infrastructure for terrorism detainees.

At times Lietzau has expressed surprise about the Bush administration’s terrorism decisions. During a talk he gave at Harvard shortly after 9/11, he said he doubted that the administration would seek to try anyone in a military commission; months later he was helping design them. And in an article for a book on terrorism and international law published in 2002, Lietzau averred that President Bush’s assurance that the military treat detainees in the “spirit” of Geneva Conventions ensured that detainees “will continue to be treated humanely.” Over the next several years, dozens and perhaps hundreds of people detained by the U.S. in Guantanamo, Afghanistan, Iraq and elsewhere were tortured — activities President Obama expressly forbid during his first week in office by issuing an executive order restricting interrogation techniques to those listed in the Army’s field manual.

Lietzau was a deputy to Haynes during the winter of 2002 and spring of 2003, when Haynes presided over an internal Pentagon debate resulting in the modified adoption for Guantanamo of “enhanced interrogation” techniques authorized for the CIA to use on senior-level al-Qaeda detainees. A Senate Armed Services Committee investigation from 2008 determined that Haynes was a powerful bureaucratic force pressing for harsher detainee treatment. A former colleague in Haynes’ office, Richard Shiffrin, told the committee that Lietzau was present at a key 2002 meeting in which participants expressed “some frustration with the quantity and quality of information being obtained” at Guantanamo, although Shiffrin did not attribute any substantive position to Lietzau. And no source for this piece had knowledge of Lietzau having anything to do with torture.

It is unclear what exactly Lietzau’s appointment signifies in terms of concrete policy decisions or shifts. An email to Defense Secretary Gates’ spokesman, Geoff Morrell, went unreturned. But Bellinger predicted Lietzau would “adopt a balanced approach between the security needs of the country and military and the need to address worldwide concerns that we do not have an appropriate legal framework or legal policies.” The senior administration official said Lietzau was “bound and determined to make sure, whether it’s in three years or seven, when he walks away from this job, there is a durable legal infrastructure” to handle terrorism detainees justly.

Both Guter and Romig, the former senior military JAGs who clashed with Lietzau’s old boss, Haynes, independently described Lietzau as intellectually “flexible” and willing to faithfully implement the policies of his bosses. “The guy is smart, so he can figure out what the Supreme Court has said” about the due process rights to which detainees are entitled, but “it troubles me the guy can go from one end of spectrum to the other, arguably,” Romig said. “It’s very curious they would take somebody to run [policy on] detainees who was in the position he was in seven or eight years ago.”

Rod Roberts

Republican gubernatorial candidate Rod Roberts was the guest of the Clay County Tea Party Patriots Thursday night, and he used the opportunity to draw distinctions between himself and former Gov. Terry Branstad.

Roberts focuses his remarks on his fiscal record and ideas such as eliminating the corporate income tax and his proposed constitutional amendment limit state spending to 99 percent of projected revenue. When the forum was turned over to public questions, it offered Roberts to opportunity to look back at Branstad’s 16 years in office and explain what he’d do differently.

From the Spencer Daily Reporter:

He stated he would not have expanded legalized gambling, nor would he have diverted dollars from the road use tax fund to pay the Iowa State Patrol, a practice current Gov. Chet Culver wants to reinstate.

Roberts also hit the conservative high points: he will fight to overturn an Iowa Supreme Court ruling legalizing same-sex marriage and protect Iowans’ right to carry a firearm. The Carroll Republican even advocated for an expansion of nuclear power in Iowa, as well as the expansion of coal-fire plants, ethanol and biodiesel.

Though most observers believe the GOP primary is really a two-man race — between Branstad and Sioux City businessman Bob Vander Plaats — the increasingly heated battle between those two chief rivals has some convinced Roberts could become the surprise candidate of 2010.

“There are probably three potential options that we could be faced with in light of where we are and what happened in Massachusetts,” Braley said today during a conference call with reporters.

U.S. Rep. Bruce Braley

The first option he addressed was House and Senate leaders to finish current negotiations and present a package to both houses prior to the swearing in of Massachusetts’ newly elected U.S. Senator, Scott Brown. A second option is to go to reconciliation of the two existing bills, and have sections of the legislation be passed on a piece-by-piece basis.

“I think there are some significant challenges in doing that, and to continue to tie up floor time dealing with the health care agenda,” Braley said.

A third option is to bring the bill passed by the U.S. Senate to House membership for as-is approval.

“I have very serious reservations about that, but am waiting to see what happens,” he said. “Obviously, leadership in the House, Senate and White House are continuing to analyze their options and at the time they present us with a choice to make I will very seriously weigh the benefits and the potential drawbacks of that legislation for my constituents and vote accordingly.”

In direct response to the Republican win of the late Edward Kennedy’s Senate seat, Braley said he is not willing to look at that one election as a bellwether for overall American sentiment toward President Barack Obama or the Democratic agenda.

“You can’t take a single senate race and try to make strong judgments about what it means for the rest of the country,” he said.

Braley believes the legislative and executive branches must work to alleviate economic pressures on the middle class.

“We know the more people we put back to work, the more money flows into the federal treasury and the more we are going to be able to reduce the deficit and relieve some of the burden that the American voters have been facing in this challenging period of recession,” he said. “I also know through the work that I have been doing as chair of the Populous Caucus, that middle class families have been struggling and left out of the benefits of a recovery that has rewarded Wall Street more than the people working on Main Street. The work that I’m doing … is trying to promote an agenda that will both enhance and expand people in the middle class because know, historically, that when the middle class has been strongest, our country has been strongest.”

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“While Kansas and North Carolina have a few little rivalries going on, [Hagan and I] have had a great time working together on health care issues, and particularly for rural citizens in this country because both of us come from states with a significant rural population,” Sebelius said.

The conference call with reporters was held in conjunction with the release of a new report by Sebelius’ office. The report, titled “More Choices, Better Coverage: Health Insurance Reform and Rural America,” documents many of the challenges faced by the estimated 15 million rural residents who seek health care insurance in the current system.

“A lot of rural Americans are self-employed or work for small businesses, including family farms,” Sebelius said. “A lot of them have to buy insurance on the individual market where they don’t have many choices and they have extremely high prices and rules that don’t protect consumers. Even when they do secure insurance, many folks in rural America then have difficulty finding a doctor. Two-thirds of the under-served community in America are in rural areas.”

According to Sebelius and Hagan, reform would begin to solve many of the access and insurance problems currently faced by rural residents.

“North Carolina does have a very large sector [of population] in rural areas,” said Hagan, who serves on the U.S. Senate Health, Education, Labor and Pensions Committee that is led by U.S. Sen. Tom Harkin of Iowa. “I think one of the critical aspects of the health care reform effort in Congress right now is that it is going to improve the quality, accessibility and affordability in our rural area.”

Forty percent of self-employed workers living in rural areas are uninsured, compared to 32 percent of self-employed workers living in urban areas, Hagan noted.

“[In North Carolina], 65 percent of of the uninsured population who are full-time workers, work for small businesses — compared to about 46 percent in urban areas,” she said. “And whereas there are nine doctors for every 10,000 North Carolinians in the larger cities, there are only about six-and-a-half for every 10,000 in rural areas. People in rural North Carolina are four times as likely to live in a county with lower access to health care professionals.”

Residents who live in these rural areas, according to the report, not only have more difficulty affording and accessing care, but typically have higher rates of poverty and chronic disease such as diabetes and heart disease. Because many of these same residents work for small businesses, or work part-time or seasonal jobs, it is much less likely that they will have private, employer-sponsored health care benefits. Nationally, a third of all rural residents work for small businesses, yet less than half have health insurance — a figure expected to climb as more small business owners drop health insurance coverage in order to keep their businesses afloat.

Farmers and agricultural workers are especially challenged in today’s insurance market. A multi-state survey of farm and ranch operators found that, while 90 percent of farmers have insurance coverage, one-third purchased it directly through an insurance agent (compared to a national average of 8 percent). The other two-third likely have a spouse that is forced to work off-farm so that the family can be provided with consistent health insurance coverage through an employer.

Sebelius and Hagan also acknowledged that simply providing rural Americans a way to pay for health care doesn’t always translate into access to health care. There were only 55 primary care physicians per 100,000 residents in rural areas in 2005, compared with 72 per 100,000 in urban areas. In the nation’s most isolated and small rural areas, that figure drops to 36 per 100,000. Hagan asserted that although the earlier stimulus had already addressed an expansion of the federal program for loan repayment of medical professionals who agree to practice in under-served areas, the current reform measure provides an extensive and necessary boost to further those efforts.

“There will be scholarships and loan-repayment programs for primary care providers who actually practice in these under-served areas,” she said. “The National Health Service Corps will provide grants and scholarships and loan-repayment programs to providers that’s going to include nurses, nurse practitioners, physician assistants, dentists and mental health providers who actually work in these under-served areas.

“The idea is to increase this dramatically from where it is right now, to be sure that we can get people who hopefully have lived in rural areas to actually go to these medical schools and into these medical professions and then return to their homes, or to agree to living in a rural area for a period of time.”

The current proposals would also provide payment bonuses to primary care providers practicing in under-served areas. Those who have studied ‘doctor drain’ acknowledge that the problem focuses on getting doctors and other health care professionals to begin a practice in an under-served.

“One of the things that we’ve found around the country is that once a person begins a practice, such as a practice in a rural area, [he/she] tends to voluntarily stay,” Sebelius said. “So it really hasn’t been necessarily the challenge of keeping folks there, it has been the challenge of getting them there and getting them back.”

Both women also expressed their optimism that the confirmation of Dr. Regina Benjamin as U.S. surgeon general would be forth-coming, as well as their belief that her personal experience will be a positive influence for young medical students to take advantage of incentive programs to not only serve in rural areas, but to build practices that add to the fabric of those communities.

For the past several months, The Iowa Independent has documented the health costs associated with provider shortages in rural areas. Without sufficient providers, some rural residents are forced to travel significant distances for general health, mental health, dentistry and pharmaceutical services.

According to a 2007 study by the National Center for Rural Health Works at Oklahoma State University, one full-time primary care physician generates, on average, approximately $1.5 million in revenue, $900,000 in payroll and creates 23 jobs. The relatively large impact is created through clinic employment, inpatient services, outpatient activities and the multiplier effect of these contributions, and it does not include potential benefits to local pharmacies.

The study also documents another important factor: If primary health care services are not available in a rural town, residents will often travel to the nearest urban centers to meet their needs. Because such urban centers often provide expanded shopping and specialty service opportunities, the traveling patients will often make other purchases out of town that may have otherwise been made locally.

In many ways, a general practitioner’s economic contributions are as important to a community as her medical contributions.

The National Center for Rural Health Works estimates that a rural community with a shortage as low as one-half of one full-time physician stands to lose $236,565 from clinic visits and $451,169 net revenue at a local hospital for in-patient and out-patient activity. When those figures are adjusted for indirect multipliers — for example, services purchased by the physician, the clinic and employees — the total impact of the shortage was 13.8 jobs and $533,493 in income.

Despite all the evidence, few rural areas currently target medical professionals as a part of their routine economic development efforts.

“Some of our larger communities struggle to attract health care providers to those communities, and I know that it gets very competitive as far as what they need to do in order to draw physicians, physician assistants, nurse practitioners, primary care providers and the whole gamut of health care providers,” said Tom Newton, director of the Iowa Department of Public Health. “It is gets very competitive to draw those individuals to your community. But when you look at the rural communities, the people (i.e., providers) just not willing to go out there and work.

“Somehow we need to re-invigorate those communities and show the benefits that they have and what they can offer to providers who are willing to go out there and work.”

It is typically only when a primary care physician leaves a community or retires that residents and local leaders understand the impact of that business on the local economy. And, unfortunately, creating a medical practice from scratch instead of transitioning from one physician to another is a much more formidable task.

There are, however, promising approaches rural communities could take to reduce the decline of medical professionals, but none is in widespread use.

Some rural communities are taking a “grow your own” approach, whereby community groups attempt to identify young adults — even as young as middle school or junior high students — who might have an interest in attending medical school. Through scholarships and other incentives, they pay for a student’s medical training in exchange for a promise to return to the community and practice medicine there.

Although most rural communities have been slow to adopt this approach, it is gaining momentum as smaller communities are faced with aging medical providers and few prospects to fill those potential voids in service. According to Newton, such approaches to provider shortages have been “the most effective” in bringing providers into rural areas.

“It is much easier for a young person to go back into a rural community if that’s where they grew up, and if that is where they raised, because they understand the benefits of living in those rural communities” he said.

Another, somewhat more popular method of training physicians and other health care providers for service in smaller communities is the implementation of rural residency programs. Not only do programs such as the Smoky Hill Family Medicine Residency Program in Kansas and the Durant Family Medicine Residency Program in Oklahoma prepare physicians for work in smaller communities and rural areas, but they also provide a boost to local communities where they operate.

“I think we also need to do a better job of selling what we have in Iowa. We don’t do that. We make a lot out of the fact that we don’t have oceans and we don’t have mountains, and everyone is under the assumption that is what attracts young people today. Well, to some degree it does. But, eventually those young people get married, have kids and have other priorities that begin to take precedent in their lives,” Newton said. “If they understand that there are safe communities, that have good schools, that have short commutes — ones in which there is a sense of community and they know their neighbors, and their patients and they can have a real relationship with them — there are aspects of that which are very appealing to people.”

As the recession takes its toll and small town populations continue to age, health care providers will become an increasingly important part of rural economic development. Doctors are an important component of the rural economy, improving conditions far beyond the walls of an examination room.

When Iowa Department of Public Health officials planned their health provider flu vaccinations, they learned that many Iowa providers were above the recommended age requirements to receive the live virus H1N1 vaccination. In fact, no providers in Van Buren County were below the cut off age of 49.

Expanding insurance coverage is important, experts say, but that is only half the battle. For many Americans, particularly in rural parts of the country, access to high quality health care services could remain elusive.

“We have some serious challenges in Iowa as it relates to the number of providers that we have,” said Tom Newton, executive director of the Iowa Department of Public Health. “We do have a high percentage of our population in Iowa that is insured at this time, and I would tell you that even some of them struggle right now to get access to health care. You can’t just assume that by providing people with a source of payment that you’ve provided them with access to health care.”

As The Iowa Independent has previously reported, the Hawkeye State, like many other rural states, is coping with a plummeting number of health care professionals, including specialists, primary care physicians, nurses and behavioral health professionals.

While several factors such as perceived career stress and compensation issues are at the root of the decline, the problem is also being amplified by a rapidly aging health care workforce.

As a part of H1N1 flu response and vaccination plan development for health care providers, Newton said he spoke with a public health administrator in Van Buren County about the department’s plan to utilize flu mist, a live-virus vaccination that is delivered through the nose like a nasal spray. Because that vaccination contains a live virus, its use has been restricted to certain age groups.

“Health care providers were going to be our targeted audience for using flu mist, at least in some cases. But, in Van Buren County they do not have any health care providers that are under the age 49,” Newton said, noting that regulations prohibit anyone 49 and up from using the live virus. “That presents problems for us from a vaccination standpoint, but what does that say about health care providers in those communities? There are probably going to be some of those folks who are eligible to retire within five years.”

The alarming demographics and shrinking number of health care workers in rural areas are not just limited to primary care doctors. Other components of health care are also in short supply in much of Iowa.

“We aren’t just talking about those people that are traditionally thought of as health care providers – it’s dentists, it’s mental health and it’s even pharmacy,” said Cheryll Jones, a southeastern Iowa pediatric nurse practitioner who serves on the board of the Iowa Rural Health Association. “There aren’t necessarily huge numbers of pharmacies in rural areas. So, even if you have a provider, you may have to travel a fair distance to get your prescription filled.

“[Workforce] is a concern that we have, and not just for rural, but especially for rural. Certainly, the need for folks to have health insurance is important, and that is where a lot of the focus has been, but access to insurance does not equate to access to care.”

A declining and aging workforce is probably the most publicly visible of the challenges facing a health care system, but it is far from the only challenge for rural areas. According to Tim Size, executive director of the Rural Wisconsin Health Cooperative, his state, like Iowa, has maintained a relatively low uninsured rate.

“We are very used to dealing with rural health in an environment where most people have insurance cards,” Size said. “People having insurance cards is much better than people not having insurance cards, but it doesn’t deal with the long, long list of issues that we have to struggle with.”

As health care companies react to the current global economic recession, there will be efforts to make health care services more centralized, which isn’t always in the best interest of rural consumers or providers.

“We need collaborative ways for rural to work with rural and for rural to work with urban that maintains services available in the rural areas,” Size said. “From that respect, we have to be very concerned about the economic incentives that will come with reform. … There are a lot of models floating around out there that have tended to be developed in urban communities and we need to be very cautious about those being mandated into rural communities without any demonstrating or testing of the idea.”

When it comes to the debate over improving health care, Newton said, “It all comes down to how you define access.” For many rural residents, the definition is likely to remain too narrow to make much of a difference.

During the month of July, the RealtyTrac U.S. Foreclosure Market Report, indicated that 601 Iowa properties had foreclosure filings. Although the change was only a 7 percent increase from June, it was a 21 percent increase from the same time during 2008.

Statewide the number of home sales during the month of August dropped 17.3 percent from the same month during 2008, according to the Iowa Association of Realtors. The agency reports that 2,981 homes were sold across Iowa in August, while 3,606 were sold during the same month the previous year. That being said, there were also 3,190 pending sales reported for the month, a typically lop-sided trend for summer and one the agency believes is related to new federal regulations regarding sales.

“We expect to see many of these pending sales reported as sold within the next 30 to 60 days,” said Terry Knapp, president of the Iowa Association, adding that he expects to see a significant rise in activity before the First-Time Homebuyers Tax Credit incentive ends on Nov. 30.

Pockets of the most increased foreclosure activity in the state continue to be centered in urban areas with larger populations. More than 80 percent of all the state’s foreclosures were concentrated in six counties: Polk, Linn, Scott, Pottawattamie, Dallas and Woodbury. In Polk County one in every 644 housing units had foreclosure activity — more than 3.4 times the state average. Linn County had a rate of one foreclosure for every 1,119 properties (twice the state average), and Scott County’s rate was one foreclosure for every 1,192 properties (almost twice the state average).

Although the percentage increase from 2008 is significant for Iowa, the state continues to represent less than 1 percent of the foreclosure filings throughout the nation. Total U.S. activity rose nearly 7 percent from June to July, and was more than 32 percent higher than one year ago. During the month, one in every 355 housing units in the nation received a foreclosure filing.

The Iowa Association of Realtors also reports that home listings increased 10 percent from last year, and that prices have remained steady. The average number of days a property is on the market prior to being sold has also slowly decreased, a good indicator that the market is recovering. Although the list price to sale price ratio for properties had dipped to below 94 percent last winter, it now stands at 95.8 percent, an indication that more sellers are listing their properties realistically.

“Every day I see the real problem of the uninsured — and that group does not only encompass the destitute,” Dr. Timothy Kresowik said during a press conference at U.S. Rep. Dave Loebsack’s office last Wednesday. “There are people who are working but don’t have health insurance, perhaps at a small business that doesn’t offer coverage or maybe self-employed. These are people who are suffering in the current system, and that’s what physicians are committed to change. We need accessible health insurance and health care for the entire population.”

Speaking with The Iowa Independent after the press conference, Kresowik said that many health care professionals — especially those in Iowa in similar states — are concerned about doctor and nurse shortages and federal reimbursement rates.

“Unfortunately, just as misinformation is out there in the public, it is also present within the medical community,” he said. “Physicians are a diverse group. They cover both ends of the spectrum. … I think you have a lot of physicians who are generally supportive, but don’t necessarily want to be seen or viewed as supporting everything that is being discussed.”

While all Americans will be impacted by reform, physicians and other health care professionals are unique in that they will be impacted both as consumers and as providers.

“Right now, unless something is done about Medicare reimbursement formulas, we are headed for a cliff,” Kresowik said. “The fear about the public option is that if the reimbursement rates are at the same levels of Medicaid and Medicare it is not sustainable. This is especially true in a state like Iowa where, because of these crazy geographic adjustments that have nothing to do with what it costs to practice medicine but focus on things like [office] rent. … We are already at the bottom of the barrel in terms of reimbursement for exactly the same service. So, [physicians] worry that if those rates are simply continued then they simply won’t be able to afford to maintain their practices.”

Another concern, according to Kresowik, is the creation of broad policy on a federal level that may or may not fit the one-on-one interaction required in health care delivery.

“A lot of the health care stuff happens between individuals and should happen at the local level,” he said. “Anytime you get the government [involved], you tend to have a lot of broad policies that don’t fit the individuals. What we have to do is create a system that provides the right incentives, but still allows individual patients and their physicians to make decisions without a lot of bureaucratic oversight.”

In northern Minnesota, however, a small group of local behavioral health specialists have created a post-doctorate program that has not only established one of the nation’s first pipelines of providers, but has enhanced the way existing agencies and providers interact for the betterment of an entire rural region.

Dr. Jeffrey Leichter

Dr. Jeffrey Leichter, one of five founding members of the Minnesota Consortium for Advanced Rural Psychology Training, told conference attendees on Tuesday that one of the major challenges associated with bringing behavioral health care providers into rural areas is that few are adequately prepared for the realities of practicing there.

“In a rural community, you can’t just say, ‘I treat eating disorders, and that’s all I do.’ You just can’t do that in a smaller community,” Leichter explained.

A mental health provider in a smaller community not only needs to be able to see a wide variety of clients at all life stages, often referred from various community agencies, but needs to understand when his or her scope of practice has been exceeded and a referral has to be made.

“That’s a very difficult thing to decide,” he said. “Do I keep a client even when I know that there is a provider several hours away with more knowledge about a specific condition? Since many clients won’t travel that far due to transportation or financial issues, are such clients actually better off with the care I can provide even when it will be more generalized? It becomes a question of whether some care is better than no care at all.”

There is also the aspect of running a “fishbowl medical practice,” in that clients and providers are thrust into the same day-to-day routines. The situation, he said, makes it difficult, if not impossible, for a provider to ever really leave the office.

“There are a lot of ethical boundary issues,” he said. “If you live in a small town, your client is pumping your gas. Your client is on the church committee with you. Your client is across the table at a supper you were both invited to attend. … Those are ethical issues that you don’t learn about in school.”

In addition to lower pay through a client-base that is primarily covered by either Medicare or Medicaid, the scrutiny and other unique demands that make it difficult for smaller communities to attract and retain providers, there is also the added burden of the inherent risk factors and cultural differences of working with a rural population.

“Most rural residents face triple jeopardy,” he said. “That is, they are poor, uninsured and live in isolated areas.”

Another way to describe the problem, he said, is by the “four As,” which are accessibility, availability, acceptability and affordability. Rural residents seeking even the most basic health care are impacted by each.

For all of these reasons and more, Leichter and four other local providers accepted a $23,000 Minnesota state grant and began writing a curriculum that would specifically provide post-doctorate psychologists with first-hand experiences of practicing in a rural setting. Since accepting its first psychology resident in 2006, MCARPT has graduated three students, all of whom have gone on to provide services in underserved areas of Minnesota. Two more residents are anticipated to complete the program this fall, and there is a possibility that the new section that begins in October will expand to three residents.

Those who developed and planned the Detriot Lakes-based training program, did so with a specific goal in mind: “Reduce the shortage of psychologists practicing in rural communities due to poor retention of mental health professionals in underserved parts of the state and thereby enhance access for rural residents to quality mental health services in their communities.” In short, it really was about creating a pipeline of professionals that could stem an existing and problematic shortage. The results of providing the service, however, have also had a local, positive impact.

“There are multiple benefits,” Leitcher said. “There is direct benefit to the community in the sense that we are populating the number of mental health professionals over the course of time that are going to be in the community. This particular project — and I don’t think I’m being overly boastful — has created cohesion among these 11 agencies that previously often times never talked with each other. There’s a connection … [and] now they all speak to one another in the interest of making sure the fellowship program works smoothly.”

Existing professionals within the community have also been able to combat feelings of isolation due to interactions, like group supervision meetings, that are built into the program.

“There aren’t a lot of psychologists in our area, but of those that are, many are involved in the program by doing supervision or teaching or some other type of training element,” he said. “I think it is very fair to say that a lot of folks who kind of felt like they were out there by themselves are now being brought into the fold of this project, and are feeling like they are a part of something that is very cutting edge and innovative.”

Since 80 of Minnesota’s 87 counties are considered to be mental health shortage areas, Leichter laughed when asked how long it would take MCARPT to provide psychologists to all underserved areas of the state.

“A lifetime at least,” he said and laughed some more. “But we are making a dent.”