Lesley O'Daniel, a nurse who works in rural Missouri, shook her head as she contemplated the nation's emotional debate over health-care reform.

"The scope of the problems is almost unimaginable,'' she said. "When we as health-care people in the field sit down to discuss it among ourselves -- how we think maybe this or that could be handled -- then the questions come: 'But what do you do about this? What do you do about that?' This is so complex, and people have so many different needs that it's going to be difficult to make one set of answers. I just don't know.''

O'Daniel is aboard the Southeast Health On Wheels (S.H.O.W.) Mobile, a fully equipped clinic on wheels, that is parked on this day in Oran, Mo., about 140 miles south of St. Louis. O'Daniel, a registered nurse, assists the mobile clinic's nurse practitioner in bringing primary care to underserved towns in the Bootheel region through a partnership between Southeast Missouri Hospital and Southeast Missouri State University (SEMO) in Cape Girardeau.

In Missouri, 18.6 percent of the population lives in primary-care shortage areas, according to the Kaiser Family Foundation. While such areas can be in both urban and rural locations, O'Daniel says the needs can be very different.

"I don't know that those in urban areas understand the problems of the rural areas. And I don't know if those in rural areas understand the challenges of the urban areas,'' she said.

'They've had years to tinker with it'

O'Daniel appreciates the joys of rural Missouri life and knows the Bootheel like the back of her hand. She was born and raised in Bernie, Mo., population 1,700, which is south of Dexter in Stoddard County. She returned to live in her hometown after completing her nurse's training.

o'Daniel

Photo by Mary Delach Leonard | Beacon staff

O'Daniel speaks fondly of the town, though she described it as "small and dying'' like many in the region, left without a major employer after a shoe factory closed. The opening of a Dollar General store was big news, she said, as it brought with it the creation of seven jobs.

"We have a school, a bank. One grocery store -- we used to have three when I was a child," she said. "Restaurants open and close. It's difficult for people to make a go of it. We used to have a fabric store and a five and dime."

The town does have a health-care provider -- a nurse practitioner -- provided by the Southeast Missouri Health Network, a community/migrant health center partially funded by the U.S. Public Health Service.

"It's hard to attract providers," O'Daniel said. "The residents are not as affluent as in the city. In terms of lifestyle for physicians, there are no museums, no theaters. Our social highlight is a trip to the Walmart Supercenter."

Throughout rural America, primary-care physicians can be few and far between, and senior citizens and the poor often have no means of transportation to reach them -- a reality that O'Daniel has witnessed firsthand in her work on the S.H.O.W. Mobile.

"Some of our patients don't have cars, and last summer when gas prices were so high, some of those who do have cars couldn't afford to keep them on the road," she said.

O'Daniel believes the nation's health-care problems will not be easily or quickly solved.

"They've had years to tinker with it and try to figure something out. I don't know that one big public health plan is the answer, but I'm not sure that turning it over to insurance companies is the answer, either. Clinical decisions about services that are provided need to be made by clinical people," she said. "I do believe everyone in this country should have access to health care at a reasonable price. But mandating that employers provide insurance to their employees; a lot of these small employers can't afford it. What happens to those employees if the businesses have to close their doors?"

A 'cookie cutter approach' won't work,' says Emerson

Lack of transportation is a major barrier to health care in rural America, agrees U.S. Rep. JoAnn Emerson, R-Cape Girardeau. Emerson said she raised that point at the White House Forum on Health Reform in March, but she has not seen it addressed in the health-care bills.

"We're talking about health-care access, but what happens if you don't even have the means to get to the health-care clinic or hospital or doctor?'' she said.

Emerson (right) represents Missouri's 8th congressional district, which covers 28 rural counties, including the Bootheel. It is one of the nation's poorest congressional districts, a ranking that can range from 12th to 20th, depending on the data used.

Adding to the social, cultural and geographic factors that can limit the attractiveness of rural life to some physicians is the fact that a significant portion of the population consists of elderly Medicare patients and low-income Medicaid patients. Medicare and Medicaid reimbursement is usually lower -- and slower -- than private-pay insurance.

"People think that it doesn't cost as much to live in rural America, so therefore it doesn't cost as much as for health care," she said. "But it's actually much more expensive because there is no competition to drive prices down, and we have to pay bonuses and incentives to entice physicians to practice in rural America."

Emerson said she understands that the newest version of the House bill addresses some disparities between rural and urban areas by providing federal reimbursement for rural health services. She doesn't yet know the specifics of the plan and doesn't expect the rewritten bill will be ready for study until next month.

"A cookie-cutter approach doesn't work, particularly on the reimbursement side of things," she said.

Emerson said she strongly supports insurance reform to eliminate pre-existing conditions and lifetime caps. She also supports a federal pre-emption of state regulation of insurance to allow an insurance company to write the same policy in Missouri that it writes in other states, thereby increasing the size of pools of the insured. She believes that would lower prices -- and serve as an incentive for more insurance companies to compete for business in her region.

"For my folks in rural Missouri, if you can afford to buy insurance, you might have two options: Anthem Blue Cross Blue Shield or United Healthcare. While in St. Louis you can get five, six, or 20 companies willing to write insurance for you or your business. And the cost is much less."

Emerson said she is opposed to any provision that would prevent a consumer from switching to a different private health insurance company after a determined length of time. Such a requirement would force consumers to stay with the company they have or switch to a public plan.

She is also wary of the pledge made by the U.S. pharmaceutical industry to spend $80 billion over 10 years to reduce the cost of senior prescriptions to help pay for health-care reform. They would pay half the cost of prescription drugs that fall under the so-called "doughnut hole" in the Medicare Part D prescription drug benefit.

Emerson said she hears from many seniors who can't afford their prescriptions now, and she wants to be sure the deal won't backfire and actually cost them more. Instead, she would push for more competition among the drug makers to lower prices and health-care costs -- savings that could be used to fund expanding health-care coverage.

Access problems are different but the same

Sandy Ortiz, director of the S.H.O.W. Mobile program at SEMO, said she has found that problems of rural health-care access are universal, no matter the geography.

"Whether you're in the mountains of West Virginia or the Bootheel of Missouri, the lack of access in rural areas is the same nationwide," she said. "Even if I have a health-care plan -- whether it's state, federal or local that will pay for it -- I have to be able to get to it."

That fact hit home with her, she said, when she attended a national conference on rural health issues.

"The folks in Wyoming couldn't understand our access-to-care problems because they're in such a wide-open rural area where the nearest doctor might be 100 or more miles away," she said. "That was the access-to-care problem for them. But if you don't have a car or a neighbor to take you, 20 miles could be 100 miles. Lack of means of transportation is the same wherever.''