PHOENIX – Obtaining health care is increasingly difficult in rural Arizona, and state budget cuts are making the situation worse. That was the conclusion at a community health forum in Marana.

Tara Plese with the Arizona Association of Community Health Centers says rising costs are forcing small rural businesses to drop health insurance for their workers, while thousands of people cut from the state's AHCCCS program are inundating community health facilities.

"Fewer people in the rural areas have health care coverage and there are fewer options for them. In some communities, the community health center is the only health care provider in that area."

Community health centers charge fees on a sliding scale, but Plese says their financial survival is being threatened by a rush of new patients with no insurance. When the state recently cut 100,000 low-income adults from AHCCCS, the adults were given letters encouraging them to call a community health center.

Jorge Ysles told the Marana forum his family doesn't qualify for AHCCCS, even though his 16-year-old son is at risk of losing his hearing and possibly his eyesight because of a childhood illness. Ysles says he can't afford the expensive surgery.

"I was trying to look for supplemental insurance that would cover an implant for his ear. I mean, I'm not trying to get it free. I'm trying to get something where I can pay it back, but it's been really hard. He can't get the operation – and now, it's even affecting his eyesight."

Tara Plese says community health centers aren't equipped to provide specialized medical services or surgeries. Specialists will take referrals for a discounted fee, but she says there are limits.

"Those specialists also have a threshold. And when that threshold is met, they cannot take any more uninsured cases, either."

Any savings from the AHCCCS cuts will be short-lived, Plese predicts, because treatable medical problems will only grow more serious, requiring expensive visits to hospital emergency rooms. And when lawmakers cut a half-billion dollars from AHCCCS, the state lost out on a two-for-one federal match, she adds.

"Arizona sent a billion dollars back to Washington, D.C. So basically, the entire health care system in Arizona took a $1.5 billion cut."

She's convinced that every Arizonan will feel the impact in higher medical costs and higher insurance prices. In rural Arizona, 22 percent of residents are uninsured, compared to 17 percent in the urban counties.

The forum was co-sponsored by Children's Action Alliance, the Center for Rural Health at the University of Arizona, and the Marana Health Center.



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The need for child care and early learning is critical, especially in rural Arkansas. One nonprofit is working to fill those gaps by giving providers a chance to get more education.

The Career Pathways Program with Save the Children partners with universities to grow the workforce of child care and preschool providers.

Joyce Taylor, Eastern Arkansas parent-family community engagement coordinator for Save the Children, had more than 20 years' experience with Head Start and said the program gave her the opportunity to pursue a bachelor's degree. It also provides her with resources she can use, in the classroom and with families.

"In particular, we have a family with a child that is autistic," Taylor noted. "Mom is working with the child at home. So I have things that I can share with that family, so she can continue to work with her child."

More than 153,000 openings for child care workers are projected over the next decade, largely driven by the need to replace those who have left the field or retired, according to the Bureau of Labor Statistics.

Taylor pointed out some children have challenging behaviors, and may have a lot of things going on at home. It is her job to help them thrive in preschool.

"Because we're the first start, when they come into Head Start, that's their first opportunity to be in a learning environment," Taylor explained. "It's up to us to do everything that we can do, to help make that first experience successful."

Karen Harrison, managing director of career in education workforce development for Save the Children, said rural areas have access to fewer resources compared to urban areas, so the program focuses on addressing the specific gaps in rural communities. She added the Pathways program aims to reduce barriers to obtaining a higher-ed credential or degree.

"All of our pathways come with incentives," Harrison emphasized. "We either pay all or partial of their tuition; we pay stipends, for books, supplies and materials. We also give 'barrier reduction' stipends. We know that child care for participants themselves can be an issue; transportation, technology needs."

Harrison added the pathway begins with a Child Development Associate credential, followed by an associate degree, and ultimately a bachelor's degree. In the process, they improve the career opportunities for workers, as well as the quality of early learning.

A persistent child care worker shortage across New Hampshire is leaving families with few options.

The state is currently short more than 7,000 child care positions but low wages and burnout are driving workers from the field and forcing some centers to close.

Shannon Tremblay, director of the New Hampshire Child Care Advisory Council, said workers are struggling to care for their own families with wages barely above the federal poverty line.

"No one wants to come in for a low wage," Tremblay pointed out. "No one wants to come in making $15 an hour, working long hours in a stressful environment."

Tremblay argued greater state investment will create long-term benefits for both parents and children, some of whom may have disabilities or behavioral issues which could be identified earlier by trained child care staff.

Last year, state lawmakers invested more than $60 million in child care services, including $15 million for the creation of child care workforce grants and investments in the state's Family Resource Centers.

Tremblay emphasized the end of career and technical education programs in New Hampshire high schools broke the pipeline of workers entering the field, putting greater pressure on current staff to do it all.

"Our providers are the case manager, the cook, the plumber," Tremblay observed. "They want to provide that high-quality care and right now it's just, they can't do it."

Tremblay stressed pandemic-era funding to support the child care industry will run out in September, so state lawmakers need to act. She added the state could increase wages so the burden does not fall on New Hampshire families, who currently spend roughly $24,000 a year on care for two children under age five.

The child welfare system in Pennsylvania faces a staffing crisis affecting children and families throughout the system.

The Child Welfare Resource Center said about 30 counties report caseworker vacancy rates of 30% or higher

Terry Clark, president and CEO of the Pennsylvania Council of Children, Youth and Family Services, at a state Senate hearing on child welfare, challenged the Departments of Education and Human Services to work together to develop a STEM-focused model for human services. It could offer young people opportunities for training, apprenticeships and careers in child welfare, juvenile justice and behavioral health.

"We spend a lot of time focusing on colleges and universities," Clark noted. "But we believe we might want to back this up a little bit, and start looking at middle schools and high schools. Try to reinvigorate, get younger students motivated and trying to come into this field."

Clark pointed out some agencies have asked supervisors and even people from other departments to take on casework responsibilities. A recent Philadelphia study found Community Umbrella Agencies had an average 45% turnover rate, with vacancies ranging from 21-60 positions.

Clark observed private providers face workforce challenges similar to the county child welfare agencies. He emphasized counties are beginning to explore more contractual relationships with private providers for needed work.

"Counties are starting to put out RFPs, calls for private providers to help supplement their workforce," Clark stressed. "That means they're asking private providers to take on roles and functions that, in the past, were primarily done by counties themselves."

Clark argued competitive wages are seen as crucial to attract and retain child welfare workers, and county funding often falls short. He added student loan forgiveness and fellowship programs may be promising ways to bring new people into the field, but lawmakers would have to agree.

"There have been House bills and different Senate bills that have been introduced, or at least in draft form over the years," Clark acknowledged. "We hope that there's continued discussion about those, because if we can get some movement on those, we think those will really help."

He told legislators the turnover trends will not change significantly without increased investment in workers.