WALSENBURG, Colo. — Don't tell Dorothy J. Tenorio that Washington is nearing a deal to improve her health care.
A former grocery clerk, Tenorio's been scraping by on disability benefits for more than a decade. The 60-year-old, and many of her neighbors, are skeptical health-care overhauls pending in Congress will change much in Colorado's rural San Juan Valley.
"I would tell Congress, they need to get out here to Huerfano County and see how bad it is, see what we're living with," said Tenorio, who suffered a neck injury in 1979 and hasn't worked since 1996.
In rural America, many like Tenorio are too poor to afford basic care. People who can afford doctors often can't find them. The lack of health care in small towns like Walsenburg is a problem Congress is just beginning to address.
Many folks in Huerfano County, population 7,900, depend on a low-cost outreach clinic for care. There's no eye doctor, no full-time dentist. The clinic relies on nurse practitioners, midwives and medical assistants to provide basic exams, but most sick patients are referred to a bigger town about 30 minutes away.
"I don't have any way to get up there to the doctor," said Tenorio, who doesn't drive. "Sometimes I can't even get out of bed because of the pain."
The 25 percent of Americans who live in rural areas are poorer, older, fatter and sicker than their city neighbors. They live farther from doctors and have a harder time getting to appointments, many depending on neighbors or church volunteers if public transportation doesn't exist.
Small towns often lack specialists and rely on family physicians. But even incentives such as covering student debt for new doctors haven't worked. Many small towns look to nurse practitioners for general care or seek foreign doctors using J-1 visa waivers.
According to the National Rural Health Association, based in Washington, D.C., only about 10 percent of U.S. physicians practice in rural areas. The problem: Medical students know they can make more money, and work shorter hours, in a specialty practice in a city.
At Spanish Peaks Regional Health Center in Huerfano County, administrators have long offered loan forgiveness to entice doctors fresh out of medical school, but have been unable to recruit a single doctor.
"They just don't have a desire to come out here, the young ones," said Bill Bolt, clinical manager at Spanish Peaks.
When small towns do find doctors, their patients are less likely to be able to afford treatment. About 23 percent of residents in U.S. communities smaller than 2,500 people have no health insurance, compared to 19 percent in urban areas, according to the NRHA.
Those covered by Medicare or Medicaid aren't always better off. Because federal reimbursement rates are routinely tied to volume, rural doctors are paid less for the same services and as a result sometimes won't treat those patients.
"If I'm a young physician, I want most of my patients to have insurance, maybe some of them on Medicare. I'm not even touching the Medicaid," said Dr. David Zehring of La Veta, Colo., a plastic surgeon who practiced in Seattle and retired to Huerfano County.
The proposals in Congress do address some rural disparities.
A Senate bill would roughly double funding — an extra $1.1 billion by 2015 — for the National Health Service Corps, which pays student debt for health providers in underserved areas. Bills pending in both the House and Senate would address disparities in Medicaid and Medicare reimbursement rates.
But some advocates say those measures aren't enough to crack the urban-rural divide. And besides, Congress has yet to smooth disagreements about an overhaul that aims to cover more than 46 million uninsured Americans.
First, rural health advocates say, reforms must get doctors into rural areas, then worry about insurance coverage.
"We keep hearing about universal coverage. From a rural perspective, that solves nothing," said Lou Ann Wilroy, executive director of the Colorado Rural Health Center in suburban Denver. "You can have an insurance card in your wallet, and that doesn't mean you're going to have care."
One solution is to start before doctors are licensed.
Dr. Allen Perkins, president of the Alabama Rural Health Association, says Congress must address medical education. Medical schools are typically in cities, Perkins says, where they have access to advanced lab equipment and specialists. Their students train in big-city hospitals, where young doctors return to practice.
The result is a shortage of doctors who understand small-town medicine, even if they're willing to take a pay cut to work there.
"If we want to change the lack of doctors in rural America, we've got to look at the pipeline of doctors coming in," said Perkins, who is professor of family medicine at the University of South Alabama College of Medicine in Mobile, Ala.
The NRHA is pushing for any overhaul to include incentives for medical schools to recruit rural students and encourage them to return to small towns. "We really need to have a pipeline program to have people come home and treat the people they grew up with," said Maggie Elehewany, NRHA's vice president of government affairs.
In the interim, rural health providers say, Congress should dramatically increase funding for low-cost clinics that provide basic health screenings.
Sylvia Martinez, a 68-year-old breast cancer survivor living in Walsenburg, said she doubts Congress will improve rural access in her lifetime. But she's says she'll consider any movement a victory.
"I'm sick of hearing them say, 'Oh, it's not going to work.' We have to start somewhere!" Martinez exclaimed, pounding the table at a senior lunch at the Walsenburg community center.
"So what if it's not perfect? We need to do to do something. Out here, we need to do something bad."