3 issues that could haunt Hillary Clinton across rural America
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Hillary ClintonHillary Rodham ClintonSanders campaign chair: Don't buy David Brock's blame game for Clinton loss Clinton aide hammers Trump campaign: 'Own up to' giving alt-right a platform Messer eyes challenging Donnelly for Indiana Senate seat MORE's contradictory and evolving positions on a trio of issues near and dear to rural voters could give her bid for the presidency heartburn in Iowa, New Hampshire and beyond.

Rural Medicare

In 2003, Clinton was one of only 12 senators to vote against an amendment by Sen. Chuck Grassley (R-Iowa) that altered Medicare payment formulas to increase payments to providers in rural areas, bringing them in line with urban areas.

Not only did dozens of Republicans vote for the Grassley amendment (as did then-Sen. Joe Biden [D-Del.]), but then-President George W. Bush praised Grassley for pushing the issue and pledged that he would support "increased funding for rural Medicare providers" as part of the bill. The final version of the Medicare Modernization Act of 2003 included a 5 percent add-on payment for rural doctors and a 10 percent bonus payment for rural HPSAs (Health Professional Shortage Areas).

However, during Clinton's last run for the White House, in the Association of Health Care Journalists (ACHJ) "Election 2008: Health Care" guide, she stated that she "will work to make Medicare and Medicaid reimbursements fair so that all communities in our country — including those in rural areas that traditionally have lower reimbursement rates and, as a result, have difficulty recruiting doctors — have qualified doctors."

This past August, when she released her policy plan for rural America in Ankeny, Iowa, Clinton said "Today, our health care system has changed dramatically, but it's still too difficult for families in rural America to find quality, affordable health care. And I know many families here in Iowa are worried about even more rural hospitals closing. Telemedicine can help — and we should streamline licensing and explore how to make that reimbursable under Medicare."

Areas of medical underservice are a huge problem for the hinterlands. Although 21 percent of Americans live in rural areas, only 9 percent of the nation's physicians practice there. According to the Ohio Department of Health, 50 of the state's 88 counties have a shortage of primary care physicians and many of the doctor-deficit areas are rural. The Pennsylvania Rural Health Association reports that 22 percent of the state's population lives in areas designated as either an HPSA or a Medically Underserved Area (MUA) and that these residents are more likely to be rural, living in poverty, with limited access to transportation. The Keystone State also has a severe distribution problem with doctors, where almost half the physicians in the state practice in only three counties (Philadelphia, Montgomery and Allegheny), even though the remaining 64 counties account for almost three-quarters of the population. In Texas, 47 rural counties have no hospital, 176 of the 254 counties are designated as MUAs and rural Texas faces critical shortages of dental health, mental health and pharmacy providers.

Asked about the disconnect between Clinton's actions and words, Carl J. Rod, director of education for the respiratory care program at Platt College in Moore, Okla., said "this has always stuck in my craw and this is the reason to this day I'm not a fan of Hillary Clinton." Rod, who spent 35 years in Jefferson, N.H., a small town of 1,107 high in the White Mountains, and used to chair the state respiratory care licensing board, noted that "no matter where you look in this country, small community hospitals are more threatened." Recalling a hospital in the state's northernmost county, Rod lamented that "that hospital is nothing more than a Band-Aid station."

Ethanol/Renewable Fuel Standard

As a freshmen senator, Clinton opposed three measures to expand ethanol production and establish a Renewable Fuel Standard (RFS). Beginning in 2002, she voted against an energy bill that created a national renewable standard to increase the use of agricultural commodities for energy. In each case, her votes were the opposite of the position of the Democratic-leaning National Farmers Union, which used them as key votes in their ratings for 2002-2004. If you are keeping score, then-Sen. Biden voted the pro-NFU position each time.

Clinton's position on renewable fuels began to change at the start of her last presidential bid, when she voted for a bill in 2007 that doubled ethanol and expanded the RFS to include biodiesel and cellulosic sources. Some industry leaders are willing to give Clinton a pass on her Senate voting record. "Early on, she probably didn't understand the RFS and the value of the RFS but I've talked with her and I believe she is very supportive now," says Growth Energy CEO Tom Buis. (Buis helped raise $35,250 for Clinton's campaign this year.)

In rolling out her rural plan, Clinton never mentioned ethanol, saying instead that she would work to "strengthen the RFS." If one of the knocks on Clinton is that she is too poll-driven, cynics will say that her current support of the RFS dovetails with recent public opinion that 62 percent of Americans back the policy.

"Some of her initial perceptions were not favorable, but her pro-RFS record goes back a long way to the 2007-2008 cycle," says Monte Shaw, executive director of the Iowa Renewable Fuels Association. He adds, "We love it when people come to learn about our issue; there is an education process that goes on," noting that Clinton has visited ethanol plants and spoken with producers. "Just because someone has had some issues, we don't brand them with a scarlet letter."

For his part, Sen. Bernie Sanders (I-Vt.), who also voted for the 2007 ethanol/RFS bill his first year in the Senate, has also received some accolades from the bipartisan group America's Renewable Future.

MTBE

MTBE, or methyl tertiary butyl ether, was a gasoline additive that was widely used in the 1990s to help refiners comply with clean air standards. Unfortunately, MTBE is highly water soluble, meaning that leaks from underground gasoline tanks spread quickly to water supplies, where it can persist for decades. In addition to making drinking water smell and taste like turpentine, MTBE has been shown to cause cancer in laboratory animals when inhaled; the federal Environmental Protection Agency (EPA) has said that it is a likely carcinogen in drinking water as well. It is also expensive to remove; the Association for Environmental Health and Sciences has determined that cleaning up all U.S. contamination would cost between $1 billion and $3 billion. Rural towns with small tax bases can't afford expensive environmental remediation bills that put a huge strain on their municipal budgets.

In June 2005, Clinton voted against an amendment to ban MTBE and require refiners to use 7.5 million gallons of renewable fuels annually by 2012. Biden was one of 70 senators to vote the other way.

Before Congress acted, 25 states had banned MTBE because it contaminated public drinking water supplies. In 2003, under then-Republican Gov. Craig Benson, New Hampshire became the first state to sue 22 oil companies because of MTBE water pollution. In 2013, after the longest trial in state history, a jury found ExxonMobil liable and ordered the oil behemoth to pay $236 million to clean up the pollution.

In Pennsylvania, 46 water systems serving 969,000 people have been affected by MTBE pollution. In 2004, Kathleen A. McGinty, then-secretary of the Pennsylvania Department of Environmental Protection (DEP), testified in favor of a Pennsylvania ban on MTBE. McGinty, now a Democratic candidate for U.S. Senate is a Philadelphia native who chaired the White House Council on Environmental Quality and acted as deputy assistant to President Bill Clinton. She was appointed DEP secretary by former Democratic Gov. Ed Rendell (a Hillary Clinton supporter) in 2003. In April 2004, McGinty told state lawmakers the extent of MTBE pollution across Pennsylvania:

In 2003, the United States Department of the Interior's U.S. Geological Survey, with the cooperation of DEP, completed a comprehensive evaluation of the extent of MTBE contamination of the Commonwealth's groundwater. The Survey found that 11 [percent] of over 350 "ambient" groundwater samples contained trace levels of MTBE and, in statewide water samples associated with leaking underground storage tanks, 22 [percent] were found to be contaminated with MTBE. While the vast majority of the detections were well below 20 ppb [parts per billion], the Survey found that MTBE contamination of the Commonwealth's groundwater is not the result of freak occurrences, nor is it completely isolated to limited geographic areas.

In tiny Lehman Township in Luzerne County (population 3,508), McGinty said that the EPA spent nearly $3 million between 1993 and 1998 to recover over 10 million gallons of MTBE-contaminated groundwater, provide maintenance and residential carbon filter systems, and provide bottled water. The release affected about 50 residences and a school in the Lehman area. The state then spent another $2.5 million on a new groundwater treatment system, providing operation and maintenance of the treatment system, continuing to maintain residential carbon filter units, and providing bottled water.

MTBE had some strong protectors on Capitol Hill, including former House Majority Leader Tom DeLay (R-Texas). The lawmaker owned stock in ExxonMobil and MTBE was manufactured in his Texas district.

So do Clinton's actions on these issues speak louder than her words? We will await the results of the upcoming caucuses and primary battles to find out.

Barron is president of MLB Research Associates, a political consulting and rural strategy firm in Chesterfield, Mass.