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We were interviewing ten residents of the Kickapoo Valley in southwestern Wisconsin-a valley named after the Kickapoo River which includes towns like Cashton and Ontario in the north, Soldiers Grove and Gays Mills in the south, and Rockton, La Farge, Viola, and Readstown in between. It is an incredibly scenic area; the communities are small (200 to 700 people); many of these villages are located in the flood plain of the river; and the highest point in the valley is Wildcat Mountain, one of Wisconsin's most scenic state parks.

The interviewees were sharing their visions for the future of the Kickapoo Valley. James De Leine, one of two physicians in La Farge, shared the current realities as well as his visions for the future of health care in the valley. Somehow it felt as if he was speaking for a large portion of the population that lives in rural America:

The single biggest problem in the Kickapoo Valley is people who are uninsured or under insured . . . these problems [with insurance] are due to the impoverished nature of the community and the lack of jobs with health care benefits.

There are several issues that need to be addressed in the valley . . . one is universal health care-the state or nation simply needs to find a way of providing health care for all . . . I believe it's more important to provide health care for all people than to continue investing our soaring health care dollars on transplants and sophisticated tests for those who are fortunate enough to have insurance.

We also need to be recruiting for another full-time doctor in La Farge . . . we just have two physicians and both are stressed by being on call 24 hours a day . . . while we are recruiting right now, it is difficult when we are asking people to be on call 24 hours a day at a fee, rate, and salary that is lower than in urban areas . . . I am much more satisfied living and practicing in this area and I hope to be able to communicate that perspective to doctors who might serve with us in the community.

Finally, we need to be continually upgrading our medical technology and our backup linkages with area hospitals . . . If we had a cardiac arrest on Main Street we would have all the equipment and skills to respond, but we're not able to address all medical problems and we need to expand our capability to respond directly or provide people with appropriate care in hospitals outside the community.

There are several forces at work helping and hindering us from reaching our vision for health care in the valley . . . on the one hand, we have had the support of our community in expanding the clinic and the area hospital also has been supportive of our regional medical clinic . . . on the other hand, the inherent poverty in the area is a force that is working against us and the indebtedness of medical graduates makes coming to an impoverished area a problem.

I think there are three policies that need to be addressed at the national level . . . the most important thing that could be done is to provide access to health care for all of our citizens . . . we also need to look at the differential rate of reimbursement for rural health care providers . . and finally, family practice should be a high priority for training programs in the health care field.

La Farge, Wisconsin is fortunate to have a doctor with the passion, commitment and vision of Dr. James De Leine. And Dr. De Leine is fortunate to have the support of his local community and the area hospital. Not all rural communities are this fortunate. Still, the comments above highlight many of the problems experienced in rural communities: rural poverty, a growing population of elderly persons, an overall decline in population, residents who are uninsured or under insured, lack of equipment and specialized backup services, lower rates of reimbursement for rural providers, the lack of health care staff trained as generalists, and the difficulty of attracting qualified staff to rural areas.