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Rural hospital labor and delivery closures are creating maternity care deserts—and costing communities physicians, jobs, families, and economic investment.
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No Doctor, No Delivery, No Future
Aug 13, 2026
Today, less than half of rural hospitals in the U.S. still offer labor and delivery services, and since 2020, 139 of them have stopped delivering babies altogether. That's usually treated as public health statistic. It's also an economic one. Each closure doesn't just push expectant mothers into longer drives to the hospital, it pushes out physicians, jobs, young families, and the investment that follows them. So, what happens to a town after it loses its only labor and delivery unit?
The answer, it turns out, is a lot more than a longer drive to the hospital. More than a third of U.S. counties, 35.1 percent by the most recent national count, are now what researchers call maternity care deserts: places with no hospital or birth center offering obstetric care and no obstetric clinicians at all. Since the end of 2020, 139 rural hospitals have stopped delivering babies, and today less than half of rural hospitals nationwide still offer labor and delivery services.
A Closure Is Rarely Just One Loss
When Bonner General Health in Sandpoint, Idaho, ended labor and delivery services in 2023, the hospital cited a familiar mix of causes: fewer pediatricians, declining birth volume, and a legal climate that pushed physicians to leave the state. Residents were left with a drive of at least 46 miles to the nearest labor and delivery unit. In the years since, Idaho has lost roughly a third of its OB-GYNs statewide, a workforce departure that now makes it harder for other hospitals in the state to keep their own units open.
Missouri tells a slower version of the same story. The state has lost 11 hospital obstetric units since 2009, and hospital administrators there describe cross-subsidizing obstetric care with revenue from other departments because Medicaid, which finances most rural births, pays less than the actual cost of delivering a baby. One administrator put it bluntly: they are robbing Peter to pay Paul.
The Economics Are Real, Even If They're Uneven
Economists studying rural hospital closures generally don't all agree on the size of the local economic hit, and I think advocates should be upfront about that rather than overstate it. Some studies find no measurable effect on county income. Others, using longer national datasets, find real declines in employment, labor force size, and population after a closure. What is well documented is the workforce effect: one study found that a rural hospital closure was associated with an 8.3 percent drop in primary care physicians and a 4.8 percent drop in OB-GYNs practicing in the county afterward. That is not a rounding error. That is a community losing the people who would otherwise deliver its babies, staff its clinics, and spend paychecks at its businesses.
Nationally, the price tag is large. One peer-reviewed cost model put the societal cost of maternal morbidity for a single year of U.S. births at 32.3 billion dollars, and a separate analysis using value-of-statistical-life methods estimated the economic burden of maternal deaths at 27.4 billion dollars over just three years. These are not abstractions. They are the dollar value of a health system that keeps failing mothers in the same places, over and over.
A Federal Program Working Against Itself
Washington's current response is genuinely two-handed. The 2025 budget law that cut projected federal Medicaid spending by an estimated 911 billion dollars over ten years also created the 50 billion dollar Rural Health Transformation Program to help rural systems absorb the impact. States are now spending that money on exactly the kind of workforce and telehealth investments this problem needs. But the fund is explicitly a response to cuts made in the same bill, not new money layered on top of stable funding, and children's health advocates have warned it may not fully offset the coverage losses in states that expanded Medicaid. Whether this program nets out positive for rural obstetric access is, honestly, an open question, and it deserves to be tracked as closely as the closures themselves.
What Would Actually Help
Three changes would matter more than most of the current conversation acknowledges. First, raise Medicaid obstetric reimbursement, or take the value-based payment model CMS is already piloting in 15 states and make it available nationally, since reimbursement below the cost of care is the single most cited reason hospitals give for closing their obstetric units. Second, track obstetric unit closures as their own category, separate from overall hospital closures, since a hospital can quietly drop labor and delivery while staying open for everything else. Third, target new rural health funding specifically at the racial gap in maternal mortality, since Black mothers still die at more than three times the rate of White mothers, a gap that has not narrowed even as the national rate has fluctuated year to year.
None of this is a purely medical problem and treating it as one is part of why it hasn't been solved. It is a hospital financing problem, a workforce problem, and a rural economic development problem wearing a stethoscope. Communities don't just lose a delivery room when the obstetric unit closes. They lose the nurses, the anesthesiologists, and, eventually, the young families who decide it isn't worth staying somewhere, they can't safely have a baby.
Manisha Kaliaperumal is a sophomore at Creighton University studying Economics on the Pre-Medicine track. She is passionate about pursuing a career in medicine, with a particular interest in rural healthcare and maternal medicine. Her interests center on improving access to quality care and supporting the health and well-being of mothers and families in underserved communities.
Disclosure: The author researched and wrote this piece as a Health Economics intern at Aaliyah in Action, a nonprofit that provides bereavement support to families experiencing pregnancy and infant loss. The analysis, framing, and opinions above are the author's own.
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What can America250 teach us about civic identity? Explore how branding, design and shared purpose can create national symbols that unite divided communities.
Marcia Straub/Getty Images
What America250 Revealed About Civic Identities That Last
Aug 13, 2026
America's 250th anniversary should have been a rare opportunity to create a unifying national moment. America250 had a simple ambition — a celebration that all Americans could share.
Instead, it struggled to capture the public imagination, facing indifference or derision. One survey found only 53% of Americans could correctly identify America250 as marking the adoption of the Declaration of Independence in 1776. President Trump's parallel Freedom250 initiative added another national identity and another version of what the anniversary was meant to represent.
The result exposed two interconnected failures. The cultural story was never clearly owned, and the visual identity was not powerful enough to overcome that uncertainty.
Civic identities are especially difficult because they must represent people who may, on occasion, disagree on almost everything else. But when they succeed, they can become lasting symbols of belonging.
Canada’s maple leaf flag emerged from one of the most divisive political fights in the country’s history—the 1964-65 "Great Flag Debate"—yet it remains one of the country’s strongest shared symbols long after the argument faded.
So, what separates civic identities that last from those that fade?
Start with a shared purpose
Every civic identity is ultimately about belonging. Whether it’s a flag, a crest, specific colors, or a logo, the symbol tells people "this is something you’re part of."
But symbols don’t create belonging on their own. They express it.
America250’s bipartisan commission began with the right intention, but high-profile civic initiatives inevitably bring together stakeholders with different priorities and different ideas of success.
The arrival of Freedom250 made America250’s lack of alignment visible. Americans were effectively presented with two competing identities celebrating the same anniversary. The result wasn’t simply confusion over which logo belonged where. It raised a more fundamental question: which vision of America was the celebration asking people to identify with?
This is where leadership and purpose come in. Brand and culture must always work together. Leaders define the vision, purpose, and values of a group. Designers then give that shared purpose a visual expression. New York’s "I heart NY" campaign shows what that clarity can achieve. Launched in 1977 to boost tourism during a time of high crime and near-bankruptcy, it succeeded because the state knew what it wanted to say before Milton Glaser designed how to say it.
That’s why branding is a valuable strategic exercise. The process of refining an identity often drives leaders to articulate what the organization actually stands for and why it exists.
Science is US demonstrates this. The non-partisan organisation exists to bring scientific evidence into public policy. The identity we designed doesn’t try to bridge political divides through symbolism. Instead, its minimalist branding reinforces an already clear mission, putting facts ahead of visual flourish. That clarity has helped it secure more than $10 million in funding from one of America’s largest charitable foundations.
Acknowledge division and look beyond
American civic design now operates in a culture where many traditional patriotic symbols have become politically coded. Displaying a flag can be interpreted as declaring an allegiance, regardless of the person’s intention.
Ignoring that reality will not make it disappear. But designers can still aim to create meaningful symbols of collective identity.
People still want to belong. They gather around local traditions, sporting events, public celebrations and common challenges. The most effective civic identities recognize that a community is not a single uniform group. It is a collection of different groups choosing to converge.
OneSD, a San Diego-based coalition bringing together organizations across business, education, faith, and civic life, offers a useful example. Rather than relying on politically coded colors, the identity we created with them draws on San Diego itself, using sandy neutrals and watery teal. Different-sized segments converge around a central mark, expressing unity without suggesting uniformity.
Successful efforts look beyond political symbolism and instead build around the shared experiences and challenges that already unite people—from global events like the FIFA World Cup or the Olympics to the issues communities solve together every day. The strongest civic identities don't manufacture unity; they give visible expression to it. Nor do they pretend differences don't exist. Instead, they create space for people to come together despite them.
Never neglect the design fundamentals
America250’s ribbon contained an appropriate idea – different strands weaving together – but the execution struggled. The “5” was not immediately legible and the mark lost clarity at smaller sizes. As a result, the elements did not always resolve into a unified symbol.
More importantly, it failed the Coke bottle test: could someone draw it from memory or describe it in a sentence?
Compare it with the star designed for the 1976 Bicentennial. Its circular, knitted form suggested separate civic and cultural threads coming together, allowing it to appear everywhere from postage stamps to souvenirs. NASA even painted it on the Vehicle Assembly Building at the Kennedy Space Center, where it stayed until 1998, over two decades after the anniversary itself.
America250 also had to compete with an enormous volume of commercial patriotic imagery: furniture promotions, holiday discounts, and AI-generated flag graphics. Around July Fourth, the familiar palette of red, white, and blue becomes visual wallpaper.
That raises the standard for an official civic identity. It must be more inspiring than a 10%-off sale banner and strong enough to remain recognizable on everything from a Times Square screen to a backpack badge.
America250 missed the opportunity to give Americans one symbol they could all make their own. Yet the celebrations themselves showed that the instinct to come together has not disappeared. People still gathered for fireworks and local celebrations. The task for civic designers is not to manufacture belonging. It is to understand it, strengthen it and create a symbol worthy of carrying it.
With over thirty-five years of design and business experience, John Ball is known for the clarity and simplicity of his work. Additionally, a passion for public good and the arts has led to collaborations with the Smithsonian, the American Association for the Advancement of Science, and the Institute of Contemporary Art, San Diego. John also served on the Lux Art Institute’s board of directors, creating the innovative arts organization’s brand identity and overseeing its award-winning communication program for fifteen years.
Anique Mautner partners with visionary organizations to define who they are, why they matter, and how they show up with clarity and humanity. A TEDx speaker coach with a background in client-side marketing and organizational culture, she brings a unique perspective to agency work across brand strategy, messaging, and digital experience. Her work shapes high-level thinking and delivers sharp insight for leaders at global organizations (Shure, Qualcomm, Petronas) and prominent regional institutions with deep community impact (Santa Barbara Foundation, Cygnet Theatre, I Love A Clean San Diego).
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people holding flag of U.S.A miniature
Photo by Frank Kastle on Unsplash
A New Standard for Ethical Immigration Reporting
Aug 13, 2026
Seven months ago, I attended the first day of my Reporting on Race class at USC. Taught by journalist and immigration reporting expert Jean Guerrero, the course offered growth I hadn’t yet imagined, showing me how much I could evolve as a journalist in just one semester.
For the next five months, I researched and reported on an immigration story of my choosing. I wrote about how educators in Los Angeles protect and advocate for students and communities living in fear of ICE deportations. These educators organized community street patrols to keep their neighborhoods safe. Finding sources and producing the final draft took months, but it was one of the most rewarding experiences of my journalism studies so far.
This project taught me the technicalities of immigration reporting, but more importantly, it taught me to treat these stories with the care and attention they deserve. I learned how to ensure that my sources’ perspectives were shared in the most ethical way possible.
Ethical, personal immigration reporting highlights immigrants’ experiences for the public, helping individuals feel more seen and protected.
Long before I started my piece, journalists across the country had reported on thousands of immigration stories, particularly after President Trump began his second term in office.
With the rise in ICE activity in neighborhoods across the U.S., journalists and media outlets have taken various approaches to sharing immigrant stories.
Journalism has played a vital role in documenting ICE sightings, arrests, and deportations, placing an immense responsibility on the media to inform the public about these events accurately.
Understanding how to tell these stories ethically is essential to avoid perpetuating stereotypes or spreading misinformation.
Despite prevalent misconceptions, ethical and accurate reporting on immigrant communities can counteract negative impacts and foster empathy.
Reporting that fails to account for the personal experiences of immigrants can have serious repercussions on a source’s mental and physical health, as well as their ability to live a normal life.
Widespread reporting that relies on tropes or fails to consider authentic perspectives can lead to lasting harm.
The American Civil Liberties Union reported three ways the media can introduce bias into immigration reporting, often depicting a harmful and untrue image of immigrants. Examples include paid political ads that fearmonger about the border, the over-publicization of violent border imagery, and a hyper-focus on border crossings at the expense of stories about immigrants already living across the country.
The Lenfest Institute for Journalism noted that newsrooms themselves are navigating these challenges. They offer a list of strategies to help journalists avoid the pitfalls identified by the ACLU and better serve immigrant communities.
Ultimately, bias and discrimination have long influenced immigration reporting, often sidelining the individual stories of those living in constant fear.
Immigration reporting is neither easy nor simple. It involves complex layers and risks that many readers may not realize. A primary concern for journalists is the potential danger these stories pose to vulnerable sources.
Journalists must grapple with difficult questions: when to provide anonymity, how to protect a source’s workplace, and how to safeguard their identity.
Despite these risks, potential threats can be minimized if the reporting process is handled correctly. By prioritizing accuracy and care, it is possible to protect a source while ensuring their story is heard.
Immigration reporting involves real lives and families. When approached correctly, a journalist can bring awareness to these issues without putting their sources at risk.
Despite the surge in reporting over the last few years, there are always opportunities to improve how news organizations share these sensitive stories with the public.
5 ways to make immigration reporting more ethical:
- Provide sources with the information they need to give informed consent. Many immigrants have no experience speaking to the media; it is a journalist’s responsibility to explain the implications of having their name associated with a story.
- Offer anonymity to especially vulnerable sources. In consultation with editors, journalists should allow sources to speak on the record anonymously when appropriate. This protects a source’s identity while still allowing their story to reach the public.
- Hold news outlets and journalists accountable. Reporters and media organizations should be held to high standards of sensitivity and accuracy, ensuring they do not endanger sources.
- Seek out stories overlooked by mainstream media. Local stories in neighborhoods, schools, and businesses often reflect major topics like immigration. Localizing these issues brings more personal perspectives to the forefront.
- Diversify storytelling platforms. Beyond print and television, social media is a powerful tool for keeping both the public and immigrant communities informed about ICE activity. For example, L.A. Taco’s Daily Memo shares ICE sightings on Instagram and YouTube.
Ethical immigration reporting is essential for helping audiences understand the immigrant experience and making these communities feel heard. However, there is always room for improvement for both journalists and audiences.
There must be a collective effort from news publications to implement ethical strategies and pressure from the public to demand meaningful stories about the communities they care about.
I still draw on the lessons from my Reporting on Race class. What stayed with me most is that the most powerful stories often belong to those who haven’t yet shared their perspectives with the media—their voices are the ones that can truly shift the conversation about immigration in the United States.
Daniela Mattson is a Fulcrum Fellow, a bilingual multimedia journalist who prioritizes diverse storytelling in my reporting.
Beyond the Border: A New Standard for Ethical Immigration Reporting was first published by the Latino News Network and republished with permission.
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A factory with smoke coming out of it
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How Utah’s H.B. 222 Set the Stage for State-level Climate Liability Shields
Aug 13, 2026
This nonpartisan policy brief, written by an ACE fellow, is republished by The Fulcrum as part of our partnership with the Alliance for Civic Engagement and our NextGen initiative — elevating student voices, strengthening civic education, and helping readers better understand democracy and public policy.
Background
Natural resource extraction and processing comprise a significant portion of economic activity in the state of Utah. There are five oil refineries in the state, and as of 2023, it is ranked 9th in the U.S. for crude oil production. Utah’s energy sector contributes $12.1 billion to the state’s gross domestic product (GDP), which represents 6.3% of the state’s total economy and 74,200 jobs as of 2019. Meanwhile, the mining sector contributes $7.7 billion to the state GDP, 4% of Utah’s total economy and 56,700 jobs.
Energy production has raised concern in Utah due to its impact on the environment and contribution to climate change. 44 percent of Utah’s carbon emissions are produced by the electric power sector. These emissions are likely high because of the relatively high presence of coal and natural gas in the state. There have been recent court cases in Utah against the gas and oil industry, mostly stemming from youth climate groups concerned with emission levels. In December of 2025, Our Children’s Trust filed a suit against the Board of Oil, Gas, and Mining claiming that fossil fuel emissions were putting children’s futures at risk. It follows a previous lawsuit, Natalie R. v. State of Utah, which was brought to Utah’s Supreme Court by young activists as well, but was later dismissed in March of 2025.
Introduction to House Bill 222
Passed in 2026, Utah House Bill 222 establishes a climate liability shield that protects individuals and organizations from civil or criminal liability related to greenhouse gas emissions. Utah’s climate liability shield legislation protects entities from climate-related legal challenges, but does not apply to emission restrictions and permits, which are still valid under the bill. Thus, if an individual or organization violates the legal limit on the amount of greenhouse gas emissions or pollution permitted under Utah law, they are still at risk of legal pushback from governing bodies. The shield, however, provides a level of legal protection that has not existed before.
Why Do Advocates Support H.B. 222?
Liability cases limit power generation
Arguments for the protections provided by H.B. 222 stress the necessity of the energy sector and its ability to produce power for the state. Representative Carl Albrecht, the chief sponsor of the bill, argues that shields of this kind would “prevent plants from being shut down,” and would evade lawsuits which “limit power generation.” Historically, Utah has been an energy exporter, but heightened demand has led to the state consuming more energy than produced. However, it is still able to meet its baseline energy needs. Utah recorded an annual net generation of 35 million megawatt-hours of energy and a consumption of 34 million megawatt-hours in 2024, suggesting that the state is still meeting its baseline electricity needs despite the growing demand.
A climate liability shield may allow businesses in Utah to increase energy production. It has been shown that legal challenges to energy infrastructure reduce investment and create costs for consumers, another argument made by Representative Albrecht. Another argument shows that cumulative climate liability may not actually reduce emissions, but instead move production. In other words, climate liability cases against energy producers could lead them out of Utah, reducing energy production in the state.
Government regulation is too overbearing
Proponents also justify the legislation though claims that the state is encroaching too heavily on the actions of individuals and organizations. Emission regulations are set at the federal level, while climate cases attempt to regulate greenhouse gas at a state level. This has led oil industries in Utah to argue that the regulation of emissions via state-level climate liability cases is an example of state powers overstepping. The American Petroleum Institute, a trade association representing oil and natural gas companies in the United States, is adamant about limiting state overreach. They have even included it in their 2026 Agenda, arguing that it would increase the affordability and security of American energy.
Who Do Opponents Critique H.B. 222?
Lack of accountability for polluters
A major argument from opponents of H.B. 222 concerns accountability. Without the ability to try individuals or organizations for their emissions, there would be few ways to hold them accountable for their impacts on the environment. Environmental groups and scientists argue that Utah residents would not be able to adequately hold polluters responsible under the protections established by H.B. 222, and large oil and gas companies will not face consequences for the harm that their emissions cause. Without access to legal pushback, residents affected by emissions will have no ground to hold energy companies responsible.
Public health and environmental costs associated with greenhouse gas emissions
There are significant risks tied to greenhouse gas emissions. In Utah, high levels of volatile organic compounds (VOCs) are caused by oil and gas emissions. These toxic chemicals have serious negative health outcomes for those who are exposed to them, including general irritation, damage to internal organs, and increased cancer risk. Additionally, opponents of the bill argue that Utah is already facing the effects of climate change, and a lack of accountability would allow polluters to continue contributing to the climate crisis. Serious concerns about the future of the state’s natural areas and habitats have been raised in response to the passage of H.B. 222 and the negative environmental outcomes that would come from unchecked energy production. Opponents of the bill claim that the liability shield would not be needed if these industries were not actively causing harm for Utah residents. The costs tied to increased health and environmental protections are argued to outweigh those associated with limited power generation.
National Significance
While Utah was the first state to sign a climate liability shield, four other states have since moved to enact their own climate liability protections, and there have also been federal attempts to shield polluters from legal damages. Iowa, Oklahoma, Tennessee, and Louisiana’s state-level climate liability shields are similar to Utah’s in that they would limit the extent to which energy industries would be held responsible for their greenhouse gas emissions. On the federal level, Texas U.S. Senator Ted Cruz introduced a bill in April that would shield any individual involved in the energy market, from extraction to marketing, from civil damages related to their impact on the planet. This bill would not explicitly impact federal emissions caps, but would protect the energy sector from civil actions.
How Utah’s H.B. 222 Set the Stage for State-level Climate Liability Shields was first published by ACE and republished with permission.
Sophia Wind is an undergraduate student at Oregon State University, where she is pursuing a major in Public Policy with minors in Statistics and Economics.
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