"It really gets down to one thing: how isolated are you?" she says. "I spend a lot of time explaining to people who may need emergency care one day: we hope to reach you with a paramedic within an hour, and get you to a hospital in another hour."
For city folks, it's easy to lose perspective, Miller said. Frontier areas are not just ultra rural. Urban areas are home to 80% of the U.S. population, but just 4% of America's geography.
Today's definitions of urban and rural have evolved, more or less by default, Hirsch says. First, it was agreed in general what areas would be called "urban." Everything else was classified as "rural," including that which was truly frontier.
Today, however, the term frontier is all too frequently lumped in with rural, which is 96% of the nation's real estate, but only 20% of its population. What is rural is usually much more urban than what is frontier. Rural and frontier, she said, are two different worlds.
"The frontier is not empty," Miller says. "These are places from which much of our national wealth is derived, from mining, agriculture, ranching, and many Native Lands. There is someone there, maybe a ranger station, a fire watcher or a national park that gets 12 million visitors a year driving through."
Miller explains the problem by describing the challenges of providing healthcare in Lordsburg, a 4,000 population town in New Mexico 50 miles from the Mexican border in Hidalgo County, an area with only 1.7 people per square mile and about as remote as anyone can be in the U.S.
A few years ago, Miller says, Charlie Alfero, CEO of HMS Health System, was trying to start a two-bed extended care service in his clinic so patients who don't need to go to the hospital 50 miles away in Silver City, or 150 miles away to El Paso, can get appropriate care closer to home. The project had been planned for years and was ready to go, or so he thought, Miller said.
But the day before his pilot project was to be approved as part of federal legislation, someone changed the rules, eliminating him from opening his service because his clinic was less than 75 miles away from the nearest hospital.
That was unfair, Miller said, because in an area this rural, many patients live in towns like Rodeo or Playas that are already at least 25 miles farther away.
"That structural barrier left out many other facilities that had worked for the legislation," she says.
Miller enumerates dozens of ways in which very rural areas are discriminated against. Bigger areas, for example, get more money per capita than smaller ones and tend to fund projects in pieces rather than taking a holistic approach to healthcare.
Frontier areas have extreme difficulties recruiting health professionals. They may be lumped in with multiple county groups, partners who may not always like to share.
Miller sums up the issue this way. "Do people throughout the entire country have access to a minimum amount of services, and if they don't, how do we create a system that allows them to get them?"