This is a weird self-perpetuating conundrum. If you live in a rural venue, the quality of justice you will receive is far less rewarding than you would receive for the identical event in Philly or Pittsburgh. Outside the major cities in Pennsylvania, voters are fairly conservative or far less democratic and hence liberal in their views. This more conservative bent is a major factor in deciding whether I will file a medical malpractice case for you in a rural county. The answer is almost always nope. And even simple auto cases get lower values in the rural areas. It is just the way it is. So, what is happening is that people in more rural areas do not get the justice or vengeance that they would like to get as compared to their more urban fellow citizens. The result of this is that there is less of a negative feedback loop for medical providers in the area. There are fewer malpractice suits and even bad instances of malpractice are not brought because the reward in the conservative venue will not outweigh the costs of pursuing the case. This then perpetuates a view among my more conservative clients that life is not fair and that they are not entitled to the same justice as one would get in Philly. They are right, but the reason that they are right is wrapped up in their desire to live in a more rural, conservative area. You don’t get big jury verdicts in conservative venues. It will happen periodically, but it is unusual. I once had a now-retired judge in Delaware County tell me that jurors there toss around nickels like they are manhole covers. And Delco is not near as bad as more northern or western venues.