Opinion - Medicaid cuts will harm rural Republican communities most

Yahoo

02-06-2025

Though President Trump promised a 'big beautiful' budget bill, what narrowly passed the House of Representatives in the early morning hours of May 22 will be anything but a big beautiful win for millions of marginalized Americans, and Medicaid beneficiaries won't be the only ones who feel the pinch.
In fact, if passed, this legislation would destabilize the publicly insured and privately insured alike, especially in America's many rural communities.
Trump's budget dramatically reduces the robustness of the federal social safety net, on which three in ten Americans (including nearly half of children) rely for critical programs ranging from health care to food security. Most drastically, the bill is set to cut Medicaid by nearly $800 billion over 10 years, add burdensome and ineffective work requirements and kick as many as 13 million people off their health insurance.
These cuts will have demonstrably negative consequences for millions of Americans, including those who are not themselves enrolled in Medicaid. The irony is that despite nearly every Republican House member voting for its passage, it is rural, Republican majority communities that will face the most extreme consequences.
Nineteen percent of Americans, or over 72 million, are insured by Medicaid and the share of the 66 million rural Americans on Medicaid is even higher at 23 percent. And not only do America's rural communities tend to vote more conservatively, but this is even true of Medicaid beneficiaries, the very people whose health coverage Republican legislators seek to strip away.
Survey data from the Cooperative Election Study reveal that the majority of rural Medicaid beneficiaries in Republican states and districts are people who identify as Republicans. This is especially true in Republican congressional districts and states with Republican senators.
For example, a majority of residents in districts held by some Republican congressmen — Reps. Hal Rogers (R-Ky.) and David Valadao (R-Calif.) come to mind specifically — are enrolled in Medicaid (54 percent and 64 percent, respectively). About 40 percent of residents of House Speaker Mike Johnson (R-La.) are enrolled in Medicaid.
What's more, in most of these cases, the beneficiaries are Republican voters themselves.
Meanwhile, in states with two Republican senators like Arkansas and Kentucky, nearly 30 percent of residents are enrolled in Medicaid, and between 40 and 55 percent of Medicaid beneficiaries reside in Republican-leaning rural areas.
In each of these instances, survey data from the Kaiser Family Foundation show that the majority of even Republican beneficiaries approve of Medicaid. Not only do 61 percent of Republicans see Medicaid as important to their communities, but 67 percent of Republicans want Congress to preserve or increase Medicaid funding.
Political scientist David Mayhew famously argued that members of Congress are single-minded seekers of reelection. Yet even with broad public support for Medicaid and health care's salience in the minds of voters, Republicans' efforts to cut Medicaid would remove health insurance from their own voters.
Beyond the effects experienced by enrollees directly, the proposed Medicaid cuts will reverberate throughout and harm all residents of rural communities by undermining the financial security of rural hospitals.
According to estimates from the Center for Healthcare Quality and Payment Reform, not only have nearly 200 rural hospitals already closed in the last two decades, but over 300 rural hospitals face 'immediate risk' of closure in the coming years. What's more, the vast majority of these vulnerable hospitals are in Republican majority communities in the Republican states that failed to expand Medicaid under the Affordable Care Act.
A key reason why these hospitals face closure is due to 'uncompensated care' costs, which accrue when uninsured or underinsured patients seek medical treatment for which they are unable to pay. Not only do rural hospitals experience higher rates of uncompensated care, but it proves more debilitating than in the case of research hospitals, which can steady themselves with higher insurance reimbursement rates and subsidies.
Medicaid expansion has proven critical in strengthening these hospitals' financial security, because it drastically decreased the percentage of people showing up at hospitals without health insurance. The result has been that more rural hospitals have been able to remain open.
In contrast, roughly 80 percent of rural hospitals that have closed since the passage of the Affordable Care Act have been in the Republican states that failed to expand Medicaid.
The economic and health effects of rural hospital closures are catastrophic for all residents of affected communities, regardless of their insurance status. Numerous studies have shown that rural hospital closures lead to significant increases in mortality. Additionally, birthing outcomes and access to obstetric-gynecological care tend to suffer following closures.
Many of these negative effects are driven by the drastically increased distances individuals must travel to receive care. When a rural hospital closes, patients are left to travel on average 20 miles farther to receive common health care services, and 40 miles farther for specialized care.
That time is precious in the setting of acute health problems. Regardless of one's insurance status or provider, the farther you are from a hospital following a car crash or after a stroke, the worse the consequences.
For most closures, Republican voters themselves and those with lower incomes are the people who face the longest distances to care following closures. Cutting Medicaid will only further restrict access to care and worsen health outcomes for rural people, regardless of insurance status.
Outside of the immediate health effects, hospitals are typically the largest employers in congressional districts, and that is no less true in rural communities. In fact, the health care sector can supply as many as 10 percent of the jobs in a rural community.
While some have argued that rural hospital closures are a symptom of communities' economic decline, their effects are also unmistakable, leading to a marked increase in unemployment and a reduction in residents' average income.
In his recent New York Times op-ed, Sen. Josh Hawley (R-Mo.) argued against Trump's budget. He wrote that while Trump promised to protect working-class tax cuts and social insurance programs such as Medicaid, the 'Wall Street wing' was instead seeking to slash health insurance for the working poor in a manner that he characterized as 'both morally wrong and politically suicidal.'
The data are clear and Hawley is correct. Trump's budget will actively harm the health and incomes of rural communities and Republican voters, well beyond those who themselves are enrolled in Medicaid.
Michael Shepherd is an assistant professor of Health Management and Policy at the University of Michigan. Miranda Yaver is an assistant professor of Health Policy and Management at the University of Pittsburgh.
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