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The End of the Rural Hospital

Nearly 700 rural hospitals face the risk of closure—a problem that will only be exacerbated by an Obamacare repeal.

On Election Day, rural American voters helped hand a historic upset victory to President-elect Donald Trump. Now, some may have to pay for it with their health.

With Trump’s inauguration just around the corner, Republicans in Congress are already working to make good on their longtime promise to dismantle President Barack Obama’s signature Affordable Care Act. The Hillreports that Republicans in the House of Representatives want to send an Obamacare repeal bill to Trump by no later than February 20th; in the meantime, their GOP colleagues in the Senate plan on voting on a budget package designed to effectively eliminate parts of the sweeping health-care law. According to Vice President-elect Mike Pence, Trump plans on attacking the legislation through executive action on his first day in office.

The consequences of a repeal, according to recent research, would be devastating to the 20 million working-class Americans now insured under the ACA. HR 3762, an October 2015 Republican plan designed to roll back Obamacare tax credits (and a model for Trump-era repeal efforts in Congress), would leave some 22 million Americans uninsured, according to a Congressional Budget Office report. A more recent December analysis by the left-leaning Urban Institute suggests that the number of uninsured people in the United States would increase by nearly 30 million by 2019, or nearly 75 percent, “as a result of eliminating the premium tax credits, the Medicaid expansion, and the individual mandate.”

It’s those rural communities that will likely experience the long-term consequences of an Obamacare repeal in a uniquely visceral way — the disappearance of their local hospital.

Local hospitals provide sustainable access to health care to more than 62 million Americans in often-poor rural communities, according to National Rural Health Association CEO Alan Morgan, serving “vulnerable Americans that are older, sicker, and poorer than their urban counterparts.” But these essential community organs have been in decline for years: Kaiser Health News reports that more than 70 rural hospitals have closed in the past six years, while nearly 700 more — one-third of the nation’s total — face the risk of imminent closure.

Local hospitals provide sustainable access to health care to more than 62 million Americans in often-poor rural communities.

That’s where Obamacare comes in: Some 1.7 million rural Americans were able to purchase health insurance on government exchanges in 2016, according to the Department of Health and Human Services, an 11 percent increase over the previous year. The expansion of Medicaid under the ACA provided a much-needed financial boost for cash-strapped local hospitals, and the ACA’s 340B drug discount plan would have provided more than 1,100 facilities with access to critical medications at a greatly reduced cost, yielding additional savings for both consumers and struggling health-care providers. The Atlantic’sVann R. Newkirk II gives the masterful example in West Virginia’s unexpected embrace of Obamacare:

In the “coal-miner country” of Appalachia, the Affordable Care Act has been vital in shoring up collapsing rural-health systems that have become overburdened with the mounting health problems of their constituents. West Virginia, which has been wracked by public-health problems, pollution, and has the most per-capita drug deaths in the country, has had to embrace Obamacare’s Medicaid expansion and subsidies in order to provide affordable healthcare for all those coal miners, other low-income workers, and their extraordinary rates of disease and disability.

The irony of an Obamacare repeal is that it would disproportionately affect so many of the very voters who put Trump in office. Some 8.9 million white Americans have gained coverage since October of 2013, more than African-American (three million) and Hispanic (four million) citizens combined, according to estimates by the Department of Health and Human Services. More than 80 percent of those Americans who would lose their health insurance are working class, per the Urban Institute; another 80 percent don’t have a college degree. And yet, Gallup data analyzed by the Wall Street Journalrevealed that counties that experienced significant declines in their uninsured rates since 2008 came out for Trump and his promise of repeal in a big way.

But why would these rural Americans vote to gut an essential organ of their local community? Admittedly, Obamacare hasn’t taken root in rural communities as it has in places like, say, New York City. Research suggests rural communities were generally at a disadvantage in the first years of the legislation, and it’ll be the poorest taxpayers who are hit hardest when Obamacare premiums inevitably rise — as they already have. The National Advisory Committee on Rural Health and Human Services urged HHS to aggressively increase outreach and accessibility of the ACA as recently as 2014. If rural Americans disproportionately benefited from the ACA, it didn’t translate into political resolve.

During the course of the 2016 campaign, Trump promised to “repeal and replace” Obamacare. Thanks to congressional Republicans, he may end up getting his wish — but to the very voters who put him in office, there will be no replacing those essential community health centers they desperately need.