Since 2010, I have incorporated Remote Area Medical (RAM) into my medical ethics teaching. RAM is an organization that relies on corporate donations, individual charitable donations, and time-and-skill donations by health care providers to provide healthcare boot camps for 2-3 days in areas with poor access to care. This poor access to health care can be from lack of insurance coverage or from geographic lack of providers; both tend to be in play in rural communities. The Affordable Care Act (ACA, AKA Obamacare) went some way to alleviating the former. Those gains are now under threat from attempts to repeal it and replace it with legislation that does not provide comparable attention to the needs of rural Americans.

This woman traveled 75 miles to see a Remote Area Medical dermatologist, who removed two lesions from her back and sent them to a pathology lab. After receiving results, RAM’s doctors follow up with patients by phone. Credit Larry Towell/Magnum, for The New York Times

I routinely use RAM to get students, who often have very little understanding of how access to health care works in the US, to understand the impetus that led to the Affordable Care Act of 2010 (AKA Obamacare).  While RAM now has a full length documentary and has been profiled in many news programs and articles, the one that I use is Mary Otto’s 2008 “Hidden Hurt” from the Washington Post in 2010, and the two accompanying short 5-minute videos (you may have to try several browsers to get the older HTML code on the videos to work for you; Chrome couldn’t do it but Explorer/Edge did). This multimedia package profiled a RAM visit to Wise County, Virginia.

What this article and the videos do is show the kinds of obstacles that rural and/or low-income people face in getting care, especially dental care which is often not covered by health insurance and where rural folks may not have access to fluoridated water. In particular, one of the videos illustrates viscerally that hard-working people who have never been long-term unemployed can be in a situation where they have literally never had employer-provided health insurance, simply because of the kinds of jobs available in their area. It illustrates the folly in basing a system around employer-provided insurance and in assuming (wrongly, so very wrongly) that people who don’t have health insurance brought it on themselves from laziness. Yet this latter myth persists.

The ACA has somewhat alleviated the issue of insurance coverage in rural areas in part by expanding Medicaid and also by expanding coverage for necessary services like drug and alcohol addiction treatment. As for the issue of sparse geographic access to providers in rural areas, medical school loan forgiveness programs and Visa programs for foreign nationals with medical skills have long been used to try to resolve this problem with only some success. But the US faces the prospect of repealing the ACA without replacing it with something that bothers to concern itself with impact on rural America. And indeed, the impact of the House AHCA and/or Senate Reconciliation Bill on rural Americans would be profound.

As the Commonwealth Fund reports, the ACA repeal bill “imperils the nursing homes, hospitals, and organizations that serve rural patients” and “threatens insurance coverage for over 200,000 people with opioid addictions.” Rural hospitals, already under strain, could see an 18% reduction in Medicaid funds if ACA is repealed with the current predicted Medicaid cuts. High Country News, which serves Western US rural areas, ran an article a week ago on how this form of repeal-and-replace could harm ranchers and farmers.
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…according to recent reports, many Americans who gained insurance under the Obama administration’s Affordable Care Act now stand to lose it — especially agricultural workers in the rural West.

The AHCA proposal would have major impacts on many aspects of current health care, but the debate over the bill centers around three issues that disproportionately affect rural communities and agricultural workers. First, the AHCA would drastically scale back coverage under federal programs like Medicaid, which was expanded in many states under the ACA. Second, the plan would likely cause fewer people to enroll in plans on the individual marketplace, where people who can’t get coverage through an employer, spouse or Medicaid buy insurance. According to a May report from the Joint Economic Committee, that would cause premiums to increase for individuals that remain covered there. And third, the AHCA could also make it harder for some people to gain coverage because of pre-existing conditions.

“(The AHCA) would devastate rural communities, including increasing the number of uninsured, stripping $839 billion from Medicaid, threatening rural hospital closures and destabilizing individual marketplaces,” Sen. Martin Heinrich, D-New Mexico, ranking minority staff member on the Joint Economic Committee, said in a recent statement.

The High Country News article has a very helpful graphic showing overall the percentage of people in primarily rural states who depend on Medicaid, and the percentage in those states who are agricultural workers who depend on Medicaid. I recommend that you click through. Notably, the Medicaid coverage rates for agricultural workers are 27% in California, 23% in Arizona, 21% in ne Mexico, and 20% in Oregon. As HCN points out, prior to the ACA, only 2% of Montana’s residents were covered by Medicaid. After the ACA’s Medicaid expansion, 14% are.

One of the reasons that so many people in rural areas and in agricultural jobs rely on the ACA’s subsidies and marketplaces, as well as the Medicaid expansion, is that they do not have access to steady employer-provided health insurance. Many are self-employed, hard-striving and hard-working folks. This applies not only to lower-income individuals but also to landowners who run ranches and farms on their property and employ relatively small cohorts of workers, so small that they also do not have access to employer-provided insurance. Others work unsteady contingent hours, only part of the year, such that they do not qualify for any employer-provided benefits that their employers might offer to full-time employees. In Medicaid expansion states overall (the Supreme Court left it up to states to decide whether to accept the expansion), rural residents make up a larger share of the ACA enrollees than they do of the state’s population. In other words, they benefit more than do non-rural residents. Correspondingly, if those particular benefits are eliminated under repeal-and-replace of the ACA, as they do stand to be eliminated, rural residents will be disproportionately harmed.

So many people who are already teetering on the edge need some form of social support. Government can provide that. Perhaps non-governmental organizations like RAM also can, for some people. But what organization has the reach to handle all persons everywhere? It is no accident that rural mail delivery is enabled by the US Postal Service (the major corporate delivery services often use the USPS networks to access rural clients because building their own is cost-prohibitive in a for-profit environment).

But no organization, government or not, can provide aid to people who it doesn’t even pay attention to when it is making policy. Any attempt to repeal-and-replace the Affordable Care Act must not reinstate vulnerability, must not worsen access to care, over what the ACA was able to provide. It certainly must not do so to populations that are already marginalized in order to provide tax relief to those who are already well off. To do so is profoundly unjust. And yet that is exactly what the Senate bill does.

The ACA hasn’t fixed everything. RAM still runs clinics all over the US in rural areas. The need is still there. The ACA hasn’t filled it. For those with health insurance, premiums continue to grow vastly in excess of wages. America continues to spend a higher percentage of its GDP on health care delivery–17.8%—than any other nation despite leaving tens of millions of Americans uncovered.  We may well need something better than the Affordable Care Act. But this? This isn’t it.