Health care is a significant issue in rural communities due to environmental racism and the lack of investment in public infrastructure. The Affordable Care Act (ACA) has been one of the most impactful advancements for Americans’ health and economic security in a generation, providing coverage for millions of uninsured people through expanded public insurance programs. It has also offered subsidies for purchasing private coverage, which help hospitals to maintain financial viability by addressing uncompensated care.
Yet the ACA’s fate remains uncertain. This week, the U.S. Supreme Court heard oral arguments in California v. Texas, a case that will determine the constitutionality of the law. Specifically, the high court will weigh whether the individual mandate is unconstitutional without a financial penalty and whether the remainder of the law is severable from that provision. Now, with Justice Ruth Bader Ginsburg’s recent passing and the nomination of Justice Amy Coney Barrett as her replacement, the chance has increased that the benefits and consumer protections that many have come to rely on could swiftly be eliminated. If the ACA is repealed, coverage for more than 4.5 million rural residents and the significant benefits and consumer protections that they have gained under the law will be at stake. This is particularly important now, as many rural communities have been ravaged by the coronavirus throughout the pandemic.
Rural America and the coronavirus crisis
Many rural communities of color, particularly tribal communities, have limited access to infrastructure that supports public health, such as clean running water, leading to many health-related issues. While discussions around rural America tend to focus on states in the heartland and images of white men tending small family farms, that depiction belies the full scope and breadth of what and who constitute the vibrant dynamic of these regions. For example, recent news stories have highlighted how the coronavirus has overwhelmed rural communities as it spreads through the Upper Midwest and Great Plains regions, but Black communities in the rural South and tourist destinations in the West were among the regions seeing the earliest massive outbreaks. Figure 1 shows how rural communities of color were seeing significant outbreaks in March and April.
While some statewide lockdowns occurred through April and early May, many states ignored the concerns of these communities of color and prematurely reopened their economies, leading to further outbreaks throughout the summer. Subsequently, in late August and through September, the rest of rural America started to experience massive outbreaks.
Populations in rural areas are particularly vulnerable to the coronavirus: Individuals in these communities tend to be older and have disabilities. Furthermore, workers in the labor markets common in rural America are less likely to have the ability to work from home due to lack of broadband, or they are employed in occupations that do not have work-family supports such as paid sick leave and paid family and medical leave. Rural residents are also more likely to face barriers to health care access due to a lack of insurance options, hospitals, and health care facilities—one area where the passage of the ACA was beneficial for rural households.
How repealing the ACA would hurt rural households
The ACA has helped rural households gain access to health care by expanding Medicaid and providing affordable options for insurance through the marketplace. These expansions of coverage—especially Medicaid—also provide support for rural hospitals, helping them to avoid closure due to high levels of uncompensated care.
A 2017 Center for American Progress column highlighted the adverse effects of a U.S. Senate bill—the Better Care Reconciliation Act—that would have repealed the ACA. The repercussions that the column explored are similar to those that would follow a Supreme Court decision ruling the law unconstitutional. The bill would have cut Medicaid spending by more than 15 percent, which would have been devastating for rural communities, as Medicaid covers a larger share of children and adults in small towns than in more urban and suburban localities. Those who were previously eligible for Medicaid would have been pushed out to the private insurance market, and those who purchased insurance on the marketplace would have seen their costs rise due to lower funding of tax credits.
Given the high rates of unemployment from the pandemic—and subsequent loss of employer-based health coverage—the authors estimate that 4.5 million rural residents would lose coverage in the event of an ACA repeal. This number is calculated using data from a CAP column and the percentage of the population that lives in a rural area from the 2010 decennial census. This estimate is particularly alarming as the country continues to contend with the impacts of the pandemic and with the rise of COVID-19 cases in rural areas. If the ACA is repealed, those who contract and survive COVID-19 will be considered as having a preexisting condition and thus could face higher premiums for private insurance, coverage exclusions, or be denied coverage outright.
Ever since the passage of the ACA in 2010, Republican leaders in Congress have sought to repeal it without any suitable replacement. The ACA provides health benefits for millions of rural residents and has increased the financial viability of many rural hospitals, and the law’s repeal would harm not only those living in rural places—many of whom are older, face increased health issues due to a lack of public infrastructure and access to health care services, and have disabilities—but women and LGBTQ people as well. The Supreme Court and Congress must preserve the ACA, especially during a pandemic that has only exacerbated the health disparities in rural communities.
Olugbenga Ajilore is a senior economist at the Center for American Progress.