As the months accumulated into years, Russell’s cancer was slowly becoming a footnote in his life’s larger story. All the follow-up blood tests, CT scans, and colonoscopies since his treatment finished had repeatedly confirmed that his colon cancer was in remission.
Yet in a recent clinic appointment with him, I did not find the emboldened cancer survivor I had expected. Instead, I found a man worried about the future. His trepidations were less about his cancer and more about his ability to access care.
Like many living in rural America, he had gained health insurance through Medicaid expansion in his home state under the Affordable Care Act. After he got access to regular, affordable care, a timely screening colonoscopy found a nascent colon cancer. With the cancer fortuitously discovered, doctors were able to intervene immediately and arrest it before it could become malignant.
Now, Medicaid cuts threaten to eliminate the very insurance that was aggressively surveilling his cancer to detect a recurrence. Without it, Russell will become vulnerable to the unchecked whims of cancer cells that had potentially evaded chemotherapy and could proliferate elsewhere unexpectedly.
It was the complete loss of control over his health that felt the most harrowing. It was not a possibility he had considered months before when casting a ballot for Donald Trump in the presidential election. He had been promised economic succor. His health was not a negotiable issue—he had not expected the result would take away his coverage.
Significant support from rural voters contributed to Donald Trump’s ascendance to the White House in November. Between 2008 and 2016, Republicans gained 9 percentage points in rural areas whereas Democrats lost 11. In suburban and urban areas during this same time span, Democratic support declined slightly while Republican support remained stable. Voters in America’s rural areas found hope in Donald Trump’s campaign promises, which were a balm for their concerns about the changing knowledge-based economy and fears about being left behind.
In return, Trump and his Republican comrades have feverishly pursued policies to downsize Medicaid, implemented a recently upheld immigration ban, and altered visa policies. These policies, though seemingly isolated, will synergize to make rural health care even thornier—they will reduce access and exacerbate physician shortages, which will be crippling for rural communities.
The problems encountered in providing rural health care are unlike those experienced in suburban or urban areas. People who live in rural counties are less likely to have employer-sponsored insurance coverage and more likely to be older, sicker, and poorer than the population in most areas. There is thus a great dependence on federal programs like Medicaid here.
Yet it is difficult to deploy Medicaid successfully in rural areas with physicians glaringly absent. While a fifth of Americans reside in rural parts of the country, only a tenth of doctors work there. According to Julia Paradise of the Kaiser Family Foundation, access to care will suffer even with high physician participation in Medicaid, as long as the supply of doctors is paltry. And recent immigration policies ensure that the supply will diminish further.
Twenty-seven percent of physicians practicing or training in America are foreign, but this figure is much higher in rural areas. Upon completion of residency or fellowship training, many foreign physicians commit to working in clinics and hospitals of underserved or shortage areas for a specified time in exchange for temporary H-1B work visas to remain in the country. For years, this process has managed to preserve a steady stream of doctors to these locations. American physicians balk at filling vacancies in these needy communities due to a lack of cultural or educational opportunities for family, concerns about how frequently they will have to be on call, limited subspecialty support, or less pay. But for foreign doctors looking for visas, these opportunities present an option that becomes a win-win for doctors and patients.
Currently, a number of foreign physicians who have recently completed training are in limbo after the Trump administration suspended the 15-day expedited H-1B visa process in favor of greater scrutiny that can potentially last many months. The hospitals and clinics that have hired them in places like Arkansas and Montana are adjusting to their indefinite absences despite already being understaffed.
The physician pipeline to rural areas will be further constrained by Donald Trump’s immigration ban affecting six-Muslim majority countries. At the moment, there are 7,000 physicians from these nations working in the United States. Combined, these doctors see approximately 14 million patient visits yearly. Of those, 2.3 million of those visits occur in rural and underserved areas. Trump’s ban, parts of which were recently upheld by the Supreme Court, threatens this critical pipeline of doctors willing to serve rural communities.
Because physician density is lower in rural America compared with urban areas, the loss of even a single care provider can have a seismic impact. Unlike other places, replacements are not readily found within the local population. Very few people from rural communities attend medical school, and only half of the ones who do ever return home to work. Already scarce primary care physicians become responsible for providing specialty care as needed, in addition to incremental care (regular, ongoing care), which, as Atul Gawande notes, “is the greatest source of value in modern medicine.” Without this, preventive care is compromised, diagnosis and management of urgent medical conditions is delayed, chronic illnesses are poorly controlled, and life spans are shortened.
In addition, doctors are so sparse here that if an individual is forced to find a new one, he or she may need to travel 45 minutes to an hour just to get to an appointment. Similarly, if a specialist responsible for complex, serious medical conditions is lost, not only are patients at risk of receiving inadequate care but they may also have to journey hours to be seen at a large medical center.
And rural hospitals, which are especially sensitive to changes in Medicaid funding and operate on microscopic financial margins, are already closing their doors. Since January 2010, 79 hospitals have shuttered, and nearly 700 are at risk of closure. Of the 79 closings, 58 were in non–Medicaid expansion states. (These hospitals do not exist in a vacuum, and their closing means more than just lost access to medical care—entire rural economies have been left decimated from the lost jobs.)
When rural voters like Russell sought deliverance in Donald Trump in November, they weren’t expecting him to solve all their problems, they just thought he could stanch some of their suffering. Yet five months into his presidency, he is unapologetically peddling an agenda that could eviscerate Medicaid. The expansion of Medicaid under the Affordable Care Act reduced the amount of uninsured rural adults by 11 percentage points over a six-year period. And yet, in addition to limiting Medicaid, Trump is also closing the pipeline of foreign physicians, which will exacerbate the already tenuous physician shortage. If Trump’s goals are even partially realized, it will come at the expense of his rural base—and their health.