In the vaunted blue-collar pieces of the Rustbelt, where Trump broke through Hillary Clinton’s “blue wall” in his near-sweep of Midwestern battlegrounds, Obamacare also holds sway in the lives of lower-income working white people. In Ohio—whose Republican Governor John Kasich accepted the Affordable Care Act’s Medicaid expansion—the law helped cut uninsurance to 6 percent. The lead crisis in Flint, Michigan, prompted an emergency expansion of Medicaid to care for mothers and children affected by lead poisoning. And although Flint is a majority-black city, its lead crisis is a harbinger for other lead-related infrastructure crises in Rustbelt towns, which mostly skew rural and white. For citizens in those towns—quite literally in Middle America—maintaining robust federal public insurance could be a matter of life and death, and of the future of their children.
But insurance coverage is only a means to an end, and that end is health. While it is undeniable that several million Americans face rising or unaffordable premiums and prescription drugs, it is also true that millions of the worst-off Americans gained coverage at low cost or at no cost, and that it allowed many of them to visit physicians or go for check-ups without fear of bankruptcy for the first time in their lives. Most of those first-timers are white people working low-paying jobs, and for them that security couldn’t have come at a better time. Especially in the rural, whitest pockets of America, the opioid crisis and a staggering number of other morbidities have actually reversed the declining trend in mortality rates among white Americans that has often been taken as a birthright. For much of this group of people, their generation is the first to give birth to children who will not live longer than them.
For all the angst about Obamacare’s overreach, rural white America has long been dependent on public insurance. For one, these residents tend to be older than urban counterparts and thus rely more on Medicare. But even among the non-elderly, a quarter of all rural residents rely on Medicaid or other public insurance for their basic health-care needs. Many of these residents rallied around Trump’s vague plans to ease their economic issues, including the erosion of stable union-protected jobs. But one of the benefits that these people have lost the most and that has contributed to family economic woes the most is employer-sponsored health care. Public insurance—now bolstered by Obamacare—has taken up much of the slack.
Extending health-insurance coverage is not, of course, a guarantee of affordable or useful healthcare. But the ACA actually does fund several direct public-health initiatives that attempt to address rural America’s deepening health issues. The president-elect has largely neglected these in his scathing analysis, but the law authorizes funding for hundreds of new community-health centers and for sending physicians to long-neglected communities outside of urban centers. While so far, the law’s implementation has been a severe strain on rural hospitals, clinics, and the healthcare workforce that caters to many low-income white patients, that strain has come because millions of people with lifetimes of unmet medical need now have a way to finally get into the system. If the goal is to help these people, that might be a case for expanding the ACA’s coverage and capacity-building measures, not abandoning the attempt.