Sean, Meg and Dustin—Thank you for the excellent comments on this one.
I'm pretty late catching this article (just found the site) but I remain "gobsmacked" that it's not been noticed that rural communities are often economic "wrecks" on a number of counts and that citizens paying lofty premiums, plus buying their way to get beyond deductibles, plus co-pays at every turn could all be changed for general community gain on nearly every economic front! IF profiteering were stripped from health care costs, (and the risk pool was opened fully to include all from newborn to very elderly - as in Canada for instance) then any premiums could be much much lower, allowing even modest income individuals and families to "pay their share", thus reducing to some extent "freeloading" (an obnoxious accusation for matters of health needs but popularly proclaimed). Profiteering schemes cause additional costs of complex administration, lots of PR and advertising, and ridiculous quantities of paperwork (the latter two adding to unnecessary waste of natural resources for printing "needs"), Individual and household economies would have higher disposable incomes to support local community businesses if so much weren't flying out of pockets to support some distant enthusiasm for extra luxury housing, yachts, and other top money (executive, financial sector) skimmer wealth accumulations. I know single payer from decades in Canada and recognize Canada too has its health care delivery "issues". But American resistance to action on behalf of common weal, when benefits would be felt from "individual cellular" to just plain economic fundamental realities, is beyond annoying to me. I have no easy patience about this issue. (It makes sense to me that deep poverty in urban sectors also could be alleviated with single-payer, no investment profit, health care delivery.)
An overwhelming correlation exists between rural hospital closures and states which have not adopted Medicaid expansion, but if I recall correctly, iVantage Health Analytics, Kaiser Family Foundation, UNC, and a handful of news organizations have each shown that many more rural hospitals are vulnerable to closure. These also exist in predominantly non-expansion states. This doesn't necessarily mean that the Medicaid expansion issue created this problem, but not expanding has certainly exacerbated the financial health of these places.
Considering that the ACA shifted all expansion costs to the Federal Government for three years, with the plan to lower reimbursements/subsidies to 90% over several years, these states are having trouble defending the position to not expand. Keep in mind-- the costs of NOT expanding Medicaid are coupled with huge cuts to uncompensated care reimbursements. Hospital financial conditions and accessibility to treatment will only get worse in rural areas in these states, thus I suspect that we'll see many more states expanding Medicaid in the future. But look at the human and financial cost of waiting...
In addition to this, rural hospital closures are devastating to rural and small town economies. For many places, these facilities are the largest employers, and high-skill employment, in particular, increases the local capacity for human capital development. Sad, indeed.
Single-payer is my vote, the ACA is better than we had, but clearly not good enough for all, which is what we knew going in. Higher taxes always look worse at first, but doesn't it make sense that we will be getting what we are paying for, and clearly what we need to save money in the long run that can be put to use elsewhere.
Democrats Have Gone off the Rails in Rural America. Can a New Report Get Them Back on Track?