When Sen. John Barrasso of Wyoming asked Robert F. Kennedy Jr. about his commitment to aiding rural hospitals during Kennedy’s confirmation hearing, it was one of the rare moments when both a Republican senator and President Donald Trump’s nominee to head the Department of Health and Human Services appeared to be making sense. Of Wyoming’s 33 hospitals, Barrasso said, six are at risk of closing. Kennedy agreed: “Rural hospitals are closing at an extraordinary rate right now.” He added that rural hospitals “not only provide important health care for the localities, but they are also important economic drivers.”
Which is true: In many rural areas, you’ll find that the two largest employers are the local schools and the nearest hospital. What you wouldn’t have heard — either from Kennedy or the Republicans on the committee, a number of whom brought up the importance of rural health care — was any mention of the single most important thing the federal government could do to stabilize rural hospitals: expand Medicaid. And that omission spoke volumes about how Republicans view rural Americans.
Kennedy doesn’t want to contradict his new Republican allies’ credo.
Barrasso’s Wyoming is one of 10 states that still refuses to accept the expansion of Medicaid that was part of the Affordable Care Act. The state’s GOP-controlled government prefers to leave millions of citizens without health insurance rather than allow them to receive it from the federal government. Since the ACA passed in 2010, over 150 rural hospitals have either closed completely or eliminated their inpatient services — most of them in the South, where the refusing states are concentrated. Texas, where Republicans dominate the Legislature and control every statewide office, has seen more rural hospital closures than any other state.
And even though rural Americans are more likely to rely on Medicaid than those who live elsewhere, Republicans in Washington are contemplating huge Medicaid cuts, partly to pay for more tax cuts for the wealthy. A list of possible cuts from the House Budget Committee includes capping the amount that will be spent in every state and imposing work requirements on recipients, which in practice provide little more than a means of taking away people’s coverage when they fail to successfully navigate a bureaucratic obstacle course. As a recent report from Georgetown University found, “rural communities are at grave risk if substantial federal cuts are enacted.”
Kennedy won’t be doing anything to persuade the holdout states to accept the ACA’s Medicaid expansion — and, like Trump, he trash-talks the ACA as a whole. “Americans by and large do not like the Affordable Care Act,” he said in the hearing. “They don’t like Medicaid.”
On this score, Kennedy is either ignorant or lying — and either quality is alarming in someone who has been nominated to oversee these very programs. The Affordable Care Act has become extremely popular; in the latest KFF poll, 64% of Americans say they approve of the law. Medicaid is even more popular; 77% have favorable views of the program, and 69% say it works well for low-income people, as do 75% of those who have used it themselves. But Kennedy doesn’t want to contradict his new Republican allies’ credo that government involvement in health care is necessarily inferior to the operation of the private sector.
Nowhere is that less true, however, than in rural America. Most of the health care problems rural people face — from closing hospitals to a lack of clinics to a shortage of doctors and nurses — happen precisely because of the limitations of the free market. It’s just not as profitable to sell health care in places with small, often poorer populations spread out over large areas. These problems can only be solved by government intervention and assistance, whether it’s by paying for people’s coverage so hospitals can stay afloat or incentivizing doctors to move to rural areas.
Those Republicans all understand an important political truth: They can take the votes of their rural constituents for granted. Then there’s the issue of vaccines. Kennedy spent much of his confirmation hearing denying that he opposes all vaccines, but the truth is that there is no single American who has done more to spread disinformation and distrust of vaccines than him — which is particularly threatening to rural health. Rural Americans were much less likely to get the Covid vaccines when they became available, which almost certainly contributed to higher rates of Covid mortality in rural areas. There were plenty of other unsettling parts of Kennedy’s testimony. But just as, if not more disturbing was hearing one Republican senator after another speak of their passion for improving rural health care, when their party seems so determined to undermine the very programs that keep it from getting even worse. Those Republicans all understand an important political truth: They can take the votes of their rural constituents for granted. No matter how much the Republican Party continues to make it harder for them to stay healthy, rural Americans — more specifically, rural white voters — will keep returning them to office, where these Republicans try to cut vital programs and confirm cranks like Kennedy to run important agencies. But that’s what we’ve come to expect from a party and a president that hold the very idea of effective government in contempt. They can try to tell us how much they care about Americans’ health, but their actions show what they really believe.
Paul Waldman is a journalist and author focused on politics and culture. 
