This story was written for Tarbell.org. It was co-published with the Hancock Herald in Hancock, N.Y., and 100 Days in Appalachia.

Most of Betty Rosengrant’s extended family needs Medicaid. They’re also mostly Republicans. Rosengrant says she knows Republicans have proposed cuts to the federal/state health care system, but that “people just vote the way their parents voted, and that’s Republican.”  

Rosengrant, 69, and her family have had their share of medical crises, including her husband’s death from cancer and her own difficult knee replacement. There have been times her family has needed to rely on Medicaid, which covers costs for those with income below 138% of the official federal poverty level. Some of her children, grandchildren and great-grandchildren have too.

Her family and her town of Hancock, New York (pop. 3,500 if you don’t count summer camp kids or fall hunters), resemble many Republican communities across the U.S. According to the Census Bureau, one in five Americans dwell in rural areas — places where the 2016 voting went heavily for Republican candidates calling for cuts in “entitlements” like Medicaid.

They’re also the communities where Medicaid is key to health care access for one-quarter of the population, according to Families USA. In fact, according to The Washington Post, 51 percent of rural births are covered by Medicaid, compared to just 45 percent nationally and an even lower percentage in urban/suburban areas. In Hancock, many people get their primary care at a storefront clinic on Main Street, where an average of 40 to 50 percent of patients are on Medicaid, according to the clinic director. (The clinic is run by the Lady of Lourdes Hospital, which is 45 miles away in Binghamton.)

There are several reasons more rural people rely on Medicaid. Incomes are lower than in cities. There are also fewer unionized employers or large employers, both of which typically have company-sponsored health plans. As well, with jobs harder to come by, a higher percentage of rural people are self-employed, work part-time or are unemployed.  

Medicaid, established in 1965 as a complement to Medicare for the elderly and disabled, was meant to provide health care access to the poor. Like Medicare, it’s been a target for Republican budget cutters ever since. In October, Senate Majority Leader Mitch McConnell (R-KY) called for cuts in both programs as have GOP House leaders.

Unlike federally administered Medicare though, Medicaid, while funded by the federal government, is administered by the states. This doubles the jeopardy as both Congress and state legislatures continue to attack the program.

One such two-pronged attack was part of the Trump administration’s effort to undo the Affordable Care Act (ACA). In addition to subsidized health insurance plans, the ACA expanded Medicaid access, enabling another 1.7 million low-income people to receive health coverage in states that adopted an option of a higher income eligibility. Most that did had Democratic state governments. Continuing attacks on the ACA threaten that access.

When the Trump administration issued a “guidance” allowing states to impose work requirements on Medicaid applicants, a number of states with Republican-majority governments quickly adopted them, though critics warn the requirement could end up denying people coverage. In three states the new work requirements were approved. Another seven have applications pending.

Pennsylvania has a Democratic governor, but the Republican-controlled legislature is still pushing legislation which, if approved, would require Medicaid recipients to be working or seeking a job, and also would raise their co-pays for care. Most of Pennsylvania’s Republican congressional representatives, primarily from rural districts, also back a Republican tax plan that could severely cut Medicaid in the future by converting it into block grants, which would cap state spending regardless of how many people qualify for coverage.

Ben Waddell, a sociology professor at Ft. Lewis College in Colorado, says he understands why Rosengrant’s extended family and so many other rural Americans vote the way they do.

“Rural people out West descend from people who moved here hoping to make their own way,” he says. “These days, with globalization taking away jobs, what matters to them is having a job and having self-respect, not so much having health care.” He recalls a coal-fired power plant near Norwood, the small Colorado town where he grew up, being ordered closed during the Obama administration and how people there worried about the lost jobs. He says Trump’s 2016 campaign promise to “bring back coal” resonated.

“People don’t always understand all the scaffolding of these programs like Medicare and Medicaid or how globalization really works,” he says, “but they do respond to the simple messages they get from Republicans about how Social Security and Medicare are ‘in trouble.’” He adds, “I think rural voters in Appalachia think the same way.”  

Rosengrant, a lifelong Republican who recently began voting Democratic, is not surprised so many people in her community support politicians who threaten their Medicaid. “Most people around here don’t read newspapers, and just watch Fox TV,” she says. “They don’t even know who the candidates are that they vote for, and even if they don’t just vote party line, they don’t know that the Republicans want to cut Medicaid.”