What awaits rural Virginians now that the big, beautiful bill is now law? Now comes the hard part for vulnerable rural Virginians with limited incomes as safety net programs such as Medicaid, SNAP, and Medicare benefits shrink or disappear. This is compounded by cuts in programs that provide meals to school age children whose families can’t afford to pack school lunches much less pay for the ones provided at school. Even the anti-immigrant sentiment will have long term impacts to America’s healthcare system. There is a tsunami of despair that will sweep rural America, compounding existing systemic troubles accessing timely health care for millions of un- or under insured Americans.
During the COVID epidemic my source for this essay – my wife – volunteered with the Remote Area Medical Volunteer Corp, a non-profit that provides dental, medical, and vision care at pop-up clinics across the U.S. (RAMUSA.org). RAM was founded in 1985 with the mission to provide mobile clinics at remote locations outside the U.S. It later began organizing these pop-up clinics to fill a need for underserved Americans that live in healthcare deserts.
The mobile clinics that my wife volunteered at were in Southwest Virginia. She provided logistical support to the medical teams, such as registering patients. Her stories are both sad and harrowing, they’re about folks that serve their communities, and the fortitude of the communities they serve.
At a typical pop-up clinic, the patients arrive at mid-night when they arrive at the designated facility’s grounds, such as a county fairground. They are given a numbered ticket and asked to stay in the designated parking area overnight. It is first-come-first-served, and the tickets go fast. The number of tickets is based on the number of volunteer doctors, dentists, nurses, other clinicians, and administrative folks. The administrative task of registering patients begins first around 6 the next morning.
At the mobile clinics where she volunteered, the patients represented a wide spectrum of ages and life experiences, according to my wife, but mostly 50 and up, with young adults being the second largest group. She recalled one young family — a woman and her three kids ages from 4 to 13. They came for dental care but were quickly referred to the medical clinic. The youngest shaking uncontrollably. He hadn’t eaten breakfast and when he had his last meal was anyone’s guess. At the medical conex, the crew scrambled to get breakfast for the kids and started to gather care kits: toothbrushes, toothpaste, soap, combs, shampoo. Their home had no running water it was learned.
For many these mobile clinics are the only healthcare they get. The services include eye exams, and if needed glasses donated by the Lions Club; hearing tests, and if necessary, hearing aids donated by a local audiologist; dental care is provided by dentists and student volunteers from dental colleges; prescriptions (one course) and follow up care scheduling; mammograms provided in a mobile RV provided by a non-profit hospital system.
My wife noted that many of the medical students assisting the doctors were from South Asia and the Middle East. That is international students attending American medical universities. More on that later.
Most patients were on or had gone off the financial precipice: Little to no health care insurance. Per RAM, 50 percent of their patients have no health insurance. It’s much worse for vision and dental insurance coverage. There were elderly on Medicare seeking care. They could pay their premiums but could not afford the co-pays for doctor visits. Because the payment assistance program for Medicare premiums was severely cut in the big, beautiful bill, those that could not even afford co-pays will most likely loose complete access to Medicare health insurance.
Another lifeline for these folks is Rural Health Clinics. Medicare Part B and Medicaid payments subsidize these clinics, but billions in cuts will mean many of these rural health clinics, to include the one in Louisa, may close, worsening the crisis in rural health care.
As context, the federal government’s first foray into healthcare came in 1946 with the Hospital Survey and Construction Act. By 1981 there were 3000 new healthcare facilities and an additional 6600 beds. 60 percent of those beds were in communities of less than 25,000. Medicaid and Medicare were created in 1965 followed by the Rural Health Clinic Services Act of 1977. These were all bipartisan Acts; however, the zenith of rural healthcare seems to have passed long ago. The partisan big, beautiful bill guts a neglected and crumbling rural healthcare infrastructure, eventually millions will be without timely adequate healthcare. And for what, $40 billion in migrant concentration camps and a trillion-dollar defense bill, 10,000 more ICE agents, and $3.4 trillion in tax breaks to the top 10 percent?
Profit driven hospital systems and insurers will not fill the gap. No profit in it for them. Sad because of the top 20 hospital systems all but one reported net revenue gains. The top company measured in total revenue – Kaiser Permanente — reported a whooping 15 percent increase in 2024. Some smaller companies reported even greater increases. Net revenue from patients also grew, according to Hospistalogy.com. Interestingly, the National Association of Insurance Commissioners, reported a 14 percent decline in net income for health insurers in the first half of 2024. On a side bar, the NAIC statistics showed that claims per month per member for Medicaid and private insurance was about the same for Individual, Group, and Medicaid: $408, $482, $481 respectively. Medicare claims per member per month was $1146, almost triple. But that is to be expected from an older age group.
Another threat to America’s healthcare system in general, and for rural America in particular, is the availability of healthcare providers. According to the Association of American Medical Colleges, about 1 in 5 physicians are foreign born. I have read other sources that indicate 25 to 26 percent of doctors in the U.S. are from abroad.
Importantly, these foreign born and trained doctors are more likely to serve in areas with greater poverty, according to the American Immigration Council. The Council further stated that areas with a 30 percent poverty rate, one-third of the doctors are foreign trained. A University of California San Diego Website reported that while 20 percent of Americans live in rural areas, only 11 percent of US doctors work in these areas, and that foreign born and trained physicians fill the shortfalls. It’s not just physicians. About 15 percent of nurses in America are foreign born and trained.
The current administration’s anti-immigrant fervor against migrants, whether legal, undocumented, or adjusting status, is sending chills across the globe I would think. Many are asking (I know I would), “do I want to come to America where I am unwanted, hated, potentially abused and imprisoned because of the color of my skin and accent?” Travel bans, blanket visa denials and revocations, potential arrest and deportation for engaging in free speech on campus, all will drive away potential medical students and foreign-born healthcare providers. Imagine the impact if America lost 15 or 20 percent of its healthcare providers? The MAGA Ebenezer Scrooges in Congress would respond, “What, are there no funeral homes and casket makers?”
While the number of international students at American medical schools is less than 2 percent, I imagine those numbers will drop significantly. With a shortfall of 45 to 50K doctors, America is already in a healthcare crisis mode, further reducing the flow of healthcare professionals to the U.S. will only hurt the most vulnerable.
No money, no clinics, and no doctors is what awaits rural America. Don’t buy the bit about Medicaid scofflaws or Medicare cheaters being the problem, this is about wealth and greed, income inequality and regressive Republican tax policies. It may take a year or two for the tsunami to reach the shores of rural America, but it is coming. If you don’t believe me, volunteer at RAMUSA.org. They have clinics looking for volunteers.
