Opinion | Self-Inflicted Medical Misery

The point is that much of the collapse of rural health care could have been avoided, and could be easily reversed, if so many state governments hadn’t chosen to impose misery on their own rural constituents.

While rural Americans often tell reporters that they feel neglected and ignored by big-city coastal elites, the people preventing them from getting health care aren’t in New York or D.C., they’re in their own state capitals. And these state politicians hold power in large part thanks to the strong Republican leaning of rural voters.

But why are Republican state-level politicians so determined to punish their own base? As I said, it’s not about the money: Rejecting the Medicaid expansion actually costs a state jobs and hence revenue.

Some of it may reflect the general meanspiritedness, the embrace of cruelty, that was already infecting the G.O.P. even before Donald Trump, and has now become one of the party’s defining traits. Yes, that’s harsh, but you know that it’s true.

There’s also, I suspect, an element of cynical calculation. As I said, rural voters often complain that national elites don’t care about their needs. Well, one way to make people feel hostile toward those elites is to block their access to federal benefits, and hope they don’t realize who’s actually causing their misery.

Is it conceivable that conservative politicians have that much contempt for their base? Yes.

In any case, the point is that while rural decline in general is a hard problem, with no easy answers, rescuing rural health care isn’t hard at all. We know how to ensure that rural Americans get the health care they need. This isn’t a problem of policy, it’s a problem of politics — and most of the blame lies with Republican state governments.

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