The rural healthcare blame game

University of Michigan

AI-assisted summary of The rural healthcare blame game — original source. Check the original for full context.

Source published: 2026-10-28

Key ideas

Roughly 25% to 30% of rural Americans rely on Medicaid compared to 15% to 20% in urban areas, leaving rural healthcare facilities uniquely vulnerable to program cuts due to a lack of commercially insured patients to offset losses. (15:50)
Rural hospital closures typically add 20 to 40 minutes to emergency driving times, escalating up to two hours in remote areas or for specialized services like labor and delivery. (18:29)
Federal policy delays and the inclusion of an insufficient $50 billion Rural Health Transformation Program allow congressional lawmakers to deflect blame for facility closures onto state executives and local hospital administrators. (25:00)
Despite 80% of rural hospital closures occurring in Republican-controlled states that rejected Medicaid expansion, complex policy environments lead rural voters to penalize Democrats or adopt anti-establishment viewpoints. (8:22)

Detailed notes

## Background Published on YouTube by the University of Michigan on October 28, 2026, this episode of the Michigan Minds podcast features Dr. Michael Shepherd, an assistant professor of health management and policy at the University of Michigan School of Public Health. According to the description, the program examines how healthcare has evolved into a primary voter priority, focusing on the intersection of rural hospital closures, Medicaid alterations, and partisan identity.

## TL;DR Dr. Michael Shepherd breaks down how collapsing rural healthcare infrastructure—from shuttering maternity wards to increased emergency drive times—becomes filtered through local news deserts and polarized media into a cycle of partisan scapegoating. Because healthcare functions as a complex 'hard issue,' voters frequently rely on party heuristics and racialized narratives, penalizing Democrats for local hospital failures even in states where Republican officials resisted Medicaid expansion. Shepherd details how Medicaid reductions jeopardize entire rural facilities regardless of an individual's private insurance status, while long policy implementation lags and federal funding loopholes effectively insulate legislative authors from electoral accountability. Ultimately, the discussion illustrates how calcified political identities and voter turnout shifts sustain a self-reinforcing rural health spiral heading into upcoming election cycles.

## Atmosphere & style The discussion carries an analytical, measured tone driven by Juan Ochoa's structured inquiries and Dr. Shepherd's systematic, policy-oriented explanations. Rather than leaning into partisan heat, the dialogue feels diagnostic and sober, patiently unpacking complex political science models and communication vacuums. Even as the conversation touches on life-or-death emergencies like strokes and remote hospital deserts, the delivery remains steady, objective, and deeply rooted in institutional critique.

## Bulletin - [15:50](https://www.youtube.com/watch?v=6N78CNuC-1c&t=950s) Roughly 25% to 30% of rural Americans rely on Medicaid compared to 15% to 20% in urban areas, leaving rural healthcare facilities uniquely vulnerable to program cuts due to a lack of commercially insured patients to offset losses. - [18:29](https://www.youtube.com/watch?v=6N78CNuC-1c&t=1109s) Rural hospital closures typically add 20 to 40 minutes to emergency driving times, escalating up to two hours in remote areas or for specialized services like labor and delivery. - [25:00](https://www.youtube.com/watch?v=6N78CNuC-1c&t=1500s) Federal policy delays and the inclusion of an insufficient $50 billion Rural Health Transformation Program allow congressional lawmakers to deflect blame for facility closures onto state executives and local hospital administrators. - [08:22](https://www.youtube.com/watch?v=6N78CNuC-1c&t=502s) Despite 80% of rural hospital closures occurring in Republican-controlled states that rejected Medicaid expansion, complex policy environments lead rural voters to penalize Democrats or adopt anti-establishment viewpoints.

## Key takeaways - [00:04](https://www.youtube.com/watch?v=6N78CNuC-1c&t=4s) Healthcare policy in rural areas is heavily racialized through political rhetoric, leading white voters to view resource distribution through a zero-sum, 'us versus them' lens. - [03:10](https://www.youtube.com/watch?v=6N78CNuC-1c&t=190s) Rural white voters experiencing local healthcare deterioration often rely on political scapegoats, assuming urban and minority populations are benefiting at their expense despite empirical evidence. - [05:12](https://www.youtube.com/watch?v=6N78CNuC-1c&t=312s) The rapid collapse of local newspapers over the last 15 to 20 years has created news deserts, forcing rural residents to interpret local crises through high-conflict national media frames. - [08:22](https://www.youtube.com/watch?v=6N78CNuC-1c&t=502s) Informal information networks, such as unmoderated local Facebook community pages, fill journalistic voids with conspiratorial, anti-establishment narratives that steer voters toward the Republican Party. - [11:00](https://www.youtube.com/watch?v=6N78CNuC-1c&t=660s) Because healthcare is an inherently complex 'hard issue,' voters rely on partisan heuristics, often blaming Democrats for bad outcomes because they are perceived as the national 'healthcare party.' - [11:00](https://www.youtube.com/watch?v=6N78CNuC-1c&t=660s) The 'rural health spiral' describes how worsening local healthcare outcomes fuel anti-government sentiment that ultimately consolidates electoral support for Republicans. - [13:40](https://www.youtube.com/watch?v=6N78CNuC-1c&t=820s) Pervasive nationalization of politics across all ballot tiers prevents down-ballot candidates from building distinct local identities separated from their national party brand. - [15:50](https://www.youtube.com/watch?v=6N78CNuC-1c&t=950s) Rural hospital shutdowns cause negative regional spillover effects, overwhelming regional urban emergency departments and medical staff with displaced patients. - [18:29](https://www.youtube.com/watch?v=6N78CNuC-1c&t=1109s) Incremental service line reductions, particularly the closure of labor and delivery units, force pregnant rural patients to drive up to two hours for delivery care. - [21:20](https://www.youtube.com/watch?v=6N78CNuC-1c&t=1280s) Calcified political identities suggest rural healthcare distress will manifest electorally as depressed voter turnout rather than large-scale ideological ticket-splitting. - [22:45](https://www.youtube.com/watch?v=6N78CNuC-1c&t=1365s) Because voters possess short political memory horizons, implementation lags on Medicaid cuts mean future incumbent administrations may absorb the blame for past legislative rollbacks. - [26:28](https://www.youtube.com/watch?v=6N78CNuC-1c&t=1588s) Medicaid reductions directly jeopardize privately insured rural residents, as the collapse of Medicaid funding threatens the solvency of entire community hospitals.

## Detailed walkthrough ### [00:04](https://www.youtube.com/watch?v=6N78CNuC-1c&t=4s) Introduction and the Racialization of Rural Healthcare Policy

Host Juan Ochoa introduces the *Michigan Minds* podcast and welcomes Dr. Michael Shepherd, an assistant professor of health management and policy at the University of Michigan School of Public Health. Dr. Shepherd’s research centers on United States health politics and policy, rural health disparities, and the mechanisms by which political parties, race, and mass media influence public attitudes and health-related behaviors. Setting up the discussion ahead of the midterm elections, Ochoa points out that healthcare has become a paramount issue for voters nationwide, yet in rural America, the subject extends far beyond routine insurance coverage or primary care appointments—it is inextricably bound to the physical survival of small towns, partisan alignment, and grievances over institutional fairness. Ochoa asks how race and racism operate within health policy and how this dynamic reaches rural voters who might not consciously view healthcare through a racial lens.

Dr. Shepherd explains that scholars view the relationship between race, racism, and rural healthcare access as a twofold process. On one level, race and ethnicity play an objective, direct role in determining healthcare access; in the American South especially, rural Black and Latino communities endure the most severe structural deprivations and restricted access to services. However, a secondary dynamic operates through political rhetoric and media framing, where specific health issues and policies—most notably the Affordable Care Act—become deliberately racialized. When political elites fuse race with policy discussions, rural white voters are primed to evaluate policy through a lens of racial grievance and zero-sum competition, assuming that government initiatives will funnel resources away from their own communities to benefit racial and ethnic minorities elsewhere, even when empirical data disproves that assumption.

As Dr. Shepherd observes regarding this psychological and political framing:

> “And and that leads rural white voters to view their healthcare access or or view healthcare policy um in terms of us versus them.”

***

[03:10](https://www.youtube.com/watch?v=6N78CNuC-1c&t=190s) The Scapegoating Mechanism and Perceived Relative Deprivation

Addressing Ochoa’s question about what rural white voters are observing when they perceive others receiving benefits they are denied, Dr. Shepherd clarifies that these viewpoints are grounded far more in rhetoric than in verifiable empirical conditions. The lived reality for many rural residents is undeniably strained: local hospitals shutter, private or public health insurance is scarce or unaffordable, and out-of-pocket medical costs continue to mount. Yet in the absence of clear institutional accountability, individuals become highly susceptible to political rhetoric that offers convenient scapegoats and status cues.

This rhetorical framing leads struggling white residents to infer that if local healthcare infrastructure is crumbling, residents in urban areas—specifically racial and ethnic minorities living elsewhere—must be thriving at their expense. This dynamic operates not as an evidence-based assessment of urban healthcare, but as an abstract narrative that gives emotional coherence to their distress. By framing systemic hospital closures or underfunded rural clinics as the result of external favoritism, political actors provide rural communities with a narrative where their neglect is someone else's fault.

Dr. Shepherd crystallizes how this dynamic hardens into a broader political grievance:

> “It's not only bad because of policy decisions or because of where um these folks happen to live. It's it's because it's someone else's fault and someone else is getting ahead uh while the rural white voter and the rural white community um perceives that they are are falling behind or being neglected.”

```mermaid flowchart TD accTitle: Rural Healthcare Blame Mechanism accDescr: Flowchart showing how local healthcare hardship is filtered through media vacuums and rhetoric into political scapegoating.

subgraph Hardship["1. Local Material Conditions"] A["Hospital Closures & Rising Costs"] B["Lack of Health Insurance"] end

subgraph Channel["2. Information Ecosystem"] C["Local News Deserts & Nationalized Media"] D["Partisan & Conspiratorial Facebook Pages"] end

subgraph Blame["3. Grievance Attribution"] E["Racialized 'Us vs. Them' Scapegoating"] F["Anti-Establishment & Anti-Democratic Blame"] end

Hardship --> Channel Channel --> Blame ```

***

[05:12](https://www.youtube.com/watch?v=6N78CNuC-1c&t=312s) The Collapse of Local News and Nationalization of the Media Ecosystem

When Ochoa asks whether urban voters are equally vulnerable to faulty information and what citizens can do to verify what they consume, Dr. Shepherd concedes that informational vulnerabilities are not unique to rural populations, even if they manifest differently along demographic and geographic lines. Dr. Shepherd identifies the rapid transformation of the American media landscape over the past 15 to 20 years as the core structural driver of this misunderstanding. While public commentary often fixates on social media algorithms, the deeper crisis lies in the decay of traditional local journalism.

In many rural towns, local newspapers have shuttered entirely, leaving vast news deserts. Television stations are typically centered in distant metropolitan media markets and rarely deploy reporters to cover rural civic affairs. Even in urban centers, surviving local stations frequently air syndicated, nationalized packages produced by media conglomerates. Consequently, coverage of hyper-local realities has been supplanted by high-conflict national political theater—pitting the president against Congress and focusing on partisan warfare or macroeconomic shifts. Without reliable local investigative reporting to explain why a nearby municipal facility or hospital closed, citizens naturally use the broad national political frames fed to them by national broadcasts and social feeds to explain local problems, even before outright digital misinformation enters the equation.

Explaining how this structural absence distorts civic understanding, Dr. Shepherd points out:

> “And so in a world where we have perhaps not hyper local focused news coverage, we don't even really need misinformation to lead people to react to the wrong sets of things or to lead people to consider some factors that are maybe less relevant for them personally or locally.”

- Local news deserts have expanded rapidly over the preceding 15 years as local print newspapers closed across rural America. - Regional television newsrooms are overwhelmingly based in urban centers, offering virtually no sustained on-the-ground coverage of rural civic affairs. - Corporate media conglomerates increasingly distribute standardized, syndicated national content across local broadcast stations, accelerating the nationalization of political discourse.

***

[08:22](https://www.youtube.com/watch?v=6N78CNuC-1c&t=502s) Informal Information Networks, Anti-Establishment Sentiments, and Partisan Realignment

Ochoa asks whether this skewed information environment explains why rural communities vote overwhelmingly Republican while urban areas lean Democratic, and whether this divide stems more from identity or policy preferences. Dr. Shepherd pushes back against attributing the trend solely to explicit misinformation, emphasizing instead the sheer scarcity of reliable local facts and the informal conduits that emerge to fill that void. When a rural hospital shuts down without local newspaper coverage, the void is filled by word of mouth—typically dominated by the most vocal, politically active conservative community members—and informal social media operations.

Dr. Shepherd refers to these informal operations as small-town "news gazettes": independently run Facebook community pages that cover local town affairs without journalistic standards. These pages often adopt anti-establishment, conspiratorial, or explicitly conservative stances. Rather than leaving residents in the dark, these informal networks actively direct community outrage toward national Democrats, federal healthcare legislation, and a nebulous government "establishment." Because major societal institutions—such as legacy news organizations and federal agencies—are perceived as remote and dismissive of rural life, the resulting disillusionment creates an asymmetric push that drives rural voters away from mainstream institutions and directly toward the Republican Party.

Dr. Shepherd summarizes this institutional backlash:

> “Um and that contributes I I think to a mixture of both partisan blame tendencies uh as well as more of a um anti-establishment anti-government reaction which is um broadly the mainstream forces in American society that is the news media uh formal news media um the national government the national political parties are letting down people um in these communities or they feel like their communities are unrepresented by those institutions.”

As the segment concludes, Ochoa challenges this blame attribution, citing Dr. Shepherd’s previous observation that rural residents routinely penalize Democrats for hospital closures even though 80% of these closures occurred in Republican-controlled states that actively refused to expand Medicaid. Ochoa presses him on where this fundamental disconnect originates and why voters fail to hold their own state leaders accountable.

[11:00](https://www.youtube.com/watch?v=6N78CNuC-1c&t=660s) Healthcare as a "Hard Issue" and the Rural Health Spiral

Healthcare policy ranks among the most complex policy domains in any nation, making it exceptionally difficult for everyday citizens to decipher why a particular health outcome has occurred—whether that means losing coverage or watching a hospital bill increase by a confusing margin. Because political scientists categorize these as “hard issues,” individuals do not parse technical policy details; instead, they rely on partisan cues, party narratives, and pre-existing political identities to interpret their experiences. When Republican voters suffer a negative outcome, they interpret that setback through Republican-aligned frames and stories. Conversely, because the Democratic Party has long cultivated a reputation as the “healthcare party,” good healthcare outcomes offer them strong political credit, while negative outcomes expose them to outsized blame. Michael Shepherd observes: “Uh, but when things are bad, that can become a vulnerability for them, which is that um, Democrats are blamed for these bad healthcare outcomes because they're perceived as being the party that did the healthcare things.”

Partisan affiliation also functions as a perceptual filter that prevents people from updating their beliefs based on objective reality. An individual asked about economic performance will assess the economy substantially worse if the opposing party occupies the White House and substantially better if their own party is in power. That same dynamic applies directly to healthcare sentiment, where baseline perceptions swing wildly based on whether a voter’s preferred party holds the presidency. When these rigid partisan lenses collide with skewed media framing and the asymmetric fallout of policy failures, rural communities become trapped in a self-reinforcing political cycle. As Shepherd summarizes: “When you pair all of those things with what I just talked about regarding media coverage or the asymmetric effects of these bad outcomes, you sort of get into what I call the rural health spiral, which is that the bad outcomes become either part of a partisan blame game uh or an asymmetric anti-government um form of resistance that benefits the Republican party down the line.”

```mermaid flowchart TD accTitle: The Rural Health Spiral accDescr: A flowchart mapping how complex healthcare issues trigger partisan blame and reinforce anti-government resistance in rural communities. subgraph IssueComplexity ["Issue Environment"] A["Complex Healthcare Shocks (Coverage losses, billing spikes)"] --> B["Voters Rely on Partisan Cues ('Hard Issue' heuristic)"] end

subgraph PerceptualFilters ["Partisan Framing"] B --> C["Democrats Blamed as the 'Healthcare Party'"] B --> D["In-Party Justifications & Partisan Media Frames"] end

subgraph PoliticalSpiral ["The Rural Health Spiral"] C --> E["Anti-Government Backlash"] D --> E E --> F["Electoral Support Tilts Toward Republican Party"] end ```

[13:40](https://www.youtube.com/watch?v=6N78CNuC-1c&t=820s) Nationalized Partisanship and Down-Ballot Polarization

When asked why voters consistently direct their anger at whole political parties rather than holding specific individual politicians accountable for how they voted, Shepherd traces the pattern to the nationalization of American politics over the last twenty to thirty years. Voters increasingly process the political universe strictly through a binary Democrats-versus-Republicans lens from the top of the ballot down to the very bottom. As Shepherd explains: “We think that that sort of nationalized partisanship keeps people from viewing individual politicians as doing things different than their political party.”

This nationalized perspective is continually amplified by political advertising and news coverage, which typically center on broad party labels or the president rather than local policy specifics. Even in down-ballot contests—such as elections for mayor, city council, or state legislature—campaign commercials routinely invoke hot-button national party disputes. This drowns out local records and prevents candidates from establishing distinctive, locally tailored profiles. While local elections still retain slightly more candidate-centered evaluation than congressional or presidential races, extreme political polarization makes it nearly impossible for individual politicians to shed the overarching brand of their national party.

- Voters evaluate candidates across all ballot levels primarily through national party identity rather than personal legislative voting records. - Campaign ads for local municipal and state legislative offices increasingly highlight polarizing national party themes rather than localized achievements. - While municipal races (city councils and mayors) display more individual candidate evaluation than presidential contests, candidate-level differentiation has markedly eroded compared to historical baselines.

[15:50](https://www.youtube.com/watch?v=6N78CNuC-1c&t=950s) Medicaid Reliance and the Urban-Rural Hospital Ripple Effect

Addressing whether rural hospital closures stem from entire rural populations being on Medicaid, Shepherd notes that although a universal majority is rare, extreme concentrations do exist. In select regions—such as specific congressional districts in Appalachian Kentucky and parts of California—a clear majority of adults depend directly on Medicaid for health coverage, making any alterations to the program economically seismic for regional providers. Across the broader nation, rural populations are disproportionately enrolled in Medicaid relative to their urban and suburban peers: roughly 25% to 30% of rural residents receive Medicaid coverage, compared to approximately 15% to 20% in urban and suburban areas.

Although urban providers also face substantial financial headwinds from Medicaid policy shifts, urban healthcare markets possess a numerical buffer because a far larger gross volume of commercially insured patients helps offset Medicaid losses. Rural hospitals lack that diversified commercial revenue cushion. Furthermore, when a rural facility shuts down, displaced patients are forced to seek treatment at the nearest surviving facility, whether that is a neighboring rural hospital or a regional urban center. While this migration can bring urban hospitals an influx of revenue, it frequently creates acute operational crises in the short term, overwhelming emergency rooms and intensifying severe staffing pressures. As Shepherd points out: “That degree is a function not only of the um disproportionate share of rural residents being enrolled in Medicaid um but is also um a function of more urban areas having more people with private insurance just numerically.”

[18:29](https://www.youtube.com/watch?v=6N78CNuC-1c&t=1109s) Surging Drive Times and Life-or-Death Emergency Care

The physical disruption caused by a hospital closure depends heavily on state geography and local infrastructure, but it consistently imposes steep increases in travel time. Across the country, losing a community hospital typically adds 20 to 40 minutes of driving time to reach the next facility. In geographically isolated regions, however, that figure expands dramatically. In parts of Michigan—particularly across northern Lower Michigan and throughout the Upper Peninsula—residents may be forced to drive well over an hour to reach the closest open hospital.

The erosion of care also occurs incrementally through service line closures even when the physical building remains open. The shuttering of obstetrics and labor and delivery units represents a widespread and devastating trend, frequently forcing expectant mothers to travel an hour and a half to two hours to deliver safely. In time-sensitive medical emergencies, added travel distance turns clinical delays into catastrophic outcomes. Emphasizing the life-or-death stakes, Shepherd notes: “I think it's important to highlight that um for a variety of different health situations, strokes, car crashes, heart attacks, snake bites, gunshot wounds, every additional minute can be consequential for the status of one's health uh after they leave.”

- Typical rural hospital closures increase patient driving times by 20 to 40 minutes, with remote areas facing additional drives of an hour or more. - The closure of dedicated labor and delivery units can force pregnant patients to travel 1.5 to 2 hours to find an operational maternity ward. - Extended drive times pose immediate mortality and disability risks for acute medical emergencies, including strokes, myocardial infarctions, traumatic motor vehicle collisions, venomous snakebites, and gunshot wounds.

[20:39](https://www.youtube.com/watch?v=6N78CNuC-1c&t=1239s) 2026 Midterm Outlook and Rural Backlash

Looking ahead to how rural voters will cast their ballots in the 2026 midterms, Shepherd views the electoral outcome as an open question that depends on specific demographic and regional cohorts, but one governed by well-established historical fundamentals. Historically, midterm elections act as a referendum on the White House, generating an almost universal backlash against the sitting president’s party. When voters confront deteriorating conditions—specifically worsening economic stability and degraded healthcare access under the incumbent administration—that historical penalty becomes significantly more pronounced. As Shepherd evaluates the upcoming electoral climate: “Typically, that's what we observe, the midterm of a president, um, there's almost always some backlash against the president's party.” Under the prevailing conditions where healthcare and economic indicators have eroded, overall dynamics point toward an electoral backlash against the governing Republican Party.

[21:20](https://www.youtube.com/watch?v=6N78CNuC-1c&t=1280s) Calcified Partisanship and Voter Turnout in Rural Communities

Evaluating how rural hospital closures translate into election results remains a complex, open question. Because Republican party identification is deeply entrenched across rural regions, observers are unlikely to see these voters cross the aisle en masse. Instead, the more probable consequence of healthcare disruption is a sharp decline in voter turnout among individuals who have suffered negative healthcare impacts. A change in who shows up at the polls can alter election margins without requiring a fundamental shift in political ideology.

Partisanship across the nation has become increasingly rigid, meaning major swings primarily reflect turnout variance rather than persuaded voters. However, certain demographic subsets—particularly younger voters and Latino voters—exhibit more fluid political preferences. These cohorts could break sharply against the Republican Party, while older or more established rural voters may stick to their partisan loyalties and merely register their frustration through dampened enthusiasm on Election Day.

As Michael Shepherd observes: > “Partisanship has really calcified in lots of parts of the country.”

[22:45](https://www.youtube.com/watch?v=6N78CNuC-1c&t=1365s) The Timeline of Medicaid Cuts and Shifting Political Blame

When assessing whether the impact of Medicaid cuts will register immediately or peak around 2027, the rollout is already in motion. Healthcare providers and insurance carriers have actively adjusted their behaviors in anticipation of these changes, and the expiration of Affordable Care Act (ACA) premium subsidies has already raised costs and reshuffled coverage. Meanwhile, state-level implementations of Medicaid work requirements and structural financing reforms are unfolding in a staggered cadence. Although initial shocks are visible now, the full operational brunt will likely land around 2027, making the 2028 and 2030 election cycles the primary moments of political reckoning.

This protracted implementation timeline often insulates the politicians who authored the legislation. Voters possess relatively short time horizons and tend to hold whoever currently occupies office accountable for their immediate economic and healthcare hardships, irrespective of historical policy origins. If Democrats capture Congress in 2027 or win the White House in 2028, they may end up absorbing the political fallout for rural hospital strain engineered by earlier Republican measures.

```mermaid flowchart TD accTitle: Policy Lag and Voter Blame Cycle accDescr: Flowchart illustrating how legislative policy delays shift voter blame away from policy authors to the incumbent party.

subgraph Legis["Policy Enactment"] A["Legislation Passed (Medicaid Cuts & Subsidy Lapses)"] end

subgraph Delay["Implementation Lag"] B["Provider & Insurer Preemptive Shifts"] C["Staggered State Rollouts (Work Requirements & Financing)"] D["Full Public Impact Felt (2027–2030)"] end

subgraph Response["Electoral Fallout"] E["Voters Focus on Present Hardships"] F["Current Incumbent Party Blamed Regardless of Origin"] end

A --> B B --> C C --> D D --> E E --> F ```

As Michael Shepherd explains regarding voter perception: > “In general, what we see is like the longer a time horizon between when a policy is passed and when those effects are felt, that the harder it is for voters to connect the outcomes to a specific policy and instead they tend to assign blame to whoever's in charge at that moment.”

[25:00](https://www.youtube.com/watch?v=6N78CNuC-1c&t=1500s) Federalism, the $50 Billion Fund, and the Rural Blame Game

The dynamics of federalism further obscure legislative accountability. As part of major federal legislation—framed colloquially as the "one big beautiful bill act"—lawmakers established a Rural Health Transformation Program. This initiative allocated a $50 billion injection of federal funds designated to assist struggling rural hospitals. Yet, the funding is mathematically insufficient to cover the aggregate losses triggered by the broader Medicaid rollbacks. Crucially, statutory language within the policy expressly prohibits states from using these transformation funds to offset their direct Medicaid shortfalls.

Despite this limitation, the program serves as an effective political shield. Republican lawmakers in Washington can deflect accusations of neglect by highlighting the massive headline figure and shifting culpability to state officials and hospital administrators. In a state like Michigan, for example, congressional representatives can conveniently question how Governor Gretchen Whitmer’s administration managed to "goof" the disbursement of those funds, effectively redirecting public outrage away from Capitol Hill and onto state executive offices and local healthcare boards.

As Michael Shepherd puts it: > “Republicans in Congress have some way to not only avoid blame due to the longer time horizon of the effects of the policy, but they can point to this major injection of resources and say, ‘Well, what happened? That's not our fault. That must be the fault of those rural hospital providers or the Whitmer administration.’”

[26:28](https://www.youtube.com/watch?v=6N78CNuC-1c&t=1588s) The Spillover Effects of Medicaid Reductions on Private Insurance

The fallout from Medicaid retrenchment reaches far beyond low-income or publicly insured individuals. The expiration of ACA premium tax subsidies pushed healthcare costs higher across the board, affecting policyholders of all tiers. More critically, rural hospitals rely directly on Medicaid reimbursements to sustain their baseline operating margins. When Medicaid funding collapses, the financial solvency of the entire institution is compromised.

If a community hospital shuts down, everyone living within that service area suffers an identical loss of access. Patients carrying private commercial health coverage are forced onto the same long, hazardous rural highways to reach distant emergency rooms. While uninsured or dropped Medicaid patients face both the loss of insurance coverage and the loss of local facilities, privately insured residents still incur the physical danger and degraded health outcomes that accompany medical deserts.

As Michael Shepherd emphasizes: > “The thing that I like to drive home to folks is your if you're in a rural area, your hospital depends on Medicaid dollars.”

- Premium costs increase across the board when subsidies lapse, irrespective of public coverage status. - Rural hospitals rely on a blended payer pool; removing the Medicaid foundation destabilizes the entire facility. - Hospital closures force identical transport burdens and delayed treatment on all community residents.

[27:39](https://www.youtube.com/watch?v=6N78CNuC-1c&t=1659s) The Value of Political Engagement in Local Communities

When asked to identify the single most critical piece of evidence a rural voter should weigh at the ballot box, Shepherd demurs from prescribing an exact priority. Every rural community possesses unique economic realities, cultural values, and local challenges, making sweeping generalizations inadequate. Academic political science even features formal models arguing that the effort required to stay informed outweighs the statistical impact of a single ballot.

Nevertheless, Shepherd firmly rejects political disengagement. Electoral outcomes generate real, tangible ripples throughout everyday life: from the stability of local hospital networks and community employment to fluctuating consumer fuel prices. Navigating and mapping personal values onto ballot choices demands dedication, making civic literacy and active engagement essential for protecting the viability of rural towns. The episode concludes with a sign-off noting that *Michigan Minds* is produced by Michigan News, a division of the University of Michigan's Office of the Vice President for Communications.

As Michael Shepherd reflects on the broader stakes of governance: > “Elections have severe consequences, in a variety of ways, or at least they can.”

## Notable quotes > [26:28](https://www.youtube.com/watch?v=6N78CNuC-1c&t=1588s) if you're in a rural area, your hospital depends on Medicaid dollars. — Michael Shepherd

> [21:20](https://www.youtube.com/watch?v=6N78CNuC-1c&t=1280s) Partisanship has really calcified in lots of parts of the country. — Michael Shepherd

## Mentioned Juan Ochoa, Michael Shepherd, University of Michigan School of Public Health, Affordable Care Act, Facebook, Gretchen Whitmer, Rural Health Transformation Program, Democratic Party, Republican Party, Michigan Minds, University of Michigan

## Video description Michael Shepherd is an assistant professor of health management and policy at the University of Michigan School of Public Health. He discusses how healthcare has become one of voters' top priorities, especially in rural America, where hospital closures, Medicaid changes and partisan identity intersect.

Listen to the full episode: https://news.umich.edu/michigan-minds-the-rural-healthcare-blame-game/

[Source](https://www.youtube.com/watch?v=6N78CNuC-1c)

中文简报

乡村医疗的推责游戏迈克尔·谢泼德博士深入分析了乡村医疗基础设施的崩溃——从产科病房关闭到急诊车程增加——如何在当地新闻荒漠和两极化的媒体过滤下，演变为党派相互推诿的循环。由于医疗保健属于复杂的“硬性议题”，选民往往依赖党派直觉和种族化叙事，即便在共和党官员抵制医疗补助（Medicaid）扩张的州，也会因当地医院的倒闭而惩罚民主党。谢泼德详细指出，削减医疗补助使整个乡村医疗机构陷入险境，无论个人是否拥有商业医保；与此同时，较长的政策落实滞后期以及联邦资金漏洞，实际上保护了立法起草者免受选举追责。最终，该讨论揭示了固化的政治身份和选民投票率的变化，如何在即将到来的选举周期中加剧自我强化的乡村医疗恶性循环。约25%至30%的美国乡村居民依赖医疗补助，而城市地区这一比例为15%至20%；由于缺乏商业医保患者来弥补亏损，乡村医疗机构在面临项目资金削减时显得格外脆弱。 (15:50) 乡村医院关闭通常会使急诊行车时间增加20至40分钟，在偏远地区或针对分娩等专科服务，行车时间甚至会延长至两小时。 (18:29) 联邦政策的推迟以及仅纳入杯水车薪的500亿美元“乡村医疗转型计划”，使国会议员得以将医疗机构关闭的责任推卸给州行政官员和当地医院管理者。 (25:00) 尽管80%的乡村医院关闭发生在拒绝扩大医疗补助的共和党执政州，但复杂的政策环境导致乡村选民转而惩罚民主党或产生反建制观点。 (8:22)

Reading summary

University of Michigan assistant professor Dr. Michael Shepherd argues that rural healthcare hardships—including facility closures and severe care shortages—are heavily distorted by nationalized media, racial scapegoating, and rigid partisanship, creating a self-reinforcing political cycle where voters misattribute policy failures. Media Vacuums and Racialized Scapegoating (0:04) According to Dr. Shepherd, the erosion of rural healthcare access intersects with political rhetoric to foster zero-sum, racialized grievances. While rural Black and Latino communities, particularly in the South, suffer the most acute structural deprivations, political rhetoric often primes struggling rural white residents to view healthcare through an 'us versus them' lens. These voters frequently infer that urban minority populations are prospering at their expense, even when empirical data contradicts that perception. This distortion is exacerbated by the collapse of local journalism over the past 15 to 20 years. As local newspapers closed, vast news deserts emerged. Regional television stations based in metropolitan centers provide minimal rural civic reporting, filling the void with syndicated national political conflict. In place of professional journalism, informal conduits such as independently run, partisan Facebook pages shape public sentiment, channeling localized grief and anti-establishment feelings into blame directed at national Democrats and federal institutions. Partisan Framing and the Rural Health Spiral (11:00) Dr. Shepherd characterizes healthcare policy as a 'hard issue' whose technical complexity leads voters to rely on partisan heuristics rather than policy details. Because the Democratic Party is widely viewed as the 'healthcare party,' it receives political credit when conditions are good, but disproportionate blame when outcomes worsen—even though roughly 80% of rural hospital closures have occurred in Republican-led states that refused Medicaid expansion. This dynamic feeds into what Dr. Shepherd calls the 'rural health spiral.' Because partisanship acts as a perceptual filter, voters evaluate the state of healthcare through party loyalties. Coupled with nationalized, down-ballot political polarization, negative healthcare outcomes routinely translate into broader anti-government sentiment and partisan blame that ultimately benefits the Republican Party down the line. Medicaid Dependency and Escalating Emergency Risks (15:50) Rural healthcare systems are uniquely vulnerable to shifts in Medicaid policy because rural populations rely disproportionately on the program—roughly 25% to 30% are enrolled, compared to 15% to 20% in urban and suburban areas. Unlike metropolitan hospitals that can lean on higher volumes of privately insured patients to offset Medicaid shortfalls, rural facilities lack commercial revenue cushions. When Medicaid funding drops, entire institutions face insolvency, threatening care for privately insured residents as well. When rural hospitals shut down, local driving times to the next emergency facility typically increase by 20 to 40 minutes, and by over an hour in remote areas such as northern Lower Michigan and the Upper Peninsula. Service cuts, particularly the shuttering of obstetric units, routinely force expectant mothers to travel 1.5 to 2 hours for deliveries. Dr. Shepherd stresses that these travel delays carry life-or-death consequences for acute emergencies, including strokes, heart attacks, car crashes, snakebites, and gunshot wounds. Policy Lag and Institutional Blame Shifting (22:45) The political fallout from healthcare legislation is heavily obscured by implementation timelines and federalism. Dr. Shepherd observes that long time horizons—such as the phased rollout of Medicaid cuts, work requirements, and lapsing subsidies reaching full impact around 2027—prevent voters from linking outcomes to the original legislative sponsors. Instead, voters tend to hold the party currently in office accountable for their immediate hardships, potentially leaving Democrats to absorb blame in 2028 or 2030 for earlier Republican measures. Federal structures also provide cover for national legislators. The Rural Health Transformation Program provided a $50 billion fund for rural hospitals under recent federal legislation, but Shepherd notes this amount is mathematically insufficient to counter broad Medicaid rollbacks. Furthermore, federal rules prohibit states from using the fund to patch direct Medicaid shortfalls. Despite this inadequacy, congressional lawmakers cite the headline figure to deflect responsibility onto state administrations and local hospital boards. Looking toward future elections, Dr. Shepherd notes that while calcified partisanship makes rural voters unlikely to cross party lines en masse, healthcare shocks could depress voter turnout or trigger sharper political shifts among younger and Latino cohorts. Despite the cognitive difficulty of parsing complex policy, he stresses that active civic engagement remains vital because governing decisions directly determine the physical and institutional survival of rural communities.

精炼阅读摘要

密歇根大学公共卫生学院助理教授 Michael Shepherd 指出，美国农村医疗的持续恶化不仅是资源供给不足的结构性危机，更被地方新闻萎缩、复杂政策时滞与全国化党派叙事异化为政治替罪机制。选民受党派滤镜与种族化修辞影响，常将医院关闭归咎于民主党或外部群体，陷入一种自我强化的“农村健康螺旋”。种族化叙事与相对剥夺感替罪机制 (0:04) Shepherd 阐释，虽然种族和族裔在现实中直接制约医疗服务获取（例如美国南部农村的黑人与拉美裔群体承受着最严重的结构性资源匮乏），但政治精英与媒体常将平价医疗法案（ACA）等政策刻意种族化。这种政治修辞诱导农村白人选民从零和博弈角度审视公共事务，使其倾向于认为政府举措正在转移本地资源去优待城市少数族裔。尽管缺乏客观实证支持，这种“我们对阵他们”的情感框架填补了缺乏制度问责时的认知真空。当农村面临诊所关停或医疗自负费用上涨的切实困境时，政客提供的外部受惠叙事使选民获得了一种情感自洽的解释，将地方医疗体系的崩溃归咎于外部偏袒，从而硬化为深刻的政治怨恨。新闻沙漠与非正式传播的党派极化 (5:12) 过去15至20年间，美国传统地方报刊大规模消亡，形成了广阔的“新闻沙漠”；区域电视媒体则大多扎根大都市，主要分发由传媒集团辛迪加制作的全国政治冲突内容。Shepherd 指出，在缺乏高质量本地调查报道的环境下，公众甚至无需接触明确的虚假信息，就会机械套用全国党派政治框架去解读身边的公共事务。当农村医院停运却缺乏本地新闻解释缘由时，信息真空迅速被口碑相传以及缺乏专业新闻规范的本地 Facebook 社区主页（非正规“新闻公报”）占领。这些渠道往往由活跃的保守派主导，充斥着反建制与阴谋论倾向，有针对性地引导居民将愤怒投向全国性民主党与联邦机构，推动农村选民系统性倒向共和党。 “硬性议题”困境与农村健康螺旋 (11:00) 医疗政策属于政治学中典型的“硬性议题”（hard issue），因其涉及复杂的报销机制与精算逻辑，普通民众极难直接厘清医疗账单暴增或失去保险的技术性原因。选民因此高度依赖自身既有的党派身份来评估医疗状况；同时，由于民主党长期被普遍视作“医疗党”，这使其在医疗体系向好时享有政治声誉，却在体系恶化时承受不成比例的责难。 Shepherd 指出，即便现实中高达 80% 的农村医院关闭发生在由共和党执政且主动拒绝扩大 Medicaid 的州，选民仍倾向于惩罚民主党。党派滤镜严重阻碍了选民基于客观现实修正信念，最终形成所谓的“农村健康螺旋”：医疗恶化带来的冲击被转化为单向的反政府情绪，并在选举中持续惠及共和党。财政挤出效应与急救车程激增现实 (15:50) 农村医疗体系面临极为脆弱的财政基础。在全美范围内，约 25% 至 30% 的农村居民依赖 Medicaid，显著高于城市及郊区的 15% 至 20%，且农村机构缺乏充足的商业保险患者来对冲政策削减引发的亏损。Shepherd 强调，社区医院倒闭对辖区内全员产生无差别冲击，即使持有私人商业保险的居民也同样被迫面临漫长路程。医院关闭通常会导致就医车程增加 20 至 40 分钟，在偏远地区（如密歇根州北部及上半岛）常超过 1 小时；产科的关闭更迫使产妇奔波 1.5 至 2 小时。对于中风、心肌梗死、严重车祸、蛇咬伤或枪伤等时间高度敏感的急症，救治时间的延误构成了直接的致残与致命威胁。政策时滞掩护与联邦制下的责任推诿 (22:45) 医疗政策的长期实施周期削弱了选举问责的精确度。虽然保费补贴到期等冲击已初现端倪，但 Medicaid 工作要求与结构性改革的全面冲击预计要到 2027 年前后才会集中显现。Shepherd 分析，选民通常具备较短的时间跨度，倾向于怪罪当下执政者；若民主党在 2027 或 2028 年重新执政，反而可能替共和党早前通过的法案背负民怨。此外，联邦通过“农村健康转型项目”设立的 500 亿美元资金在制度上起到了政治护盾的作用。尽管该拨款在数额上远不足以抵消 Medicaid 的整体削减，且法定条款禁止其直接填补资金赤字，但国会共和党人仍可借此宣称已给予重大支持，并将医院关闭的责任推诿给州政府执行不力（如批评密歇根州 Whitmer 政府失职），以此转移选民问责。 Shepherd 认为，在两党极化严重固化的背景下，医疗困境更可能导致农村选民投票率下降或部分年轻及拉美裔群体分化，而非整体选民的大规模跨党倒戈。尽管政策时滞与政党修辞持续扭曲问责机制，选举对农村社区基础设施与生存安全依然具有直接且实质的影响，这凸显了审慎参与公民政治的现实必要性。

Source quotes

[26:28] Michael Shepherd: if you're in a rural area, your hospital depends on Medicaid dollars. [21:20] Michael Shepherd: Partisanship has really calcified in lots of parts of the country.

Original transcript

[0:04] Welcome to the Michigan Minds podcast [0:06] where we explore the wealth of knowledge [0:08] from faculty experts at the University [0:10] of Michigan. I am Juan Choa, [0:12] international public relations [0:13] representative for the Michigan news [0:15] office. I'm pleased to welcome Dr. [0:17] Michael Shepard, assistant professor of [0:19] health management and policy at the [0:20] University of Michigan School of Public [0:22] Health. Dr. Shepherd's research examines [0:25] US health politics and policy, rural [0:27] health disparities, and the roles that [0:29] political parties, race, and mass media [0:32] play in shaping health attitudes and [0:33] behaviors. Welcome, Dr. Shepard. [0:35] >> Thank you for having me. [0:37] >> With the midterms approaching, [0:39] healthcare has become one of voters top [0:41] priorities across the country. But when [0:43] we look closer at rural America, [0:45] healthcare isn't just an issue of [0:48] insurance or doctor visits. It's tied to [0:51] local survival, partisan identity, and [0:54] deep-seated ideas about who the system [0:56] works for. With that in mind, what role [0:59] does race and racism play in shaping US [1:02] health policy, and how does that connect [1:05] to rural voters who may not think of [1:07] healthcare as a racial issue? Race and [1:10] racism play very important roles um in [1:14] shaping how many rural voters in [1:17] particular understand or think about [1:19] health policy and healthcare access. Um [1:23] but importantly um most scholars in this [1:25] area um believe that this process is [1:28] twofold at least. Um, one is that um, [1:31] race uh, and ethnicity play [1:35] straightforward or direct roles in [1:37] shaping health care um, access in a [1:40] variety of rural areas. There's no [1:42] doubt, especially when we look um, at [1:44] the South that it is rural black [1:46] communities in particular and rural [1:48] Latino communities that have the most [1:51] restricted access to health care. So, in [1:54] that way, we think healthcare access is [1:56] directly shaped um, by race. Uh but in [1:59] terms of racism, what we see is that [2:02] from time to time, health issues or [2:04] health policy issues become racialized. [2:06] That is politicians or the media connect [2:10] particular health outcomes uh or [2:13] particular health policies such as the [2:15] Affordable Care Act um in racialized [2:18] ways. And and that leads rural white [2:20] voters to view their healthcare access [2:22] or or view healthcare policy um in terms [2:25] of us versus them. uh in a ma in matters [2:29] of race and racism or race and ethnicity [2:32] that is seeing certain health policies [2:35] as going to benefit racial and ethnic [2:38] minority group members more um than [2:41] rural white folks. Um even though [2:44] objectively that's not true. Um what we [2:47] can see um is that once politicians or [2:50] the media connect or fuse um racial [2:53] matters or racial considerations with [2:56] health policy um voters, especially [2:58] rural white voters, um respond by [3:01] viewing those health policies or those [3:03] health outcomes as um something that is [3:07] related to their racial attitudes. [3:10] >> You say that they see others getting [3:12] benefits that they're not getting. What [3:14] are they looking at? Um, some of this is [3:16] actually more rhetorical than it is um, [3:20] objective or empirical. Um, the process [3:23] tends to be more along the lines of I [3:26] view health care access as being [3:28] restricted um, in my community. Um, I [3:31] lost my local hospital. Um, I lack [3:34] health insurance. Health care is [3:36] expensive. Um, and in those moments, [3:39] white voters and rural white voters [3:41] perhaps in particular are susceptible to [3:44] rhetoric that provides scapegoats um or [3:47] provides um status uh cues that [3:51] essentially um lead rural white voters [3:54] to view those types of outcomes, health [3:56] care u health insurance access, hospital [3:59] access um as not only worse off in their [4:04] community or for them personally um but [4:06] must be better off for people who live [4:09] in cities, [4:11] racial and ethnic minority group members [4:13] who live elsewhere. Um, and in that way, [4:16] these things become more abstract. Um, [4:18] they're more rhetorical rather than [4:20] substantive. Uh, and it feeds into uh a [4:23] narrative, a blame structure if you [4:25] will. Um, that provides some [4:27] understanding or some story of why [4:30] healthcare access in a rural [4:32] predominantly white community is bad. [4:35] It's not only bad because of policy [4:38] decisions or because of where um these [4:40] folks happen to live. It's it's because [4:42] it's someone else's fault and someone [4:44] else is getting ahead uh while the rural [4:47] white voter and the rural white [4:49] community um perceives that they are are [4:52] falling behind or being neglected. [4:53] >> You know, I think that's a topic that [4:56] might not apply just to rural voters, [4:58] but you're the expert. you you can tell [4:59] me a little bit more, but it could also [5:02] be, you know, urban voters that get [5:04] information that is wrong. What can we [5:07] all do to make sure that what we're [5:09] listening to or reading is correct? Um, [5:12] I think it's fair to say that this isn't [5:14] exclusively a rural thing. Um, I think [5:18] perhaps compositionally or um just [5:21] disproportionately these things tend to [5:23] play out the way I've described and in [5:24] rural white communities, but that [5:26] doesn't mean that they're the the only [5:28] communities where they occur. Um, in [5:30] general, I think our our information and [5:32] media ecosystem have changed pretty [5:35] substantially over the last 15 to 20 [5:37] years in ways um that make these [5:40] mechanisms or make these sort of [5:42] misunderstandings of policy realities [5:45] more likely. Um, I think it's tempting [5:47] to focus on things like social media, [5:49] which which no doubt play a role here, [5:51] but a lot of this has to do with changes [5:53] in local media as well as national [5:56] media. Um, for at least the rural [5:59] communities that that I study, local [6:01] media doesn't really exist um, in lots [6:04] of them. We've seen newspaper closures [6:06] over the last 15 years. Local television [6:08] news is often far off and in an urban [6:11] area and very unlikely to be reporting [6:13] what's going on on the ground. Um but [6:15] even in more urban areas, local news [6:18] media have become more focused on [6:20] national issues uh and national [6:22] political discussions or reporting um [6:26] nationalized coverage of content that is [6:28] things that have been shared throughout [6:30] their media conglomerate to be reported [6:33] everywhere. And so that kind of changes [6:35] the relationship between local outcomes [6:38] um and why they're occurring uh and how [6:40] people understand politics. That's [6:42] that's what we refer to as like the [6:44] nationalization of news media and of [6:46] politics. Um but also people are are [6:48] just exposed to national content a lot [6:51] more um either on social media um or in [6:55] what they observe in like nightly news [6:57] or cable news um or um you know online [7:00] in a variety of ways and that elevates [7:03] national considerations that is the [7:05] president versus congress the national [7:08] political parties the rise and fall of [7:11] of national outcomes related to the [7:14] economy. um those tend to be what voters [7:17] are responding to because that's what [7:19] kind of information that they have. Uh [7:21] and so in a world where we have perhaps [7:24] not hyper local focused news coverage, [7:27] we don't even really need misinformation [7:30] to lead people to react to the wrong [7:32] sets of things or to lead people to [7:34] consider some factors that are maybe [7:37] less relevant for them personally or [7:39] locally. Um but when you add on things [7:41] like misinformation online um or or [7:44] coverage that is biased in particularly [7:47] partisan ways um folks are are are no [7:49] longer really being exposed um to the [7:51] kinds of information that we think might [7:53] be helpful for understanding um who is [7:56] responsible for that hospital closure in [7:59] your community. Why did that happen? Um [8:01] and that can lead people to to do all [8:03] kinds of things politically that maybe [8:05] um they would not have 30 40 years ago. [8:08] Could that misinformation be attributed [8:11] to the reason why most rural communities [8:14] tend to vote Republican as opposed to [8:16] urban voters who vote Democrat? And how [8:18] much of that is identity versus policy? [8:22] >> Yeah, I don't, you know, I I personally [8:24] haven't seen that misinformation [8:26] inherently uh is the driving cause, but [8:29] but rather the kind of information that [8:31] people have available to them. One of [8:33] the things that I've noticed a lot in my [8:35] work is when a rural hospital closes in [8:37] a particular rural community, um there's [8:40] often times not a local newspaper. Uh [8:42] it's often times not covered by local [8:44] news, although those things have changed [8:45] more recently. Um and instead what [8:48] happens is um coverage, if you will, [8:51] vaguely is um via word of mouth. um [8:55] often times with um louder, more [8:58] politically active, more politically [8:59] conservative folks providing the [9:02] narrative, understanding the story of [9:04] why this thing closed, but also um less [9:08] formal small town um I I call them news [9:11] gazettes. They're basically Facebook [9:12] news pages where someone local has [9:15] decided to run a social media account [9:17] that covers what's going on in the small [9:19] town. Those media outlets are often, if [9:23] not outright conservative, somewhat [9:26] conspiratorial or anti-establishment [9:29] um in their coverage and those are also [9:31] contributing some narrative [9:33] understanding. So rather than um there [9:35] being no discussion at all of the rural [9:37] hospital closure, instead what we see is [9:39] a particular kind of discussion uh [9:42] particular a discussion that is placing [9:44] particular blame on things like the [9:46] Democratic party but also national [9:49] health policy decisions, the [9:51] establishment vaguely, government [9:53] vaguely. Um and that contributes I I [9:55] think to a mixture of both partisan [9:58] blame tendencies uh as well as more of a [10:02] um anti-establishment [10:04] anti-government reaction which is um [10:06] broadly the mainstream forces in [10:10] American society that is the news media [10:12] uh formal news media um the national [10:15] government the national political [10:17] parties are letting down people um in [10:19] these communities or they feel like [10:21] their communities are unrepresented by [10:23] those institutions. ions and that has an [10:25] asymmetric effect that pushes people [10:27] away from these establishment [10:29] institutions and in our two-party system [10:32] that often means towards the Republican [10:34] party. [10:35] >> In recent interview, you mentioned how [10:38] rural voters tend to blame Democrats for [10:41] hospital closures, for example, even [10:44] though 80% of the closures occurred in [10:46] Republicancontrolled states that did not [10:49] expand Medicaid. Where is that [10:51] disconnect? And why can't voters see [10:54] that their own party's policies may have [10:56] caused them harm? [10:58] >> There are lots of things going on that [11:00] can explain why that happens. Um, one is [11:03] that healthc care policy is one of the [11:05] most complex policy areas um in the [11:08] country or in any country. It's very [11:10] difficult for any person to understand [11:13] exactly why some health care outcome has [11:16] occurred. Um why they've lost health [11:18] insurance, why their hospital bill has [11:20] increased by some margin. Um those are [11:23] all things that are just really [11:25] difficult to understand. And as a [11:27] result, um political scientists call [11:29] these hard issues. And when there are [11:31] hard issues, people tend to fall back on [11:34] things like partisan cues to understand [11:37] them. So, if you identify as a [11:39] Republican and you experience a bad [11:41] outcome, [11:43] you might fall back on Republican party [11:46] um stories, narratives, um frames of why [11:49] these things have happened to understand [11:51] why this is happening um to you. The [11:54] other thing is that Democrats have long [11:56] been known as the healthc care party. Uh [11:59] and so when healthc care outcomes are [12:00] perceived as as good, that's a really [12:03] strong thing for the Democratic party. [12:04] they can say, you know, we passed this [12:07] policy that had these positive outcomes. [12:09] Uh, but when things are bad, that can [12:11] become a vulnerability for them, which [12:13] is that um, Democrats are blamed for [12:15] these bad healthcare outcomes because [12:17] they're perceived as being the party [12:19] that did the healthcare things. Um the [12:22] other thing that that I think is [12:23] important to note is that um once [12:26] someone strongly identifies with a [12:28] political party, they start to [12:30] understand the world in ways that [12:33] reflect those predispositions and and [12:35] that don't update them. So um if you [12:38] were to ask a Democratic voter right [12:40] now, um how is the economy doing? [12:42] they're going to say substantially worse [12:46] um than if the you were at the same time [12:48] to ask a Republican the same question. [12:51] And that's because there's a Republican [12:53] um in the White House. And the same [12:54] holds for for health policy. If you were [12:57] to ask people how the healthcare [12:58] environment is currently, you would see [13:00] a large partisan difference just because [13:02] people tend to um believe that their [13:06] party is doing a better job um than the [13:09] than the other party is regardless of [13:11] what the actual outcomes are. When you [13:14] pair all of those things with what I [13:16] just talked about regarding media [13:18] coverage or the asymmetric effects of [13:21] these bad outcomes, you sort of get into [13:23] what I call the rural health spiral, [13:25] which is that the bad outcomes become [13:28] either part of a partisan blame game uh [13:31] or an asymmetric anti-government [13:34] um form of resistance that benefits the [13:37] Republican party down the line. Why do [13:40] you think voters tend to blame parties [13:44] rather than individual politicians who [13:46] might have voted against policies [13:49] affecting them if not all of us? [13:51] >> Yeah, I think there are a few things [13:53] going on there. One is that over time, [13:55] especially over the last 20 or 30 years, [13:58] voters have viewed the political system [14:01] as Democrats versus Republicans full [14:03] stop. Top of the ballot all the way [14:05] down. Um, we think that that sort of [14:08] nationalized partisanship keeps people [14:11] from viewing individual politicians as [14:13] doing things different than their [14:15] political party. Those things are [14:16] reinforced by news coverage that tends [14:19] to focus on Democrats and Republicans [14:21] vaguely or just the president. Um, but [14:24] also um things like campaign ads which [14:26] tend to focus on the top of the ticket [14:29] even for for local races. Um, you can [14:32] see in races for city council, for [14:34] mayor, for state legislature, [14:36] discussions of national political [14:39] issues, national partisan issues that [14:41] that reinforce all of those national [14:43] partisan differences and minimize any [14:46] local um considerations or distinct [14:49] candidate um differences. The other [14:51] thing is that um I think as we've become [14:53] more polarized um it's just difficult [14:56] for politicians to shake the brand of [14:59] their national parties and voters tend [15:02] to view things as Democrats versus [15:04] Republicans as opposed to, you know, my [15:07] candidate does this um better than this [15:10] other candidate or local office holder. [15:12] It's important to note though that as we [15:14] do go down, when we move from president [15:17] and congress down to city council and [15:19] mayor, we do see more of what you're [15:22] talking about. We do see more evidence [15:24] that people are evaluating [15:27] um these local candidates differently or [15:30] local representatives differently, but [15:33] not as much as they used to. Uh and so [15:35] when we look at the world now, we look [15:37] at um the rise and fall of state [15:39] legislative candidates or or mayors, um [15:42] it's more partisan than it used to be, [15:44] but it's less partisan than um when we [15:47] think about voting for president. [15:49] >> Going back, you you slightly touched on [15:52] hospital rural hospitals closing. [15:55] For rural hospitals closings due to [15:57] recent Medicaid changes, does this mean [15:59] that most people in those communities [16:01] are on Medicaid? If not, then what's the [16:04] reason behind it? [16:05] >> Yeah. Uh so there are some rural areas [16:08] where um we can say that the majority or [16:12] most uh to use your term of the of the [16:15] voters are on Medicaid or receiving [16:17] their health insurance from Medicaid. If [16:19] we look at um there's a Appalachin [16:22] congressional district in Kentucky, [16:23] there's a congressional district in [16:25] California where the majority of adults [16:28] are enrolled in Medicaid. And so those [16:29] changes have had seismic effects on um [16:33] the financial uh wellness of rural [16:36] health providers. But even in places [16:38] where it's not most, what we see is that [16:40] across the vast majority of states, [16:43] rural voters are disproportionately [16:45] likely um to to be enrolled in Medicaid [16:48] or be be receiving Medicaid. It's very [16:50] rarely most. Um but when we're looking [16:53] across the country, we might see 25 to [16:55] 30% of residents in rural areas um are [16:59] receiving their health insurance from [17:00] Medicaid. Whereas in more urban and [17:02] suburban contexts um that tends to be [17:04] more in the 15 to 20% range. [17:07] >> And in what ways are communities in [17:11] urban settings being affected by [17:13] Medicaid changes uh including hospitals? [17:16] Well, providers everywhere face um [17:18] significant financial challenges as a [17:20] result of the changes to Medicaid. Um so [17:23] that's not a rural urban um distinction. [17:26] It's just a matter of degree um to which [17:28] this is affecting things. That degree is [17:31] a function not only of the um [17:34] disproportionate share of rural [17:36] residents being enrolled in Medicaid um [17:38] but is also um a function of more urban [17:41] areas having more people with private [17:43] insurance just numerically. And that [17:46] means that providers in urban areas, [17:47] even though they faced a hit, they have [17:49] a broader population that they can draw [17:51] from to maintain revenue streams. [17:54] >> Um whereas rural areas really don't have [17:57] that. Um the other effect is that lots [17:59] of rural people, especially once they [18:00] lose a hospital, well, they're going to [18:02] that next closest hospital. Sometimes [18:05] that's another rural hospital, but other [18:07] times that's an urban hospital. And so [18:09] now there's an influx of new people. [18:11] That can mean um new revenue. Uh but [18:14] that can also mean really significant [18:16] headaches at least in the short term [18:18] navigating staffing concerns when [18:20] there's a major increase in the number [18:22] of people who are showing up at an [18:24] emergency room especially at to the next [18:27] closest more rural hospital. [18:29] >> Do you know the average time where a [18:32] hospital closed? How much time do they [18:34] have to spend traveling to a hospital or [18:36] a clinic? Yeah. So that really depends [18:39] on the geography of the state and the [18:41] healthcare infrastructure of a state. Um [18:44] it varies wildly from place to place. Um [18:47] there are rural communities where when [18:49] the local hospital closes we're talking [18:51] about an increase of a 20 minute drive. [18:54] Um there are rural communities however [18:56] that the closure of a rural hospital [18:57] means an increase of an hour drive or [19:00] more. Um when we look at the state of [19:02] Michigan, um we can see places in the [19:04] northern part of the state and in the [19:06] upper peninsula that if a hospital if [19:09] one particular hospital were to close um [19:12] folks might have over an hour drive to [19:14] the next closest hospital um when we [19:17] think about things like um labor and [19:19] delivery, for example, that's where we [19:21] can see real large effects. Even if the [19:23] hospital stays open, if they close down [19:26] their labor and delivery unit, you might [19:28] be looking at an hour and a half or [19:30] 2hour drive to the next closest hospital [19:32] that has an open labor and delivery [19:33] unit. So, there are lots of changes [19:35] there that that can drive things. In [19:36] general, what we see is an increase of [19:39] drive time of somewhere in the range of [19:41] 20 to 40 minutes. It's a big range. Um, [19:45] but that really is because there are [19:46] some rural places that are quite close [19:48] to cities. Um there are some rural some [19:51] states that have lots of rural [19:53] hospitals. Um and there are some places [19:55] where those rural hospitals are laid out [19:57] in a way that geographically means that [20:00] if one were to close, well maybe there's [20:02] another one that's just 30 minutes down [20:03] the road, even though 30 minutes is [20:05] quite a long u uh quite a long increase. [20:08] Um but there are others where it could [20:10] be an hour or more. I think it's [20:12] important to highlight that um for a [20:14] variety of different health situations, [20:17] strokes, car crashes, heart attacks, [20:19] snake bites, gunshot wounds, every [20:22] additional minute can be consequential [20:24] for the status of one's health uh after [20:28] they leave. And so if it's a 20-minut [20:30] increase, well, that's not as bad as an [20:32] hour increase, but there are certain [20:35] situations where that 20 minutes might [20:37] be consequential. with everything going [20:39] on, in which direction do you think [20:41] rural voters will lean this coming [20:43] election? [20:44] >> I think that's somewhat of an open [20:45] question and some of some of it depends [20:47] on which voters we're we're talking [20:49] about. Um, I think it's fair to say in [20:51] the 2026 midterms, we should expect some [20:54] backlash against the Republican party. [20:57] Typically, that's what we observe, the [20:59] midterm of a president, um, there's [21:02] almost always some backlash against the [21:04] president's party. That's especially the [21:06] case when things like economic outcomes [21:09] or healthcare outcomes have worsened [21:10] under um the the current president as is [21:13] the case now. So I think it's fair to [21:15] say overall we should see some some [21:18] backlash against the Republican party [21:20] and against Republican candidates. Um [21:22] how rural hospital closures or or how [21:24] this plays out in rural places in [21:26] general I think is much more of an open [21:29] question. Um because of the strength of [21:31] Republican party ID in rural areas. It's [21:35] unlikely that we would observe much of a [21:37] change in the way rural voters um you [21:40] know who they choose to vote for. I [21:42] think the more likely scenario is that [21:44] we observe a decrease in in voter [21:47] turnout by those who have been [21:48] negatively affected um by these negative [21:51] healthc care changes and and that might [21:54] shift the percentage of people in any [21:56] given area voting for one party or [21:58] another just by who showed up to vote. [22:01] uh and so we could see some changes in [22:03] the overall election outcomes even if we [22:06] didn't observe much change in the way [22:07] people view politics in those areas. Um [22:10] partisanship has really calcified in [22:12] lots of parts of the country. And so [22:14] mostly what we what we see in terms of [22:17] election changes are changes in who [22:19] showed up to vote. Um but then also some [22:22] voters, younger voters, um Latino and [22:25] Latino voters tend to be a little bit [22:28] more in flux currently in their [22:30] partisanship or their political [22:32] tendencies. And so we might expect [22:34] voters in those groups to shift [22:36] seismically against the Republican [22:38] party, even if other voters maintain [22:41] their current loyalties and mostly just [22:43] differ in their enthusiasm to turn out [22:45] to vote this cycle. when it comes to [22:47] Medicaid cuts, are they going to fully [22:50] hit in 2027 or is it something that it's [22:55] starting now? [22:56] >> So, I I think that's somewhat of a [22:58] difficult question to answer in part [23:00] because providers have already started [23:03] to update their behaviors. Insurance [23:06] companies have already started to update [23:08] their behaviors. the expiration of the [23:11] ACA premium subsidies has already had a [23:14] pretty large effect on um people's [23:16] insurance status or the cost of health [23:18] insurance. The Medicaid effects in [23:21] particular though states are [23:23] implementing as we speak their work [23:25] requirements. Um those things are sort [23:28] of st being uh felt in staggered ways [23:32] currently but likely won't feel the full [23:35] change there until 2027. other effects [23:37] to the Medicaid program such as changes [23:40] to the way states can finance them are [23:42] being slowly unrolled. And so I would [23:45] expect to see the majority of the [23:47] effects of the recent Medicaid changes [23:50] um to be politically responded to in [23:53] 2028 and and in 2030. Um whereas now [23:57] we're going to see more of a a staggered [23:59] response, if you will, um to the the [24:01] Medicaid changes specifically. Does that [24:04] timing let politicians off the hook or [24:07] are voters already connecting the dots? [24:09] >> Yeah. So, in general, what we see is [24:11] like the longer a time horizon between [24:13] when a policy is passed and when those [24:16] effects are felt, that the harder it is [24:18] for voters to connect the outcomes to a [24:21] specific policy and instead they tend to [24:23] assign blame to whoever's in charge at [24:26] that moment. U what that could mean is [24:28] that um when a if a Democrat is elected [24:31] in 2028 to the White House um or [24:33] Democrats control Congress starting in [24:36] 2027 um the voters might well blame [24:39] Democrats for those things um rather [24:41] than the Republican party that passed [24:43] the policies that ultimately unleash [24:45] some of these changes because voters [24:47] tend to have short time horizons and and [24:49] what they're actually responding to and [24:51] they they tend to blame the incumbent [24:53] president's party kind of regardless um [24:56] of what the actual policy cause was. I [25:00] think more interestingly will at least [25:02] with rural voters will be um to to see [25:04] how um federalism that is the shared [25:07] power between the national government [25:10] and state governments affects this [25:12] dynamic. Um as part of the one big [25:14] beautiful bill act um congress and the [25:16] president uh uh implemented a rural [25:19] health transformation program. um that [25:21] is a large chunk of money that is [25:24] supposed to be injected into rural [25:26] health care. Um importantly that it's [25:29] not enough money to recoup the losses [25:31] from the Medicaid changes. And in fact, [25:33] the policy itself expressly forbids that [25:36] money from being used to fully offset or [25:39] even attempt to fully offset the [25:41] Medicaid losses. However, it does [25:44] provide some political cover for [25:47] Republicans in Congress to say, "Well, [25:49] we created this $50 billion program that [25:52] is supposed to help rural hospitals. How [25:54] did those state governments messed this [25:56] up?" Um, you know, in in Michigan, the [25:58] question might be, how did the Whitmer [26:00] administration [26:02] decide to goof this money up that we we [26:04] sent them? And so Republicans in [26:05] Congress have some way to not only avoid [26:08] blame due to the longer time horizon of [26:11] the effects of the policy, but they can [26:12] point to this [26:14] >> um this major injection of resources and [26:16] say, "Well, what happened? That's not [26:18] our fault. That must be the fault of [26:19] those those rural hospital providers or [26:22] the Whitmer administration." Um and so [26:24] I'm curious to see how that's going to [26:26] ultimately play out over time as well. [26:28] And for those who are on private [26:30] insurance, why does it matter for them? [26:32] What happens with Medicaid? [26:34] >> There's a couple of things that that are [26:35] important. So the expiration of the [26:38] premium ACA subsidies led to increases [26:41] in insurance costs for everybody um just [26:44] by differing degrees. Um so we've seen [26:47] costs of insurance go up pretty much [26:48] across the board. Um and that's the case [26:51] even if you're not receiving your [26:52] insurance from Medicaid. The thing that [26:54] I like to drive home to folks is your if [26:56] you're in a rural area, your hospital [26:59] depends on Medicaid dollars. So any [27:02] change to the Medicaid program, [27:03] especially ones this seismic, threaten [27:05] your access to hospital care, even if [27:08] you don't receive uh Medicaid because [27:10] that hospital is serving more than just [27:13] the Medicaid population. It's serving [27:15] the private insurance population as [27:17] well. But if it's gone, that means you [27:20] lost your hospital, too. Um it's just [27:23] the case that the folks who lost their [27:25] Medicaid coverage lost their hospital [27:27] and their Medicaid coverage. Um but you [27:30] still have to make that same longer [27:32] drive. Your health may suffer uh as a [27:35] result of the same policy effect even if [27:37] you maintained your health insurance. [27:39] One final thing, what's the single most [27:41] important thing a rural voter should [27:43] know about the upcoming election and how [27:46] it will affect their local community? [27:48] And what's the number one piece of [27:49] information or evidence you'd ask [27:52] anybody to look at before they vote? [27:54] >> Voters of any geography have differing [27:58] considerations, values, experiences, and [28:01] local outcomes vary a lot from place to [28:04] place. Uh, and so I think it requires [28:07] some herculean assumptions for someone [28:09] like me to say this is the thing that [28:11] you should think about the most. Uh, and [28:13] so I'm I'm hesitant to to ever to say [28:15] that because I I don't know every rural [28:18] voter and I don't know every rural [28:20] community, but I I will say I think [28:21] there's a a tendency to um view being [28:26] informed about politics as as not worth [28:28] the time. And there are actually some [28:31] formal models of politics that suggest [28:33] that it really isn't worth the time for [28:36] people to to understand. So, uh, I would [28:38] just say elections have severe [28:41] consequences, um, in a variety of ways, [28:44] or at least they can. And the outcomes [28:46] of elections can shape one's access to [28:49] health care, um, jobs in local [28:52] communities, the rise and fall of gas [28:54] prices. And it's important to take it [28:56] seriously, to think through um, why are [28:59] things the way they are for me [29:01] personally or for my community or for [29:02] the country. Um, and it's important to [29:05] invest the time into becoming [29:07] knowledgeable about politics and [29:09] participating in politics because these [29:11] election outcomes have seismic effects [29:14] um on societies and on local [29:16] communities. Uh, and understanding how [29:19] best to map your values or local [29:21] outcomes or personal outcomes to the [29:23] political sphere um is a really [29:25] difficult thing to do without being [29:27] informed. Uh, and so I just encourage [29:29] people to to pay attention, to be [29:32] active, to be engaged, um, because that [29:34] can really shape the rise and fall of [29:37] communities that you care about. [29:43] Thank you for listening to this episode [29:44] of Michigan Minds, produced by Michigan [29:47] News, a division of the university's [29:49] office of the vice president for [29:51] communications.