Who needs the ACA? Look closer — it’s rural America

Republicans in Congress have spent years campaigning against the Affordable Care Act. Yet a new national report shows that the people most reliant on the ACA’s insurance subsidies aren’t urban liberals or government workers — they’re farmers, ranchers, small business owners, and self-employed Iowans.

According to new data from the nonpartisan Kaiser Family Foundation, more than one in four farmers, ranchers, and agricultural managers buy their health insurance through the ACA marketplace. So do thousands of real estate agents, contractors, and small business owners who work more than 20 hours a week but don’t have access to employer-based coverage. In all, over 90% of people with individual-market insurance now rely on ACA subsidies to keep their premiums affordable — and the vast majority receive a tax credit.

Those enhanced premium tax credits, first expanded during the pandemic, are set to expire at the end of 2025. If Congress lets that happen, premiums will rise by more than 75% on average. The Congressional Budget Office estimates that nearly 4 million people will lose their health coverage.

That’s not just a Washington statistic. That’s Iowa’s farm families, contractors, and self-employed rural workers — the people keeping local economies alive while their leaders in Congress pretend the problem is someone else’s.

For years, Republicans have claimed the ACA was “socialized medicine.” But the truth is, it’s the only system keeping much of rural America insured. When those subsidies vanish, it won’t be lobbyists or federal workers feeling the blow. It’ll be the independent farmers in Fayette County, the small business owners in Washington County, and the self-employed workers who can’t afford to lose even a month of coverage.

It’s not just hypocrisy — it’s governing malpractice.

While rural hospitals fight to survive, congressional leaders are promoting the so-called Rural HealthTransformation (RHT) Program as evidence they’re “doing something” about health care. But that bill isn’t reform — it’s a rerun of ideological talking points about deregulation and “choice.” It does nothing to stabilize hospitals, fund broadband for telehealth, or make childbirth safer for rural mothers. It doesn’t lower premiums, protect patients from surprise bills, or expand mental-health access. It’s a brand, not a blueprint.

Meanwhile, nearly half of small rural hospitals already operate at a loss. Since 2010, well over 170 have closed nationwide — almost one in 10 — taking maternity wards, emergency rooms, and hundreds of local jobs with them. In many Iowa counties, expectant mothers now drive an hour or more for obstetric care. Patients needing dialysis or behavioral-health support are often forced out of network or out of reach altogether.

The ACA’s enhanced tax credits aren’t perfect, but they are working. They’re keeping working-class Iowans insured. They’re helping rural hospitals stay open by maintaining a paying patient base. And they’re proving that targeted federal investment — not slogans — is what keeps the system alive.

Letting those credits expire would hit red states hardest. It’s no accident that the top states where more than 10% of workers rely on ACA coverage are also the most Republican leaning. Those voters have been told for years that the ACA was someone else’s safety net. The truth is, it’s theirs.

Health care shouldn’t be a partisan loyalty test. In Iowa, where hospital closures are no longer a warning but a pattern, we can’t afford political theater. The moral and economic stakes are the same: when health care access collapses, communities collapse with it.

It’s not enough to criticize the system; leaders have to protect what’s working before they tear it apart.

If Congress wants to prove it still represents the people it serves, it can start by protecting the coverage that rural America already depends on. That means making the ACA’s enhanced tax credits permanent and rejecting hollow distractions like the Rural Health Transformation (RHT) Program.

The next time politicians promise to “transform” health care, Iowans should ask a simple question: for whom? Because right now, it’s not the families they represent who stand to benefit — it’s the talking points.

Dr. Christopher R. Crossett, DNP, MBA, MSN, RN, CRRN, is a board-certified rehabilitation nurse and health-systems leader based in Cedar Rapids.