"Rural" all over the news as Senate passes "Big Beautiful Bill" that will undermine rural services, especially health care

Analysis of what Trump's "Big Beautiful Bill" would do to rural health care has been in the news for several weeks, and it stayed there today as the Senate passed the Bill by a vote of 50-50, with Vice President J.D. Vance breaking the tie.  Here I'm going to highlight just what Ezra Klein and Matt Yglesias had to say about the impact of the bill on rural healthcare.  This appeared on the Ezra Klein Show today, July 1, but much of it was recorded in advance in anticipation that the bill would pass.  I'm just going to highlight the bits about rural health care, including as they relate to "red state" voters: 

Klein: [T]hey are very substantially cuts to the Republican Party’s voters. They’re cuts to Republican states. They’re cuts to Republican hospitals — rural hospitals in areas that vote for Republicans and are very dependent on the care that gets financed by Medicaid in order to stay open.

This is the Republicans’ old ideology coming into conflict with their new coalition.

Yglesias:  Absolutely. If you look at the share of people who are on Medicaid by state, there are seven states where more than a quarter of the population is on Medicaid.

One of them is New York, and one of them is California. But the other five are New Mexico, Louisiana, Arkansas, Kentucky and West Virginia.

And then you look at states like Mississippi and Alabama: If they would accept Medicaid expansion funding, there’s a huge, potentially eligible population share in those states.

It’s a big conflict inside the heart of Republican politics. [Details about Mitch McConnell and Kentucky] 

There’s just a conflict between the Republican Party electorate and their ideology, which has shifted in some ways but really remains focused on low taxes, on investment income, low corporate taxes and wanting to cut spending on programs for the poor.

About work requirements and how they've worked out so far, Klein and Yglesias shared this conversation:

The most conservative states don’t accept Medicaid expansion funds. They have tried to impose work requirements in Arkansas, for example.

So we ran the experiment: Does putting work requirements on Medicaid increase employment? And the answer was no. When they did it, employment didn’t go up. People did lose coverage, but employment didn’t go up.

And Republicans didn’t reverse course after that. They didn’t say to themselves: Oh, our goal here was to get more people working, but we didn’t succeed at that. They said: You know what? This cut the rolls. It cut spending. We’re happy with that.

That’s a free market view: If you want a television, you’ve got to pay for it yourself. If you want chemotherapy, you’ve got to pay for it yourself.

On work requirements, I published this three years ago in Politico.   

Here's more from Yglesias, on perverse incentives: 

There’s this threat that hospitals will go out of business. I’m in Maine right now in a very rural area, and hospitals don’t have a ton of customers here. If they lose let’s say 10 percent or 15 percent of their customer base and have higher uncompensated care burdens — some of the facilities will just close.

Senate Republicans have discussed creating a hospital bailout fund to prevent this, but it seems crazy to me to address hospitals’ business model problems by giving them direct payments to stay in business even though they’re not treating patients, rather than just letting people get the treatment they need.

Senator Lisa Murkowski of Alaska ultimately voted for the bill, but only after she was offered big concessions for her state.  Read more about those here. 

Also instructive is this interview by NPR with Kaiser Health News reporter Sarah Jane Tribble, published yesterday, leading with Juana Summers questioning Tribble: 

SUMMERS: Rural America is poised to be greatly impacted by these proposed cuts. Roughly 20% of the U.S. population lives in rural areas where Medicaid covers 1 in 4 adults. Here to talk about what could be at stake for those communities is Sarah Jane Tribble. She's the chief rural correspondent for KFF Health News. ...

Sarah, just start if you can by telling us a bit about what you have been hearing from people in rural communities across this country about these proposed cuts.

TRIBBLE: Yeah, I'm not hearing good things. They're very concerned, because Medicaid rates are so high in rural America, that these cuts will be very detrimental, they'll cause more hospitals to close, they'll tax rural health clinics. I was sitting next to a CEO of a rural hospital from Colorado. He has a 25-bed critical access hospital, the only hospital between the Kansas border and Denver on the Colorado I-70 corridor. And he had been talking about the cuts and not happy about them. And then we heard about the rural transformation fund that the Senate has been working on to sort of help offset the cuts. And he leaned over and he just scoffed. He just said, that's just not going to be enough. So I think that there's a lot of concern out there in rural America.

iPhone factory rises in rural India; does it provide rural development lessons for the United States?

Alex Travelli and Hari Kumar report from Devanahalli, India in yesterday's New York Times on the pending opening of an iPhone factory.  The story features many descriptors suggesting the remoteness and rurality of the place and concludes with a brief comparison to rural development efforts in the United States.  The plant, which will be fully functioning and employing 40,000 people by the end of this calendar year, responds to Prime Minister Narendra Modi's “Make in India” policy, announced in 2015.  The Modi government has committed $26 billion to subsidizing strategic manufacturing goals since 2020. 

A new iPhone factory in an out-of-the-way corner of India looks like a spaceship from another planet. Foxconn, the Taiwanese company that assembles most of the world’s iPhones for Apple, has landed amid the boulders and millet fields of Devanahalli. 

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By the end of 2025, with the Devanahalli plant fully online, Foxconn is expected to be assembling between 25 and 30 percent of iPhones in India.

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The effects on the region are transformative. It’s a field day for job-seekers and landowners. And the kind of crazy-quilt supply chain of smaller industries that feeds Apple’s factory towns in China is coalescing in India’s heartland. 

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India’s most urgent reason for developing industry is to create jobs. Unlike the United States, it does not have enough: not in services, manufacturing or anything else. Nearly half its workers are involved in farming.

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India is thick with people. A five-minute walk away, a village called Doddagollahalli looks the same as it did before Foxconn landed. Nearly all the houses clustered around a sacred grove belong to farming families growing millet, grapes and vegetables.

Some villagers are renting rooms to Foxconn workers. Many more are trying to sell their land. But Sneha, who goes by a single name, has found a job on the Foxconn factory’s day shift. She holds a master’s degree in mathematics. She can walk home for lunch every day, a corporate lanyard swinging from her neck.

It is people like Sneha, and the thousands of her new colleagues piling into her ancestral place, who make Foxconn’s ambitions for India possible. Mr. Trump wants to revive the fortunes of left-behind American factory towns, but the pipeline of qualified young graduates is not there.

Thus, while Trump wants this to happen in the United States, it probably won't, "without sustained government financial support to revive U.S. manufacturing and training to expand the pool of qualified factory workers."