Michigan Minds: Rural Healthcare Blame Game

Juan Ochoa

Welcome to the Michigan Minds podcast, where we explore the wealth of knowledge from faculty experts at the University of Michigan. I am Juan Ochoa, international public relations representative for the Michigan News office. I'm pleased to welcome Doctor Michael Shepherd, assistant professor of health management and policy at the University of Michigan School of Public Health. Doctor Sheppard's research examines U.S. health politics and policy, rural health disparities, and the roles that political parties, race, and mass media play in shaping health attitudes and behaviors.

Juan Ochoa

Welcome, doctor Shepherd.

Michael Shepherd

Thank you for having me.

Juan Ochoa

With the midterms approaching, health care has become one of voters top priorities across the country. But when we look closer at rural America, health care isn't just an issue of insurance or doctor visits. It's tied to local survival, partisan identity, and deep seated ideas about who the system works for. With that in mind, what role does race and racism play in shaping U.S. health policy, and how does that connect to rural voters who may not think of health care as a racial issue?

Michael Shepherd

Race and racism play very important roles in shaping how many rural voters, in particular understand or think about health policy and health care access. But importantly, most scholars in this area believe that this process is twofold. At least one is that race and ethnicity play straightforward or direct roles in shaping health care access in a variety of rural areas.

Michael Shepherd

There's no doubt, especially when we look at the South, that it is rural black communities, in particular in rural Latino communities that have the most restricted access to health care. So in that way, we think health care access is directly shaped by race. But in terms of racism, what we see is that from time to time, health issues or health policy issues become racialized.

Michael Shepherd

That is, politicians or the media connect particular health outcomes or particular health policies such as the Affordable Care Act and racialized ways. And that leads rural white voters to view their health care access or view health care policy in terms of us versus them in matters of race and racism or race and ethnicity. That is saying certain health policies are going to benefit racial and ethnic minority group members more than rural white folks, even though objectively, that's not true.

Michael Shepherd

What we can see is that once politicians or the media connect or fuse racial matters or racial considerations with health policy, voters, especially rural white voters, respond by viewing those health policies or those health outcomes as something that is related to their racial attitudes.

Juan Ochoa

You say that they see others getting benefits that they're not getting. What are they looking at?

Michael Shepherd

Some of this is actually more rhetorical than it is objective or empirical. The process tends to be more along the lines of I view health care access as being restricted in my community, I lost my local hospital, I lack health insurance, and health care is expensive. And in those moments, white voters and rural white voters, perhaps in particular, are susceptible to rhetoric that provides scapegoats or provides status cues that essentially lead rural white voters to view those types of outcomes.

Michael Shepherd

Health care, Health insurance access, hospital access is not only worse off in their community or for them personally, but must be better off for people who live in cities, racial and ethnic minority group members who live elsewhere. And in that way, these things become more abstract. They're more rhetorical rather than substantive. And it feeds into a narrative, a blame structure, if you will, that provides some understanding or some story of why health care access in a rural, predominantly white community is bad.

Michael Shepherd

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

Juan Ochoa

You know, I think that's a topic that might not apply just to rural voters, but you're their expert. You can tell me a little bit more, but it could also be, you know, urban voters that get information that is wrong. What can we all do to make sure that what we're listening to or reading is correct?

Michael Shepherd

I think it's fair to say that this isn't exclusively a rural thing. I think perhaps compositionally or just disproportionately, these things tend to play out the way I've described in rural communities. But that doesn't mean that they're the only communities where they occur. In general, I think our information and media ecosystem have changed pretty substantially over the last 15 to 20 years in ways that make these mechanisms or make these sorts of misunderstandings of policy realities more likely.

Michael Shepherd

I think it's tempting to focus on things like social media, which no doubt play a role here. But a lot of this has to do with changes in local media as well as national media. For at least the rural communities that I study, local media doesn't really exist. And lots of them. We've seen newspaper closures over the last 15 years.

Michael Shepherd

Local television news is often far off and in an urban area, and very unlikely to be reporting what's going on on the ground. But even in more urban areas, local news media have become more focused on national issues and national political discussions or reporting, nationalized coverage or content, that is, things that have been shared throughout their media conglomerate to be reported everywhere.

Michael Shepherd

And so that kind of changes the relationship between local outcomes and why they're occurring and how people understand politics. That's what we refer to as the nationalization of news media and politics. But also people are just exposed to national content a lot more, either on social media or in what they observe and like nightly news or cable news or, you know, online in a variety of ways.

Michael Shepherd

And that elevates national considerations. That is the president versus Congress, the national political parties, the rise and fall of national outcomes related to the economy. Those tend to be what voters are responding to, because that's what kind of information that they have. 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.

Michael Shepherd

But when you add on things like misinformation online or or coverage that is biased in particularly partisan ways, folks are no longer really being exposed to the kinds of information that we think might be helpful for understanding who is responsible for that hospital closure, closure in your community. Why did that happen? And that can lead people to do all kinds of things politically that maybe they would not have 30 or 40 years ago.

Juan Ochoa

Could that misinformation be attributed to the reason why most rural communities tend to vote Republican, as opposed to urban voters who vote Democrat? And how much of that is identity versus policy?

Michael Shepherd

Yeah. I don't know, I, I personally haven't seen that misinformation inherently is the driving cause but rather the kind of information that people have available to them. One of the things that I've noticed a lot in my work is when a rural hospital closes in a particular rural community, there's often not a local newspaper. It's oftentimes not covered by local news, although those things have changed more recently.

Michael Shepherd

And instead, what happens is the coverage, if you will vaguely, is, via word of mouth, oftentimes with louder, more politically active, more politically conservative folks providing the narrative, understanding the story of why this thing closed, but also less formal small town. I call them news gazettes. There are basically Facebook news pages where someone local has decided to run a social media account that covers what's going on in the small town.

Michael Shepherd

Those media outlets are often, if not outright conservative, somewhat conspiratorial or anti-establishment in their coverage, and those are also contributing some narrative understanding. So rather than there being no discussion at all of the rural hospital closure, instead what we see is a particular kind of discussion, particularly a discussion that is placing particular blame on things like the Democratic Party, but also national health policy decisions, the establishment vaguely, government vaguely.

Michael Shepherd

And that contributes, I think, to a mixture of both partisan blame tendencies as well as more of an anti establishment, anti-government reaction, which is broadly the mainstream force in American society. That is the news media, formal news media, the national government, the national political parties are letting down people in these communities, or they feel like their communities are unrepresented by those institutions.

Michael Shepherd

And that has an asymmetric effect that pushes people away from these establishment institutions. And in our two party system, that often means towards the Republican Party.

Juan Ochoa

In a recent interview, you mentioned how rural voters tend to blame Democrats for hospital closures. For example, even though 80% of the closures occurred in Republican controlled states that did not expand Medicaid. Where is that disconnect? And why can't voters see that their own party's policies may have caused them harm?

Michael Shepherd

There are lots of things going on that can explain why that happens. One is that health care policy is one of the most complex policy areas in the country or in any country. It's very difficult for any person to understand exactly why some health care outcome has occurred, why they've lost health insurance, why their hospital bill has increased by some margin.

Michael Shepherd

Those are all things that are just really difficult to understand. And as a result, political scientists call these hard issues. And when there are hard issues, people tend to fall back on things like partisan cues to understand them. So if you identify as a Republican and you experience a bad outcome, you might fall back on Republican Party stories, narratives, frames of why these things have happened, to understand why this is happening to you.

Michael Shepherd

The other thing is that Democrats have long been known as the health care party. And so when health care outcomes are perceived as good, that's a really strong thing for the Democratic Party. They can say, you know, we passed this policy that had these positive outcomes, but when things are bad, that can become a vulnerability for them, which is that Democrats are blamed for these bad health care outcomes because they're perceived as being the party that did the health care things.

Michael Shepherd

The other thing that I think is important to note is that, once someone strongly identifies with a political party, they start to understand the world in ways that reflect those predispositions and they don't update them. So if you were to ask a Democratic voter right now, how is the economy doing? They're going to say substantially worse than if you were at the same time to ask a Republican the same question.

Michael Shepherd

And that's because there's a Republican in the white House. And the same holds for health policy. If you were to ask people how the health care environment is currently, you would see a large partisan difference, just because people tend to believe that their party is doing a better job than the other party is, regardless of what the actual outcomes are.

Michael Shepherd

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 Partizan blame game or an asymmetric anti-government form of resistance that benefits the Republican Party down, down the line.

Juan Ochoa

Why do you think voters tend to blame parties rather than individual politicians who might have voted against policies affecting them, if not all of us?

Michael Shepherd

Yeah, I think there are a few things going on there. One is that over time, especially over the last 20 or 30 years, voters have viewed the political system as Democrats versus Republicans, full stop, top of the ballot all the way down. We think that that sort of nationalized partisanship keeps people from viewing individual politicians as doing things different from their political party.

Michael Shepherd

Those things are reinforced by news coverage that tends to focus on Democrats and Republicans vaguely, or just the president, but also things like campaign ads, which tend to focus on the top of the ticket, even for local races. You can see in races for city council, for mayor, for state legislature, discussions of national political issues, national partisan issues that they reinforce all of those national partisan differences and minimize any local considerations or distinct candidate differences.

Michael Shepherd

The other thing is that I think as we've become more polarized, it's just difficult for politicians to shake the brand of their national parties, and voters tend to view things as Democrats versus Republicans as opposed to, you know, my candidate does this better than this other candidate or local office holder. It's important to note, though, that as we do go down when we move from President and Congress down to city council and mayor, we do see more of what you're talking about.

Michael Shepherd

We do see more evidence that people are evaluating these local candidates differently or local representatives differently, but not as much as they used to. And so when we look at the world now, we look at the rise and fall of state legislative candidates, our mayors. It's more partisan than it used to be, but it's less partisan than when we think about voting for president.

Juan Ochoa

Going back, you slightly touched on hospitals, rural hospitals closing for rural hospitals closing due to recent Medicaid changes. Does this mean that most people in those communities are on Medicaid? If not, then what's the reason behind it?

Michael Shepherd

Yeah. So there are some rural areas where we can say that the majority or most, to use your term of the, the, the voters are on Medicaid or receiving their health insurance for Medicaid. If we look at there's an Appalachian congressional district in Kentucky, there's a congressional district in California where the majority of adults are enrolled in Medicaid.

Michael Shepherd

And so those changes have had seismic effects on the financial wellness of rural health providers. But even in places where it's not most, what we see is that across the vast majority of states, rural voters are disproportionately likely to to be enrolled in Medicaid or be receiving Medicaid. It's very rare. But when we're looking across the country, we might see 25 to 30% of residents in rural areas are receiving their health insurance for Medicaid, whereas in more urban and suburban contexts, that tends to be more in the 15 to 20% range.

Juan Ochoa

And in what ways are communities and urban settings being affected by Medicaid changes, including hospitals?

Michael Shepherd

Well, providers everywhere face significant financial challenges as a result of the changes to Medicaid. So that's not a rural urban distinction. It's just a matter of degree to which this is affecting things. That degree is a function not only of the disproportionate share of rural residents being enrolled in Medicaid, but is also a function of more urban areas having more people with private insurance just numerically.

Michael Shepherd

And that means that providers in urban areas, even though they faced a hit, have a broader population that they can draw from to maintain revenue streams. Whereas rural areas really don't have that. The other effect is that lots of rural people, especially once they lose a hospital, well, they're going to that next closest hospital. Sometimes that's another rural hospital, but other times that's an urban hospital.

Michael Shepherd

And so now there's an influx of new people that can mean new revenue, but that can also mean really significant headaches, at least in the short term. Navigating staffing concerns when there's a major increase in the number of people who are showing up at an emergency room, especially to the next closest, more rural hospital.

Juan Ochoa

Do you know the average time a hospital closes? How much time do they have to spend traveling to a hospital or a clinic?

Michael Shepherd

Yeah, so that really depends on the geography of the state and the health care infrastructure of a state. It varies wildly from place to place. There are rural communities where when the local hospital closes, we're talking about an increase of a 20 minute drive. There are rural communities, however, that the closure of a rural hospital means an increase of an hour drive or more.

Michael Shepherd

When we look at the state of Michigan, we can see places in the northern part of the state and in the Upper Peninsula that if a hospital, if one particular hospital were to close, folks might have over an hour drive to the next closest hospital. When we think about things like labor and delivery, for example, that's where we can see real large effects, even if the hospital stays open, if they close down their labor and delivery unit.

Michael Shepherd

You might be looking at an hour and a half or two hour drive to the next closest hospital that has an open labor and delivery unit. So there are lots of changes there that can drive things. In general, what we see is an increase of drive time of somewhere in the range of 20 to 40 minutes. It's a big range, but that really is because there are some rural places that are quite close to cities.

Michael Shepherd

There are some rural, some states that have lots of rural hospitals, and there are some places where those were hospitals are laid out in a way that geographically means that if one were to close, well, maybe there's another one that's just 30 minutes down the road, even though 30 minutes is quite a long, quite a long increase.

Michael Shepherd

But there are others where it could be an hour or more. I think it's important to highlight that 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 after they leave. And so if it's a 20 minute increase, well, that's not as bad as an hour increase.

Michael Shepherd

But there are certain situations where that 20 minutes might be consequential.

Juan Ochoa

With everything going on, in which direction do you think rural voters will lean this coming election?

Michael Shepherd

I think that's somewhat of an open question. And some of it. Some of it depends on which voters were talking about. I think it's fair to say in the 2026 midterms we should expect some backlash against the Republican Party. Typically, that's what we observe the midterm of a president. There is almost always some backlash against the president's party.

Michael Shepherd

That's especially the case when things like economic outcomes or health care outcomes have worsened under the current president, as is the case now. So I think it's fair to say overall, we should see some backlash against the Republican Party and against Republican candidates. How rural hospital closures or how this plays out in rural places in general, I think is much more of an open question because of the strength of Republican Party ID in rural areas, it's unlikely that we would observe much of a change in the way rural voters, you know, who they choose to vote for.

Michael Shepherd

I think the more likely scenario is that we observe a decrease in voter turnout by those who have been negatively affected by these negative health care changes. And that might shift the percentage of people in any given area voting for one party or another just by who showed up to vote. And so we could see some changes in the overall election outcomes, even if we didn't observe much change in the way people view politics in those areas.

Michael Shepherd

Partisanship has really calcified in lots of parts of the country. And so mostly what we see in terms of election changes are changes in who showed up to vote, but then also some voters, younger voters, Latino and Latina voters tend to be a little bit more in flux currently in their partisanship or their political tendencies.

Michael Shepherd

And so we might expect voters in those groups to shift seismically against the Republican Party, even if other voters maintain their current loyalties and mostly just differ in their enthusiasm to turn out to vote this cycle.

Juan Ochoa

When it comes to Medicaid cuts. Are they going to fully hit in 2027, or is it something that it's starting now?

Michael Shepherd

So I think that's somewhat of a difficult question to answer, in part because providers have already started to update their behaviors. Insurance companies have already started to update their behaviors. The expiration of the ACA premium subsidies has already had a pretty large effect on people's insurance status, or the cost of health insurance. The Medicaid effects in particular, though states are implementing, as we speak, their work requirements.

Michael Shepherd

Those things are sort of stacks being felt in staggered ways currently, but likely won't feel the full change there until 2027. Other effects to the Medicaid program, such as changes to the way states can finance them, are being slowly unrolled, and so I would expect to see the majority of the effects of the recent Medicaid changes to be politically responded to in 2028 and 2030, whereas now we're going to see more of a staggered response, if you will, to the the Medicaid changes specifically.

Juan Ochoa

Does that timing let politicians off the hook or are voters already connecting the dots?

Michael Shepherd

Yeah. So in general, what we see is like the longer 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. What that could mean is that when a if a Democrat is elected in 2028 to the white House or Democrats control Congress starting in 2027, the voters might well blame Democrats for those things rather than the Republican Party that passed the policies that ultimately unleashed some of these changes, because voters tend to have short time horizons and what they're actually responding to, and

Michael Shepherd

they tend to blame the incumbent president's party, kind of regardless of what the actual policy cause was. I think more interestingly, well, at least with rural voters, will be to see how federalism, that is, the shared power between the national government and state governments affects this dynamic. As part of the One Big Beautiful Bill act, Congress and the president implemented a rural health transformation program that is a large chunk of money that is supposed to be injected into rural health care.

Michael Shepherd

Importantly, that it's not enough money to recoup the losses from the Medicaid changes. And in fact, the policy itself expressly forbids that money from being used to fully offset or even attempt to fully offset the Medicaid losses. However, it does provide some political cover for Republicans in Congress to say, well, we created this $50 billion program that is supposed to help rural hospitals.

Michael Shepherd

How did those state governments mess this up? You know, in Michigan, the question might be, how did the Whitmer administration decide to goof this money up that we sent them. And so 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, this major injection of resources and say, well, what happened?

Michael Shepherd

That's not our fault. That must be the fault of those rural hospital providers or the Whitmer administration. And so I'm curious to see how that's going to ultimately play out over time as well.

Juan Ochoa

And for those who are on private insurance, why does it matter for them what happens with Medicaid?

Michael Shepherd

There's a couple of things that are important. So the expiration of the premium ACA subsidies led to increases in insurance costs for everybody just by differing degrees. So we've seen costs of insurance go up pretty much across the board. And that's the case even if you're not receiving your insurance from Medicaid. But the thing that I like to drive home to folks is if you're in a rural area, your hospital depends on Medicaid dollars.

Michael Shepherd

So any change to the Medicaid program, especially ones this seismic, threaten your access to hospital care, even if you don't receive Medicaid, because that hospital is serving more than just the Medicaid population, it's serving the private insurance population as well. But if it's gone. That means you lost your hospital too, it's just the case that the folks who lost their Medicaid coverage lost their hospital and their Medicaid coverage.

Michael Shepherd

But you still have to make that same longer drive. Your health may suffer as a result of the same policy effect, even if you maintained your health insurance.

Juan Ochoa

One final thing. What's the single most important thing a rural voter should know about the upcoming election and how it will affect their local community? And what's the number one piece of information or evidence you'd ask anybody to look at before they vote?

Michael Shepherd

Voters of any geography have differing considerations. Values, experiences and local outcomes vary a lot from place to place. And so I think it requires some Herculean assumptions for someone like me to say, this is the thing that you should think about the most. And so I'm hesitant to ever say that because I don't know every rural voter and I don't know every rural community.

Michael Shepherd

But I will say, I think there's a tendency to view being informed about politics as not worth the time. And there are actually some formal models of politics that suggest that it really isn't worth the time for people to understand. So I would just say elections have severe consequences in a variety of ways, or at least they can.

Michael Shepherd

And the outcomes of elections can shape one's access to health care, jobs in local communities, the rise and fall of gas prices. And it's important to take it seriously, to think through, why are things the way they are for me personally, or for my community or for the country? And it's important to invest the time into becoming knowledgeable about politics and participating in politics, because these election outcomes have seismic effects on societies and on local communities, and understanding how best to map your values or local outcomes or personal outcomes to the political sphere is a really difficult thing to do without being informed.

Michael Shepherd

And so I just encourage people to pay attention, to be active, to be engaged, because that can really shape the rise and fall of communities that you care about.

Juan Ochoa

Thank you for listening to this episode of Michigan Minds, produced by Michigan News, a division of the university's office of the Vice President for communications.