Echoes of Appalachia

A healthcare catastrophe is quietly unfolding, and Appalachia may soon be one of the hardest-hit regions in America. The so-called “Big Beautiful Bill,” now moving rapidly through Congress, is expected to eliminate Medicaid coverage for a staggering 12.8 million people. While backers of the bill claim it targets undocumented immigrants and welfare abuse, the numbers tell a different story: over 11.6 million of those losing coverage are American citizens—many of them in the country’s poorest, most medically vulnerable areas.

Appalachia, home to more than 25 million people across 423 counties in 13 states, could suffer some of the most severe consequences. In many parts of Central Appalachia, more than 40% of adults rely on Medicaid for their health coverage. That’s not an anomaly—it’s a reflection of deep-rooted poverty and a decades-long erosion of healthcare infrastructure. With a regional poverty rate of 16.3%, compared to the national average, access to Medicaid isn’t a luxury here. It’s a lifeline.

While nationwide Medicaid enrollment stands at around 74 million, Appalachia’s dependence on the program is far higher than average. And though data isn’t reported by county in a way that would offer an exact regional impact, analysts agree that Appalachia could lose hundreds of thousands of enrollees if even a fraction of the 11.6 million are located in this region. That could mean entire communities losing access to healthcare overnight.

Hospitals in many Appalachian counties are already under severe financial stress. In rural areas, Medicaid dollars don’t just pay for individual care—they keep entire health systems afloat. Clinics, nursing homes, and local hospitals rely heavily on these reimbursements. If the Big Beautiful Bill becomes law, some of these facilities may be forced to shut down. Others could cut staff or services, creating healthcare deserts where the nearest care is hours away.

The bill’s proponents argue it will cut government spending and reduce fraud, but what’s actually on the table is the rollback of Medicaid expansion under the Affordable Care Act—an expansion that significantly reduced uninsured rates across Appalachia and brought much-needed stability to struggling health networks. Undoing that progress will leave thousands of families without access to regular doctor visits, prescription drugs, mental health services, or even emergency care.

Those most at risk include working adults who earn too much to qualify for traditional Medicaid but not enough to afford private insurance, as well as children in low-income households, seniors in nursing homes, and people with disabilities. Many of them have never known another form of healthcare coverage.

The potential impact doesn’t stop at individual households. In towns where a rural hospital is one of the largest employers, economic ripples could follow closely behind healthcare cuts. Job losses, reduced services, and population decline are all on the table. For a region that’s been fighting to recover from the collapse of the coal industry and decades of disinvestment, this could be a fatal setback.

Supporters of the bill claim it’s about balancing budgets but make no mistake. This is about delivering tax cuts for the wealthy, and the price is being paid by America’s most vulnerable. This is not reform. It is a gutting of the social contract.

Trump’s betrayal is undeniable. He said he would fight for forgotten Americans. But instead of protecting them, he is selling them out. Appalachia is being used as collateral to finance tax cuts for millionaires, billionaires, and political donors.

The Big Beautiful Bill may still face hurdles before becoming law, but the silence around its real-world consequences is deafening. In Appalachian communities—where health systems are fragile, options are limited, and needs are great—the bill could trigger a public health emergency.

For those living in or connected to Appalachia, the message is clear: this isn’t just another Washington debate. It’s a direct threat to the health and survival of millions. If leaders and citizens don’t act now, the damage could be swift, sweeping, and irreversible.

-Tim Carmichael