Echoes of Appalachia

The Affordable Care Act (ACA) is entering a period of significant change, and for communities across Appalachia, the consequences could be both immediate and long-lasting. Recent developments including projected premium increases, legislative changes introduced in the “One Big Beautiful Bill,” and the potential expiration of enhanced premium subsidies are converging in a way that may disproportionately affect this economically fragile region. Appalachia, with its unique demographic and economic makeup, faces a storm that could deepen existing health disparities and threaten access to care for hundreds of thousands of residents.

Premiums for ACA plans are expected to rise across the country in 2025. Initial filings from major insurers suggest an average increase of about 7 percent. While that may not sound catastrophic on its face, for low-income families in Appalachia, even modest increases can push health insurance out of reach. Compounding the issue is the scheduled expiration of enhanced premium subsidies at the end of 2025. These subsidies, first introduced during the COVID-19 pandemic through the American Rescue Plan and later extended by the Inflation Reduction Act, dramatically lowered out-of-pocket costs for marketplace insurance. Without them, premiums could rise by an average of 75 percent. For many families in Appalachia, that could mean annual increases exceeding $1,200.

That alone would be troubling. But it is only part of the picture. The One Big Beautiful Bill, passed in July 2025, introduces sweeping changes to both Medicaid and ACA marketplace eligibility. With over $900 billion in Medicaid cuts scheduled over the next decade, experts estimate that between 7.8 and 11.8 million people nationwide could lose Medicaid coverage. Many of them live in Appalachian states like Kentucky, West Virginia, and Tennessee, which have some of the highest Medicaid enrollment rates in the country. These states expanded Medicaid under the ACA and saw hundreds of thousands gain coverage over the past decade. That progress is now under direct threat.

The new law tightens eligibility rules, introduces more stringent documentation requirements, and allows states to impose work requirements on Medicaid recipients. These changes will almost certainly create bureaucratic obstacles for many low-income residents, especially in rural areas where internet access and transportation are limited. In communities where residents already face steep barriers to navigating the healthcare system, new red tape could result in coverage loss even among those who technically still qualify.

For Appalachian residents who fall off Medicaid but do not qualify for substantial ACA subsidies, the future looks particularly bleak. The region is marked by lower-than-average household incomes and higher-than-average health needs. Chronic illnesses like diabetes, heart disease, and respiratory conditions are more common here than in most other parts of the country. Losing access to regular care and prescription medications is not just an inconvenience in this context. It can be life-threatening.

The pressure is not only on individuals. Healthcare providers across the region are bracing for the fallout. Rural hospitals, many of which operate on thin margins, depend on Medicaid reimbursements to stay afloat. With fewer insured patients and more uncompensated care, some hospitals may face closure. Others may cut services, forcing patients to travel even farther for specialty care, maternity services, or even emergency treatment. In a region already grappling with limited infrastructure and geographic isolation, every additional mile to care matters.

The anticipated rise in ACA premiums in 2026 if subsidies are not renewed will only worsen the situation. A smaller insured pool and greater cost-sharing will discourage healthy individuals from enrolling, creating a sicker risk pool and prompting insurers to raise premiums even further. Appalachia, where healthcare access is already fragile, may see some counties become ACA insurance deserts altogether.

State-level responses may vary. Some governors may resist implementing the full scope of the federal law, particularly those with a track record of defending Medicaid expansion. However, the sheer magnitude of the federal cuts and the restrictions introduced by the new legislation will limit how much states can do to buffer the impact. Even modest resistance may only delay rather than prevent coverage loss.

Community health centers and nonprofit clinics are expected to absorb some of the strain. These organizations already serve many uninsured patients and may see demand skyrocket. However, they too operate with limited resources and will likely be overwhelmed without additional support. Philanthropic aid and state grants can help, but they cannot fill the gap left by shrinking federal funding.

The social consequences of this healthcare rollback will ripple across the region. Families burdened by healthcare costs often delay care, skip medications, or rely on emergency rooms for issues that could have been addressed earlier and more cheaply in a primary care setting. Children may miss school due to untreated illnesses. Adults may be forced to leave jobs or work fewer hours due to unmanaged chronic conditions. The economic costs of untreated health issues are substantial and self-perpetuating.

The changes to the ACA and Medicaid are national in scope, but Appalachia is especially vulnerable. This is not just a matter of policy; it is a question of survival for many families. Without swift and targeted intervention, the region could face a healthcare crisis of historic proportions. Expanded outreach, legal challenges to the new federal requirements, and aggressive efforts to renew enhanced subsidies may help soften the blow. But time is short, and the challenges are many.

In the coming months, the national conversation about healthcare reform will likely intensify. For Appalachia, the stakes could not be higher. This is a moment that calls for leadership, innovation, and above all, compassion. Because while the legislation may have passed in Washington, its consequences will be most deeply felt in places where every dollar counts and every hospital bed is needed.

And in the 2026 election, voters in Appalachia and beyond may be faced with a choice that cuts to the core of this crisis: whether to support candidates focused on preserving access to healthcare, or to be swayed by political distractions designed to provoke fear and division. The consequences of that decision will echo far beyond the ballot box.

-Tim Carmichael