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Behind every hospital visit, emergency responder interaction, insurance co-payment, and much more, governmental and corporate policies play a leading role in determining how these facets of life operate. Unfortunately, these policies have not been working for the country, especially for North Carolinians living in rural areas. In some cases, intentionally and, in other cases not, government and corporate policies have conspired against their health interests. Rural North Carolinians have seen their vital emergency services run inefficiently, healthcare costs raised to soaring heights, and government intervention that has caused more problems than it has solved. Overall, current policies from both the government and private corporations are adversely affecting rural North Carolinians’ access to affordable and quality healthcare.

A key example of these policies is the Affordable Care Act (ACA). The ACA is a piece of legislation designed to combat the financial barriers to healthcare in the United States. This law, colloquially known as Obamacare, has three primary goals: making healthcare more affordable for the public by offering subsidies to families who made between 100-400 percent of the federal poverty line, expanding the Medicaid program to all adults living under 138 percent of the federal poverty line, and support medical innovation that will lower healthcare costs (US Department of Health and Human Services). Now, many people view the ACA as a successful piece of legislation. When it was enacted in March 2010, 46.5 million Americans were uninsured; in 2021, that number dropped to 27.5 million (Tolbert). While this number proves a major accomplishment of this legislation, it is deceptive to say that its benefits were universally enjoyed. The ACA, through a combination of expanding government bureaucracy and naïveté, has actually increased the price of healthcare in rural North Carolina.

One story regarding this well-intentioned policy is that of Brad Barringer. Mr. Barringer owns BRS, a general contracting firm, in Stanly County. In his interview, he said:

“Over the years, the healthcare system has gotten so complicated, that it’s hard to navigate what you can do and what you can’t do…It’s just gotten out of hand. And there’s so much waste in it…the cost of healthcare is probably 25 percent healthcare and 75 percent waste…[Obamacare] required changes that came along that certainly hurt us, hurt us tremendously…It was a disaster.” [0:43:57.9] – [0:44:56.1]

Unfortunately, Barringer’s views are far closer to reality than one would think. In the last decade, the Affordable Care Act added a surprising $273.6 billion in bureaucratic overhead (costs not directly attributable to patient care); these costs now constitute 22.5 percent of total federal spending on this program (Physicians for a National Health Program). This and a regular underestimation of the costs of this policy have led to premium hikes to compensate for the spending deficit. In North Carolina, a state that is 40 percent rural, before the enactment of the ACA, the average individual market monthly premium was $240. In the year after its enactment, that number jumped 29 percent to $310. The egregious price hike in North Carolina is not an isolated event as other rural states such as Montana, Kansas, and Alabama have witnessed post-enactment price hikes ranging from 30 to 84 percent (Kowalski). This surcharge is more detrimental to rural communities in North Carolina where the median income of $39,100 is 23 percent lower than that of urban counties in the state (US Census Bureau and American Community Survey).

The ACA also hurts small businesses and the people who work in them. This legislation requires most businesses to offer health insurance to their employees or risk fines. Unfortunately, the ACA does not do enough to offer financial assistance to offset the imposed burden of offering insurance. This leads to either employers offering good insurance plans and cutting salaries or keeping salaries intact and offering nominal plans (Cowley). Regardless of the choice a company makes, workers are adversely affected. With good insurance, their cut salaries cannot keep pace with the rising cost of premiums, and with nominal insurance, their regular salaries cannot compensate for what would be higher out-of-pocket costs (Lucia). The increase in financial barriers, whether by premiums or out-of-pocket costs, has been tied to poor medication adherence and the delaying of vital, potentially lifesaving treatments for cancer, heart disease, diabetes, and other ailments. This catch-22 situation is one of the main reasons why 60 percent of small-businesses owners and 54 percent of rural Americans want the Affordable Care Act repealed (Pofeldt, Wu). The system is simply unsustainable, and one must ask: what good is expanding healthcare access, if the people who need it the most, are the ones who cannot afford it?

Another example of policies doing more harm than good is healthcare privatization. Ebony Talley-Brame lives in a county where typically public-run healthcare entities such as EMSs (Emergency Medical Systems) and hospitals are becoming increasingly privatized. To combat the lack of adequate services privatization created, especially for ambulance response times, she created her own medical transportation system.

“My goal is, is to come back to Warren County and provide a medical transportation business where I can take people back and forth to the hospital at a lower cost…I think the community right now are contracted with a company called CARTS…my husband…worked for CARTS…he would come home and tell me different stories about how the elderly people would have to wait so long for that company to come back and pick them up” [0:30:01.9] – [0:31:17.2]

Many counties, especially smaller and more rural ones, decided to privatize various parts of their healthcare system to save money in the aftermath of the Great Recession. As corporations were now in charge of large swaths of healthcare systems, the telos of those systems shifted from helping the sick to cutting costs and maximizing profits. And in pursuit of those goals, rural residents paid the price. In rural communities with privatized EMSs, one-in-ten citizens wait half an hour for an ambulance, and the average wait time is twice that of public, urban systems (Minemeyer). However, the most egregious problem with privatization is the cost incurred on patients. EMS systems run by the private sector in rural areas charge on average 38 percent higher than their public sector counterparts (Adler). To complicate matters further, many rural counties outsource their healthcare systems to the same companies, allowing for rural monopolies to occur.

The ACA even plays a role in this situation as since it requires people to purchase health insurance or have insurance through their jobs, the few insurance companies that cover rural areas thrive off this forced demand. While some may view this as an unintended consequence of good policy, consolidation was a goal of the ACA. Before the ACA’s enactment, then-President Obama’s top healthcare advisors penned an open letter saying that “these reforms will unleash forces that favor integration across the continuum of care” (Kochner). Unfortunately, integration was what happened across America and especially in rural North Carolina. Monopolistic insurance companies conspired with the private equity firms who operate rural EMS systems to raise prices that are then passed on to either the government or, more likely, individual consumers, who cannot dispute the charges due to a severe concentration of ownership among a few private companies. In fact, in rural areas where there is only one insurer offering plans through the ACA, monthly premiums were found to be $128 higher than in areas with five or more insurers (Robert Wood Johnson Foundation).

While immense efforts have been made to reduce the disparity between the insured and the uninsured, there has not been enough progress to combat the disparities facing rural areas. In North Carolina, private insurers charge the average person 280 percent of what Medicaid says that procedure should be, causing unnecessary premium hikes to trickle down to rural North Carolinas. Today, the average rural worker loses 20 percent of their paycheck to healthcare costs, one-in-five families are facing medical collection debt, and the state is considered one of the most monopolistic and unaffordable in the country (Claxton). The state treasurer, Dan Folwell, described this situation last year as “‘the Wild West…Nobody’s watching it. Nobody’s holding them accountable. We need a commitment from the cartel to get back to their original mission and to stop putting profits over patients’” (North Carolina Department of State Treasurer). Overall, a combination of well-intentioned government programs and corporate avarice, there has been an amalgamation of policies that have severely and adversely affected rural North Carolinians’ access to affordable and quality healthcare.


Adler, Loren, et al. “Ground Ambulance Billing and Prices Differ by Ownership Structure.” Health Affairs, vol. 42, no. 2, 18 Jan. 2023, pp. 227–236.,

Barringer, Brad. Interview with Carolina Efird. 7 August 2018 (Y-008). Southern Oral History Project Program Collection (#4007), Southern Historical Collection, Wilson Library, University of North Carolina at Chapel Hill.

Claxton, Gary, et al. “How Affordability of Employer Coverage Varies by Family Income.” Peterson-KFF Health System Tracker, 10 Mar. 2022,

Cowley, Stacy. “Health Care Law Forces Businesses to Consider Growth’s Costs.” The New York Times, The New York Times, 18 Nov. 2015,®ion=Footer.

Glied, Sherry A, and Benjamin Zhu. “Catastrophic Out-of-Pocket Health Care Costs: A Problem Mainly for Middle-Income Americans with Employer Coverage.” Catastrophic Out-of-Pocket Health Care Costs: Employer Coverage | Commonwealth Fund, 17 Apr. 2020,

Kocher, Robert, et al. “The Affordable Care Act and the Future of Clinical Medicine: The Opportunities and Challenges.” Annals of Internal Medicine, vol. 153, no. 8, 2010, p. 536.,

Kowalski, Amanda. “The Early Impact of the Affordable Care Act State-by-State.” NBER, 20 Oct. 2014,

Lucia, Laurel. “The ACA Excise Tax Is Not a Progressive Tax Policy.” UC Berkeley Labor Center, 10 June 2020,,health%20plans%2C%20regardless%20of%20income.

Minemyer, Paige. “Rural Patients Face Long Waits for Paramedics to Arrive.” Fierce Healthcare, 20 July 2017,

North Carolina Department of State Treasurer. “Report: North Carolina Hospitals Make Millions in Profit on Medicare .” Report: North Carolina Hospitals Make Millions in Profit on Medicare  | NC Treasurer, 25 Oct. 2022,

Physicians for a National Health Program. “ACA Adding Billions to Health Care Bureaucratic Waste: Study.” PNHP, 19 July 2018,

Pofeldt, Elaine. “Why 60 Percent of Small-Business Owners Want Obamacare Repealed.” CNBC, Consumer News and Business Channel, 6 May 2017,

Robert Wood Johnson Foundation. “Changes in Marketplace Premiums and Insurer Participation, 2022–2023.” RWJF, 3 Apr. 2023,

Talley-Brame, Ebony. Interview with Darius Scott. 22 June 2018 (Y-0054). Southern Oral History Project Program Collection (#4007), Southern Historical Collection, Wilson Library, University of North Carolina at Chapel Hill.

Tolbert, Jennifer, and Patrick Drake. “Key Facts about the Uninsured Population.” KFF, Kaiser Family Foundation, 7 Feb. 2023,,to%2027.5%20million%20in%202021.

US Census Bureau, and American Community Survey. “The Urban and Rural Faces of North Carolina – NC.” North Carolina Office of State Budget and Management, 6 Dec. 2018,

US Department of Health and Human Services. “Affordable Care Act (ACA) – Glossary.” Glossary |, 2013,

Wu, Bryan Wu, and Liz Hamel. “The Health Care Views and Experiences of Rural Americans: Findings from the Kaiser Family Foundation/Washington Post Survey of Rural America – Findings.” KFF, 3 Dec. 2018,

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