Communities like this aging West Virginia coal town along the Kanawha River were key to President Trump’s victory last year; more than two-thirds of voters in surrounding Fayette County backed the Republican nominee.

Now, families in this rural county and hundreds like it that supported Trump face the loss of a critical safety net for children as congressional Republicans move to cut hundreds of billions of dollars over the next decade from Medicaid, the half-century-old government health plan for the poor.

Much of the debate over Republican efforts to roll back the Affordable Care Act has focused on the impact cuts would have on working-age adults, millions of whom gained coverage under the healthcare law that President Obama signed in 2010.

But in Fayette County and 779 other mostly rural counties across the country — the vast majority of which went for Trump — more than half the children rely for coverage on Medicaid and the related Children’s Health Insurance Program, or CHIP, according to a Times analysis of county voting data, census data and Medicaid enrollment data.

Medicaid and CHIP provide a critical backstop across this region of West Virginia, where coal mining jobs have increasingly been replaced by lower-paying work that often doesn’t provide health insurance.

Montgomery General Hospital, where Acklin practices, is one of the few remaining employers in Montgomery, a town that’s been losing population for nearly half a century.

A small university campus here is closing, as is the local high school. And although coal trains still rumble past town, automation and declining demand mean fewer and fewer jobs in coal. Down the river, even the hulking coal-fired power plant has shuttered.

Acklin, who came back to Montgomery to practice 16 years ago, sees many families who struggle to putfood on the table. Routine checkups regularly uncover heart murmurs, untreated asthma and other serious medical issues.

And with the advent of the opioid epidemic, Acklin is seeing more children being raised by grandparents.

“I don’t think people understand how all this affects kids,” Acklin said between seeing patients, nearly all of whom are on Medicaid.

Some of the same issues challenge large urban areas. Several of the 780 counties most dependent on Medicaid and CHIP to cover children include cities with more than 1 million residents, including Miami, Philadelphia and parts of New York City, which covers five counties.

But in many big cities such as Los Angeles and Chicago, where jobs are relatively plentiful, most children don’t have government health coverage, according to the enrollment data assembled by the Center for Children and Families at Georgetown University.

By contrast, 622 of the 780 counties where a majority of children are on Medicaid or CHIP have fewer than 50,000 people. Most of the counties are overwhelmingly white, with the exception of predominantly African American counties in the Mississippi Delta and heavily Latino counties in New Mexico and along the Rio Grande Valley in Texas.

In several poor, rural states — including Arkansas, Mississippi and New Mexico — a majority of children in more than three-quarters of counties rely on one of the two government health plans.

“This is the safety net here,” said Keith Goodwin, president of East Tennessee Children’s Hospital in Knoxville, more than two-thirds of whose patients are on Medicaid. “It is hugely important for our families.”

Since Medicaid’s founding in the mid-1960s, the federal government has paid a share of all medical expenses incurred by patients in the program, nearly half of whom are poor children.

But the Republican legislation in the House and Senate would end that open-ended flow of money, replacing it with fixed payments to states, no matter how much patient care costs.

The funding cap in the Senate bill would increase only at the rate of inflation, leaving states with an increasingly larger share of medical costs, which have typically increased faster than inflation.

And because the same flow of federal Medicaid money covers care for children as well as for poor seniors and the disabled, deep cuts would probably force states to decide who is more deserving of medical care.

“That is a terrible, terrible choice,” said Greg LaFrancois, president of the Aroostook Medical Center in northern Maine.



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Children in pro-Trump rural areas have a lot to lose if GOP rolls back Medicaid