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Much has been made of the  and  in rural areas during the 2016 U.S. presidential election. Few realize, however, this is also felt through unequal health.

Researchers call it the “ .” While rates of mortality have steadily fallen in the nation’s , they have actually climbed for rural Americans. And  for specific groups, such as rural white women and people of color, who . In every category, , rural residents’ health has been declining since the 1990s.

Republican Congress inches closer to repealing Obamacare and replacing it with a feeble alternative.

While some have blamed these  on “culture” or “lifestyle” factors—such as a supposed or overconsumption of unhealthy products such as—the truth is that the biggest culprit is limited access to health care and challenging economic circumstances.

The passage of the Affordable Care Act (ACA) in 2010  as more rural Americans gained insurance coverage and the government invested more money into regional health facilities and training.

This progress , however, as the Republican Congress inches closer to repealing Obamacare and replacing it with a feeble alternative that greatly weakens rural health care access. As researchers who study the mental and physical health of rural Americans, we believe this would have disastrous consequences.

The travails of rural America

Even as  feeds the country,  in rural areas.

Some  live in food deserts—defined as counties in which one must drive more than 10 miles to get to the nearest supermarket. This makes it challenging to maintain healthy and nutritious diets, leading to  that greatly increase the risk for diabetes, heart disease and certain cancers.

As rural workers struggle to  in a , the increasing poverty is contributing to mental distress and . On a larger scale, the economic changes that have hit rural areas have resulted in a declining tax base, lower incomes and strained educational institutions. Together, they challenge rural residents’ health not just in the immediate term but cumulatively over their lives.

Barriers to accessing health care

Yet, despite all these medical issues, rural residents have a tough time getting the health care they need.

The nature of rural employment, for example, is characterized by . This means rural workers are  when buying their own policies.

The lack of public transportation in most rural areas is also a major hurdle to seeing a doctor, particularly as residents than those in urban areas to reach health care providers.

Rural health care has at times been characterized as patchwork.

Rural residents get most of their services through primary care providers, , like behavioral health clinicians, because of longstanding specialist shortages. When handling  during a single medical encounter, primary care providers may concentrate on the most acute health concerns of their patients, undermining the ability to diagnose all their conditions and , such as exercise, weight and substance use. When providers are rushed or deliver sub-par care, rural residents may wonder if seeking it out is worth the challenge, .

These and other constraints make it tougher for rural Americans to get the screenings needed to spot serious diseases such as  early or to maintain adequate followup on conditions such as . Finding the regular medical care necessary to manage chronic conditions, such as diabetes, or , is even more challenging.

Rural health care has at times been . In part, that’s because the  thanks to the large service areas, the inability to negotiate bulk pricing and lack of financial incentives to fill in provider gaps.

The ACA and the plan to repeal it

The ACA, intended to turn this around, has in fact led to dramatic gains in insurance coverage among rural Americans.

Broadly speaking, insurance rates in rural areas  in early 2015, up from an estimated 78 percent in 2013.

In Kentucky—a state with high poverty, a large rural population (42 percent of residents) and a successful  initiative— began using preventative services after previously being unable to afford it. The state’s uninsured fell by half and, as a result, because of financial hardships relative to other states that didn’t expand Medicaid.

The ACA also  by investing in upgrades to hospitals and clinics, preventative health programs and support for providers to stay in rural areas. While rural hospitals are often laden with the expense of providing extensive care without payment to indigent patients, rural hospitals in states that expanded Medicaid under the ACA . At the same time, the ACA supported innovative models ideal for rural areas that prioritized ,  and .

Both the bills to repeal and replace Obamacare would and significantly threaten the ability of . that the bill would provide insufficient tax credits to pay for rural premium costs, drastically increase the price of rural premiums and increase uncompensated care in rural hospitals.

What rural areas need from health care reform

Previous efforts at health care reform show us that rural areas are uniquely vulnerable. Efforts need to take account not only of coverage and access—as has been the focus of the current debate—but also how reform affects rural health care institutions and the larger social factors shaping overall health.

The particular economic factors affecting rural health care institutions  that disrupt services for existing patients and for those newly insured, creating immense challenges for rural providers. Steps that fail to account for the impact of financial hardship on these institutions not only hurt their bottom line but contribute to  and larger-scale decisions to reduce services, which decrease their ability to address patient needs.

At the same time, commitment to improving the health of rural Americans requires attention to the so-called upstream factors shaping rural health. That means  with underemployment and low-paying jobs, and investing in .

If our leaders are serious about reform that will lessen the rural-urban mortality gap, they should recognize the unique needs of rural America and ensure health care policy reflects how vital access to quality care is to their financial success—not to mention their well-being.

This article was originally published by . It has been edited for ¾«¶«Ó°Òµ Magazine.