Ted Slafsky

Opinion contributor

It has become axiomatic that Republican presidential candidates trounce their Democratic rivals in the South and other rural areas. The last time Democrats truly competed was in 1996, when Bill Clinton won such states as West Virginia, Kentucky, Arkansas, Louisiana and Tennessee. While no one can debate the GOP’s rural dominance, the level of support for candidate Donald Trump in the 2016 election was striking. He crushed Hillary Clinton by 26 points, a much bigger margin than the past four GOP nominees.

President Trump remains very popular in small town America. While he has lost his edge in the suburbs and continues to be toxic in the cities, rural America is his last stronghold. However, even this reality has its limits. In the swing state of Iowa, his popularity has dropped by 20 percentage points since the 2016 election.

That makes his recent decision to go full monty on repealing the Affordable Care Act that much more puzzling and politically unwise.

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In March, the president shocked the world by announcing that the Justice Department would support a lawsuit that would fully repeal Obamacare. In December, a federal judge in Texas ruled that the ACA was unconstitutional, and that the entire law needs to be scrapped.

The U.S Court of Appeals for the 5th Circuit, considered perhaps the most conservative in the country, is now reviewing the case. The administration's first court filing, arguing that the law must go, is due Wednesday. If the case is affirmed, it is very likely headed to the Supreme Court, where its fate is uncertain.

ACA repeal would be a blow to rural care

With so much attention to the ACA battle, the country is now well aware of the most popular provisions in the landmark 2010 law. Insurance companies must cover preexisting medical conditions, for example, and must allow people to keep their kids on the family insurance plan until they're 26. And nearly 20 million more Americans have insurance coverage.

However, few Americans are familiar with another element in the ACA that is helping to keep rural hospitals afloat. Deep in the 1,000-plus page statute is a provision that expandeda little known drug discount program to include more types of hospitals, including rural hospitals. Since 1992, urban hospitals that provide a lot of care to poor patients have been able to acquire pharmaceuticals at a steep discount through Section 340B of the Public Health Service Act. Now rural hospitals can save hundreds of thousands of dollars on their drug costs.

Under 340B, drug companies are required to sell pharmaceuticals at a major discount — generally 25% to 50% cheaper than what is available in the private market. The expansion was championed by key lawmakers from both parties, including Republican Sen. John Thune of South Dakota and former Democratic Congressman Bart Stupak of Michigan.

Drug prices would soar without Obamacare

If the ACA is repealed, lower-priced pharmaceuticals go away in rural America. “340B is a lifeline,” says Alan Morgan, CEO of the National Rural Health Association.

Morgan points out that 75% of rural hospitals use their drug savings just to keep their doors open. “Just over 100 hospitals have closed in the last 10 years and more than 1 in 3 are at risk of closure. These closures not only cut off patients from direct access to care, they have a devastating impact economically. These hospitals are generally the largest or second employer in the region and also an economic engine in the community,” Morgan told me.

It’s not just dollars and cents. Cancer patients in Childress County, Texas, will have to drive up to four hours each way to receive chemotherapy if 340B goes away. Boone County Hospital in Iowa is only able to staff its labor and delivery unit because of 340B. Imagine not having a hospital nearby when you are about to deliver! For Lake Regional Health System in Missouri, 340B allows it to set up off-site primary care visits for the elderly who can’t make it to the hospital.

Some will argue that Congress will come to the rescue if the courts overturn the ACA. The administration says it is also working on a plan. As a 25-year Washington veteran fighting for affordable health care and low-cost prescription drugs, I am not as optimistic. I am well aware of the challenges of enacting health care legislation, even bipartisan legislation — let alone a bill that lowers drug industry profits.

Regardless, it’s a shame that we have even arrived at this period of anxiety and uncertainty. Rural Americans deserve better.

Ted Slafsky, the former president and CEO of 340B Health, founded and runs the health care consulting firm Wexford Solutions. Follow him on Twitter: @tslafsky