In 2013, then secretary of Health and Human Services Kathleen Sebelius addressed the Rural Assembly in person in Bethesda, Maryland. She spoke virtually to participants in Rural Assembly Everywhere on Tuesday, October 28, 2020. (Daily Yonder/Shawn Poynter)

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A legal challenge to the Affordable Care Act that goes to the U.S. Supreme Court in less than two weeks could devastate rural America’s fragile healthcare system, according to former Kansas Governor Kathleen Sebelius. Sebelius was secretary of the U.S. Department of Health and Human Services during the landmark legislation’s passage and rollout.

The Affordable Care Act (ACA) prohibits health-insurance discrimination based on preexisting conditions, lets children stay on their parents’ insurance until age 26, subsidizes premiums for millions of Americans, and expands eligibility for Medicaid.

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“What we have today is a very precarious situation where all of that could be struck down,” Sebelius said in remarks to Rural Assembly Everywhere on Tuesday, October 28. “All of those provisions could vanish, including Medicaid expansion.” Kansas has lost three rural hospitals in the last two years, in part because the state has not expanded Medicaid, Sebelius said.

Since 2010, 133 rural hospitals have closed nationally, according to the University of North Carolina Sheps Center. Most have been in states that did not expand Medicaid.

The Supreme Court case against the ACA is one of multiple attempts to overturn the legislation. In 2012, the Supreme Court partially rebuffed a lawsuit seeking to undo the law, but the split decision allowed states to opt out of expanding Medicaid coverage, as the act originally required. Since then, 39 states and Washington, D.C., have expanded Medicaid and 12 states, including Kansas, have not. Another Supreme Court challenge to the law failed by a vote of 6-3 in 2015.

In 2017 President Donald Trump and congressional Republicans narrowly failed to overturn the Affordable Care Act in a series of votes.

The lawsuit that will be heard next month in the Supreme Court began in 2018, when Texas and 19 other states sued to have the ACA declared unconstitutional. The Trump administration has refused to defend the federal government against the suit. When the case is argued November 10, the bench will include newly appointed Associate Justice Amy Coney Barrett, who replaced the late Ruth Bader Ginsburg.

“If indeed the ACA is struck down, [more rural hospital closures] will happen all over the country, including in the states that have already chosen to expand Medicaid,” Sebelius said.

Kathleen Sebelius, second from right, leaves the U.S. Supreme Court on March 4, 2015, after oral arguments in an unsuccessful case against the Affordable Care Act. The Trump administration has not defended the ACA from another lawsuit that the Supreme Court will hear November 10. (AP Photo/Pablo Martinez Monsivais)

The pandemic has brought health-care disparities in rural areas into stark relief, Sebelius told participants in the Rural Assembly’s online conference. In Kansas, where Sebelius served as governor from 2003 until joining the Obama Cabinet in 2009, the virus is spreading at a rapid rate in three quarters of the counties.  Last week, Norris County, where Sebelius’ husband grew up, had the highest rate of new infections in the nation, according to the Daily Yonder’s weekly analysis.

Rural healthcare providers in the U.S. are not adequately equipped to deal with the challenge, she said. “You can’t save a Covid patient if you don’t have highly trained personnel and the medical equipment with which to treat them,” she said. “It’s a nightmare waiting to happen, and we are seeing it play out right now in the United States.”

Sebelius cited a rise in maternal mortality in rural areas as an example of how a decline in healthcare services has led to disastrous results. “It’s a shocking place to be in where maternal mortality has gone up,” she said. “Rural women now have to travel much farther to get care, to get to a hospital, to find a qualified OB-GYN.”

Positive developments that have grown out the pandemic include the expansion of telehealth and the growing awareness the rural areas need better internet access, Sebelius said. “Part of the recovery from Covid has to be a big and sustained investment in internet access for rural areas.”

Sebelius said she hopes the pandemic encourages Americans to solve problems. “I think the opportunity is there for a post 9/11 moment,” she said.  “That we will have an urgency as we recover to finally address some of the issues we’ve identified but have never really fixed in the past.”