When people learn that I’m an Emergency Medicine doctor, they often ask “what’s the craziest thing you’ve seen?” I know they’re anticipating a story about a ghastly gunshot wound or a five-car pile-up. I don’t blame them for being interested in the more sensational aspects of my job. It’s human nature. But the truth is, the craziest things I see working in the emergency room (ER) are the folks presenting with life-threatening complications of diabetes because they could no longer afford their insulin. Or the twinge of embarrassment in a parent’s eye when they ask how much their child’s ER care is going to cost. Despite astronomical costs and the fact that medical debt is the leading cause of bankruptcy in the country, the United States has some of the worst health outcomes of any wealthy nation. I’ve seen these scenes play out in every ER I’ve worked in, from Los Angeles to New York. But it is at a rural hospital in El Centro, California, particularly in the context of the current Republican plan to decimate Medicaid, where I see the healthcare crisis in this country really coming to a head. 

A few times a month, I commute to El Centro from my home in San Diego to work at the only ER serving the city’s 44,000 residents. Though it’s less than a two-hour drive from the wealthy coastal communities of San Diego, it feels like another world. Heading east along the U.S.-Mexico border, you traverse a mountain range before descending into Imperial County, which consists of a rural, low-lying desert valley with El Centro serving as its largest population hub. The county relies heavily on agribusiness, and like so many rural communities in the U.S., it has struggled economically. Imperial’s poverty rate is almost twice the national average. It was hit particularly hard by the 2008 recession, during which it had the highest unemployment rate in the country. Politically, Imperial County is typical of the parts of the country that have recently caused so much consternation for the Democratic Party. Rural, working-class, and predominantly Hispanic (about 85 percent), the county had historically served as a fairly reliable Democratic stronghold—Hillary Clinton beat Trump there in 2016, winning 67 percent of the vote. In 2020, Joe Biden won with a similarly dominant 61 percent. But in 2024, Imperial was one of ten California counties to flip and vote for Trump. 

The shift seen in Imperial County has played out all over the country. The working class has left the Democratic Party in droves. The reasons for this have been the topic of endless debates and editorials. Hillary Clinton, like many liberal elites, sees the shift as an expression of “racist, sexist, homophobic, xenophobic, [and] Islamophobic” views, long harbored by a “basket of deplorables” who have finally found a home in Trump’s Republican party. Others, myself included, see it more as a reaction to a Democratic Party that has failed to deliver for working people time and time again. The Democrats have become so elitist and out of touch that they no longer resemble the party that delivered Roosevelt’s “New Deal” or Johnson’s “Great Society.” The evidence for this latter view includes the fact that it is not just the white working class changing sides, but also working people of color, particularly Hispanics, as in Imperial County’s 2024 shift. Or consider the respective parties’ national conventions. The 2024 Republican convention made history by featuring a speech by the president of a major labor union. The Democrats, on the other hand, opted for a speech by the richest elected official in the country, Illinois governor J.B. Pritzker, who attempted to differentiate himself from Trump by boasting about being “an actual billionaire.” Whatever the reasons for this shift in political allegiance, the more important question is how to bring the working class back to the Left. The healthcare crisis in places like El Centro could act as a catalyst for building a productive populist movement that, unlike the xenophobic and perfidious counterpart on the Right, might actually serve the interests of the working class.

Healthcare in the United States is an utter scandal. As a nation, we spend around 18 percent of our GDP on healthcare. That is about twice the average of other wealthy countries and more than four times that of South Korea, New Zealand or Japan. Despite the price tag, we are the only wealthy nation that does not guarantee healthcare to all its citizens (an estimated 26 million Americans are currently uninsured). Not only that, but health outcomes in the United States are an embarrassment. When compared to the other 37 countries in the Organization for Economic Co-operation and Development (OECD)—which represents the globe’s wealthiest nations—the U.S. is well below average in life expectancy, higher than our peers in number of avoidable deaths, and ranks last in infant and maternal mortality. 

These problems are even more acute in rural areas like Imperial Valley. Compared to more urban settings, residents of rural communities in the U.S. are more likely to die early from preventable illnesses such as heart disease, chronic lung disease, and stroke. Not only is age-adjusted mortality higher in rural communities compared with urban ones, but the divide is widening. In 1999 there was an estimated 7 percent higher mortality rate in rural compared with urban communities, and by 2019, the difference had increased to 20 percent. As rural counties tend to lean heavily conservative, many have attributed these differences to policy choices, noting the predominance of Republican-led state and local governments in these areas. This idea gained particular fanfare during and after the COVID-19 pandemic, when researchers noted worse outcomes in Republican compared with Democratic-led states. And there is some truth to it: no doubt certain policy choices, such as some red states’ refusal to expand Medicaid, or cultural peculiarities, such as the profound vaccine skepticism seen in conservative communities during the pandemic, have played a role in the health disparities we now see between urban and rural populations. But the root cause of this overall trend is more a matter of class than anything else. Rural or urban, there is perhaps no more consistent predictor of health in the U.S. than socioeconomic status. Endless studies have demonstrated that “across the lifespan, residents of impoverished communities are at increased risk for mental illness, chronic disease, higher mortality, and lower life expectancy.”

How has the Republican party chosen to repay their new working-class constituency? By pulling the rug out from under them. Republican lawmakers are currently working on crafting a new budget into law—Donald Trump’s “big, beautiful bill.” Their plan will likely include cutting nearly $880 billion in Medicaid spending, and Medicaid provides health care coverage to 83 million low-income Americans. These cuts would be devastating for poor and working-class people in the United States. Considering the new political alignment, the MAGA base will be disproportionately affected, and they know it. This was reflected in a recent poll that showed that a majority of 2024 Trump voters were against cutting Medicaid. What’s more, over 75 percent of respondents from rural areas reported that they favored either leaving Medicaid spending as is or increasing it. 

It is not surprising that rural voters, even those who support Trump, are wary of Medicaid cuts. The program plays a particularly important role in rural communities, and the proposed cuts would be a disaster for rural America. As Alan Morgan, CEO of the non-profit National Rural Health Association, explains, “the Medicaid program is a lifeline for rural hospitals, providers, and patients. Any cuts to the Medicaid program will disproportionately affect rural communities. Rural Americans rely on Medicaid coverage more so than their urban counterparts with about 20% of adults and 40% of children living in rural areas enrolled in Medicaid and CHIP [Medicaid’s counterpart for children].” 

One of the principal reasons that rural communities tend to have worse medical care is a lack of vital medical infrastructure that provides emergency and specialty care services. In El Centro we struggle to maintain consistent specialty staffing for even basic things like pediatrics or obstetrics. When someone presents to the hospital requiring emergency intervention by a neurosurgeon, for example, they have to be flown out of Imperial Valley since there are no neurosurgeons operating in the county. And things are likely to only get worse. The past decade has already seen a dangerous trend in hospital closures. An American Hospital Association report identified 136 rural hospitals that folded between 2010 and 2021. Without a well-funded Medicaid program to reimburse providers and hospitals for their services, medical facilities like the one I work at in El Centro won’t survive. As the hospitals shutter and providers are forced to find work in more affluent areas, the entire community will be left behind to languish—even those who are able to afford private insurance. What good is it to have health insurance if there is nowhere to go when you have a heart attack? 

If the Left in this country wants to be more than an intellectual exercise played out on college campuses and instead be a real political project that delivers for poor and working-class people, it can start by making healthcare a signature issue. There is no question the American people would respond. A recent poll showed 62 percent of Americans believe the government should ensure health coverage to everyone. But the Democrats have already proven they are not the champions of this issue. Despite Kamala Harris’ support for Bernie Sanders’ Medicare for All plan during the 2020 Democratic primaries, she abruptly flipped and distanced herself from the proposal as a 2024 presidential nominee. Even the so-called “insurgent” Democrat Alexandria Ocasio-Cortez has been a disappointment on this score, acquiescing to party leadership and declining to support a grassroots effort aimed at forcing Congress to vote on Medicare for All. 

Like other disenfranchised groups, the rural working class has been taken for granted by politicians and ignored by the rest of society. In a political system in which the elite have all but assured there are only two options—Republican or Democrat—poor and working people’s shift toward the Republican party is perfectly understandable. We saw a similar dynamic amongst some Arab and Muslim voters who were so appalled by the Democrats complicity with the genocide in Gaza that they refused to vote for Harris in 2024, contributing to her loss to Trump in the crucial swing state of Michigan. In both cases, it’s not so much the strength of the GOP platform as the failure of the Democrats to provide a worthy alternative. What’s needed is a mass movement of working-class people, organized outside of either major party. The current political landscape is ripe for it. Over the past few years a record number of Americans have become dissatisfied with both major political parties and have expressed interest in something new. 

The rift between urban and rural communities, along with the related identity politics of gender, sexual orientation, and race have divided the working class. This is not to say that identity is not an important factor in a truly liberatory political project, but without a way to unite across these divisions, the Left has become paralyzed. Healthcare is an issue that can transcend those boundaries and bring working people together in common cause. Martin Luther King Jr. noted the potential of such a movement when, describing a diverse coalition of working people, he said,  “Together, they could exert massive pressure on the government to get jobs for all. Together they could form a grand alliance. Together, they could merge all people for the good of all.” There are some that might balk at the idea of organizing a political movement with erstwhile Trump voters, worried that they might not share our values. Those people have probably not spent much time in these communities. The principal reason I choose to work in El Centro is the people. They are proud, generous and welcoming. You don’t have to spend much time there before you see how deeply they care about the well-being of their family, their neighbors, and their community, and I suspect the same is true for many other rural places. What better starting point could there be for a political movement?