The have and the have-not states, when it comes to Medicaid expansion, have been clearly delineated in the five years since the expansion began under Obamacare. On the one hand, there's evidence that it’s making people in expansion states healthier. On the other, "medical deserts" are commonplace.
There are still studies in the works to determine the health effects of the law, with just five years of data available. But there are some identifiable gains: fewer hospital admissions of low-income people with asthma and diabetes in Michigan; 25,000 smokers in Ohio getting cessation assistance through Medicaid and quitting; more people with severe kidney disease and on dialysis living longer in all expansion states. Reports The Washington Post, "One National Bureau of Economic Research paper in July, looking at deaths from all causes among adults from their mid-50s to mid-60s, found that dying in a given year has been significantly less common in the states that expanded Medicaid."
Then there's Texas, where 68-year-old Dr. Ed Garner, was for five long years "the only working doctor left to care for three remote counties east of El Paso, an area similar in size to the entire state of Maryland, home to far-flung oil encampments, a desolate stretch of interstate, communities of drifters living off the electric grid, and highway towns made up of truck stops and budget motels." Rural hospitals around the country have been closing, providers leaving, because they can't afford to stay open while providing uncompensated care. Medicaid expansion was at the top of the list of priorities for the Texas Medical Association in 2019. It hasn't happened.
There's Missouri, where "emergency medical care has become a standoff between hospitals and patients who are both going broke." In just this year, one medical center in southeast Missouri alone has sued more than 1,100 people for unpaid medical bills, bills they can't pay. Unpaid medical bills are the leading cause of bankruptcy, still, and it's largely the people at the margins and in that Medicaid gap who suffer.
This makes the very real possibility that federal courts will decide to completely do away with the ACA—as the Trump administration and more than a dozen Republican states are asking—even more dire. Trump and the Republicans have no alternative in the wings, just junk insurance and a return to pre-ACA days. The Republicans have absolutely no alternative besides what's playing out right now in rural America: poverty, debt, and early death.