To win reelection, Donald Trump is relying on the continued support of rural Americans, 62 percent of whom voted for him in 2016 compared to 34 percent for Hillary Clinton. But while rural Americans do continue to favor Trump, this time it’s by a much smaller margin. Among the roughly 60 million people who live in rural areas of the United States, Trump boasts only a thirteen-point lead over Joe Biden.

It can’t have helped Trump that rural America has struggled mightily with health care access throughout the coronavirus pandemic, a failure that more than a few rural voters are likely to lay at Trump’s feet.

A new report measuring the impact of the coronavirus pandemic on rural America shows just how bad the situation is. Conducted by NPR, the Harvard T. H. Chan School of Public Health, and the Robert Wood Johnson Foundation, the report finds that 24 percent of rural households report that someone in their household was “unable to get medical care for a serious problem when they needed it during the coronavirus outbreak.” Of this group, 56 percent report “negative health consequences as a result.”

The reasons that rural Americans are struggling to obtain health care during the coronavirus pandemic can be separated into two broad categories: poor rural health infrastructure and inadequate health financing.

Before the coronavirus pandemic, the United States was already enduring a wave of rural hospital closures, for which 2019 was a record year. Over a hundred rural hospitals have been shuttered in the last decade, and six hundred more are at risk of closing. When a hospital in a rural community closes, people are forced to drive sometimes hundreds of miles to receive care. Increasingly, rural patients are being airlifted by helicopter to the nearest hospital during emergencies.

In the United States, hospitals are run like businesses and must carefully attend to their own bottom lines in order to remain in operation. As austerity unravels the rural health care safety net, rural hospitals find that the costs of treating patients outweigh the benefits. Eventually, if they operate at a loss for too long, they end up on the chopping block. To illustrate the principle, states that expanded Medicaid saw far fewer rural hospital closures over the last decade than states that refused to.

Due to these rural hospital closures — and the economic hole they leave behind in communities, causing even more jobs, people, and non-hospital health services to leave the region — it’s already difficult for rural Americans to physically access nearby care. The pandemic, however, made everything worse, as doctors stopped seeing in-person patients and hospitals stopped scheduling less urgent treatments for long stretches of time.

As a result, throughout the pandemic many rural Americans who have become sick with COVID-19 have had to endure lengthy journeys to hospitals that are serving ever-larger regions. Meanwhile people still suffered from all the usual ailments, especially as rural Americans tend to be older and less healthy than urban and suburban Americans. For rural Americans experiencing medical conditions other than COVID-19, medical care has been harder than ever to come by.

Of the rural households who reported facing challenges accessing health care, 46 percent say they “could not get an appointment during the hours they needed,” 40 percent say they “could not find a doctor who would see them,” and 25 percent “felt the health care location was too far or too difficult to get to.”

But the difficulties don’t stop at poor rural health infrastructure. Once a patient has found a place to obtain care and a provider to administer it, they still have to find a way to pay for it. Of the rural households who reported that a member had difficulty accessing health care during the pandemic, 39 percent said they couldn’t afford the particular care they needed, and 12 percent said they couldn’t find a doctor who would take their insurance.

In addition to the United States’s profit-driven hospital model resulting in a patchy hospital network, our profit-driven insurance model has left an estimated 87 million Americans either uninsured or underinsured.

Many who have trouble affording the cost of health care due to inadequate coverage are rural Americans, who tend to be poorer on average than urban and suburban Americans. The problem is especially severe in states that refused Medicaid expansion, where one-third of low-income adults lack medical coverage entirely — to say nothing of insurance plans with unaffordable copays, premiums, and deductibles.

For people dealing with non-coronavirus medical issues, the struggle to find an in-network doctor or facility and obtain affordable treatment has become that much harder during the pandemic. Not only are providers less accessible than ever, but mass unemployment is leading to millions being kicked off their employer-provided health insurance. Additionally, loss of income is draining Americans’ bank accounts. The report finds that

four in ten rural households (42%) report facing serious financial problems during the coronavirus outbreak, including about three in ten (31%) who have used up all or most of their savings, and an additional 10% who report not having any household savings prior to the outbreak.

Taken all together, that means that rural America is looking simultaneously at more uninsured and underinsured people, fewer in-network and affordable providers, and less money to make up the difference. Add to this the fact that low-income adults and those without adequate insurance are more likely to be at risk for developing serious complications from COVID-19, and you’ve got a perfect storm.

In our current political climate, it’s easy to forget that up until the late aughts rural America’s political loyalties were evenly split between the two major political parties. In the last decade rural Americans’ Republican leanings have grown so pronounced that they sometimes seem self-evident to us now. But there’s nothing automatic or inevitable about people who live in the countryside voting for Republicans.

Rural political alignment won’t be reversed in 2020, but it’s already looking possible that Trump has lost his shot at another rural landslide. No doubt his administration’s failure to keep the pandemic in check or provide adequate relief is playing a huge part in his waning popularity.

And rightly so. Though we would also do well to remember that the for-profit hospital and insurance systems predate Trump, and will remain stubbornly in place unless we fight to replace them with a national health system.