18-07-2025
Vance wrote Hillbilly Elegy in tribute to this town. Now Trump's cuts are tearing it apart
Beatrice Hall is waiting for word that her husband is out of surgery and his colostomy has gone well. It is the latest in umpteen procedures, check-ups and tests he has been forced to ensure since being diagnosed with colon cancer.
'I don't know what we would do without this hospital,' she says, standing in the 33C heat outside the Kentucky River Medical Centre.
Yet that is a very real prospect facing this poverty-riddled corner of Kentucky as a consequence of the passage of Donald Trump's 'one, big, beautiful bill'.
The bill will slash trillions of dollars from the Medicaid budget – dollars that pay for healthcare for those who cannot otherwise afford it. Without those patients and that money, some 300 hospitals across the country may struggle to survive, according to a study by the University of North Carolina, including 35 in Kentucky alone.
The hospital outside which Mrs Hall, 60, is waiting in the shade is 'Hillbilly Elegy' territory.
It is the place where JD Vance rose to prominence with a memoir detailing the poverty and hopelessness of Breathitt County, a book that became a cipher for understanding the forgotten parts of America that elected Donald Trump.
And Mr Vance has been tasked with selling the legislation to the country. On Wednesday, he was in a blue-collar corner of Pennsylvania, describing how it would give $1,000 to every newborn and banish taxes on overtime pay.
'So what I ask every single person to do is take what I've said… go and talk to your neighbours, go and talk to your friends about what this bill does for American citizens,' he said.
But he made no mention of the Medicaid shake-up.
Democrats are salivating. They believe Mr Trump has miscalculated, giving them a chance to win back blue collar and working-class voters.
'How could the second poorest district in the country not revolt against what happened?' asked Ned Pillersdorf.
The lawyer, who practises an hour away in Prestonsburg, is running for Congress as a Democrat in a district that covers south-eastern Kentucky and where the incumbent Republican won more than 82 per cent of the vote last time around.
He admitted that made for an uphill battle. But he said voters will see through the Republican bill and mercenary calculations that its worst impacts will be in deep red districts that are unwinnable for Democrats.
'They have made the cynical calculation, which has some truth to it, that if you're on Medicaid, you're probably not voting, and you're certainly not contributing money to campaigns,' he said, leaning back at a conference table at his law offices.
By coincidence, his next meeting was with a cousin of Mr Vance. That is how things go in this part of Appalachian Kentucky.
The future vice-president may have been born in neighbouring Ohio, but his family has its roots in Breathitt County. His difficult childhood – his mother was a drug addict and alcoholic – was brightened by summers spent running wild in the hills around the town of Jackson.
His 2016 memoir described the poverty then and the opioid addiction he saw when he returned as an adult.
'At Mamaw Blanton's, we'd eat scrambled eggs, ham, fried potatoes, and biscuits for breakfast; fried bologna sandwiches for lunch; and soup beans and cornbread for dinner,' he wrote. 'Many Jackson families couldn't say the same, and I knew this because, as I grew older, I overheard the adults speak about the pitiful children in the neighbourhood who were starving and how the town could help them.'
Today the town has the quaint charm of a place where time stood still. But shopping is limited to a handful of hardware or ramshackle second-hand stores, standing beside shopfronts that have been turned into makeshift homes.
They are a reminder of how the money was sucked away when coal mines closed in the 1980s and 1990s.
After the success of his book, Mr Vance returned with Ron Howard, the director, as they scouted locations and worked on turning it into a movie starring Glenn Close.
They stayed at Paul's Motel, as most visitors do, a neat complex of rooms and parking spaces just past the Breathitt County High School, home of the Bobcats football, baseball and basketball teams.
The Medicaid cuts are everywhere. Ask anyone and they open up, even at the motel.
'I'm worried about losing my medical coverage. I'm worried about losing my benefits,' said Anita, a member of staff, who asked that her real name not be used because of fear of running into trouble with Trump supporters. 'Even as a family with two working people in the house, if you don't get the benefits, you literally, pretty much have to scrape to get by.'
Earnings of $300 a week each do not go far when the month's electricity bill can top $400, she explained. Supporting three children and keeping a car would make health insurance a luxury were it not for the 'medical card,' as she knows it.
Like in many states, it is issued by a private medical insurer and often beneficiaries do not even realise that they are being helped by Medicaid.
'Appalachia can't afford to lose this,' she added, close to tears as she described the weekly struggle to pay the bills.
'I can't sleep at night now.'
Eastern Kentucky has some of the highest Medicaid enrollment rates in the country.
The bill, signed into law by Mr Trump on July 4, requires most users to prove 80 hours of work a month and increases eligibility checks.
In Kentucky, that is forecast to reduce Medicaid spending by $21bn over a decade, and end health coverage for up to 346,000 people, according to the non-partisan KFF health policy organisation.
Most residents are still trying to work out what it all means, as they dissect the headlines, said Mark Wireman, an old family friend of Mr Vance's. His farm stands on 130 acres of a reclaimed strip mine above a 'holler' outside town. He wears a handgun on his hip, loaded with anti-snake shot, for any copperheads or rattlesnakes spotted when he mows the lawn in front of his house.
'We'd hate to see the hospital close,' he said. 'There's no doubt it's saving people's lives over there.'
But he and his wife were sceptical of the doom-mongers claiming it would shut.
'I think some people will think that's just what the other side is saying,' said April, 54.
'I mean, I think in general, rural hospitals are struggling.'
The hospital study lists 15 facilities that are under threat in this one congressional district alone. But its findings are disputed by White House officials, who say it was conducted on an earlier draft of the bill and does not take account of an extra $50 billion directed to rural facilities.
'They struggle because they are low volume, and what we are doing through this bill is taking some of the savings and providing a once in a generation investment into these types of facilities that is not dependent upon an inflow of patients that they're never going to see,' said a senior White House official.
'Political propaganda'
Plenty of people in Breathitt County see the benefits of tightening Medicaid requirements and say opponents are spreading lies.
'It's totally political propaganda,' said Bobby Deaton, a conservative columnist who joins retired friends to talk current affairs each morning at Jackson's Hardee's fast food restaurant.
'Right now we are paying for the healthcare of illegal immigrants. That has to stop.'
And taxpayers are footing the bill for the healthcare of hill country people who have been raised to live off handouts, according to Gabrielle Hensley, 36.
'You have some people that live so far out, still up these little roads that are still set in their old ways. They don't travel, they don't have vehicles,' she said, waving her hand beyond the DG Market car park, where she was loading groceries into her car to feed her three children.
'Some of them are still just stuck on old habits and the way that they were raised by previous parents who teach them that government living is okay.'
Scott Jennings, who is best known as a conservative pugilist on CNN and whose own roots lie in Kentucky, said the bill was popular in places like Breathitt County, where residents knew the value of hard work.
'I've heard so many lies about this bill my head is spinning,' he said, explaining that the bill would redirect money to struggling hospitals. 'There's no political downside to encouraging work.'
For its part, the Kentucky River Medical Centre played down the threat, saying any impact would not be felt for another five years, if that.
Susie Morgan, the chief executive, said rural hospitals also had access to federal and state support programmes.
'Fortunately, we are part of a larger network that provides shared resources, operational support, and strategic guidance—especially valuable when navigating industry changes like this one,' she said.
For now, however, local headlines have focused on the danger to her hospital and the uncertainty around Medicaid. Even a Vance loyalist, in the form of his fifth cousin (twice removed) is worried about what it might mean politically.
'It'll be negative for Trump, and it'll be negative for me too,' said Joe Profitt, whose mother was a Bowman (the vice-president's family name). 'The people back here, if they believe in something or somebody and you betray him, you don't get any more chances.'
Mr Profitt lives just outside Jackson, in a bungalow set above a neatly tended garden. He described how Appalachian hospitality – illustrated with copious offers of the local soft drink Ale-8-One – came with a barb.
'You get this wherever you go here,' he said, as an 'It's Time for Trump' clock ticked on the wall of his front room. 'We love people. We're friendly, but don't cross us.'
