On the Medicaid front, several states, including Florida, Wisconsin, Texas, Kansas, Maryland, and Louisiana, will also have to wait and see how the battle to expand their Medicaid programs plays out. The Republican governors of these states have said they will opt out of the ACA's call to expand Medicaid to insure more of their citizens. Texas Governor Rick Perry penned a letter to HHS Secretary Kathleen Sebelius, in which he describes Medicaid as "a system of inflexible mandates, one-size fits-all requirements, and wasteful, bureaucratic inefficiencies.
Nevertheless, even though the Supreme Court's ruling last month upheld the right to opt out of the Medicaid expansion, Hunt says the governors in those states will face mounting pressure to partake.
"The pressure is going to come from two places," Hunt says. "First there are millions of people who will be left out of health insurance reform if the governors decide not to go forward with Medicaid reform. And second the providers have been relying upon the Medicaid expansion as a way to cover those large numbers of uninsured."
Elehwany says many people who are otherwise firm supporters of rural healthcare may resist supporting any provisions of the ACA for fear of political blowback. "They don't want to look like they are supporting any part of it. That has been incredibly frustrating," she says.
"The great thing about being a rural health advocate is we have friends who are Democrats, Republicans, and Independents. But because some of these provisions are in healthcare reform, it is tainting that relationship."