By skyforbes 
Appalachia is a land that has always known its fair share of hardships — from the many dangers of mining coal, to the wild and sometimes woolly weather, and the general remoteness of the region itself. This is not a land for the faint of heart. Our history, woven into the very fabric of our mountains and valleys, is one filled with self-reliant explorers, trend-bucking trailblazers, and folks who are no strangers to hard work. Survival in these hills all but necessitates a temperament that borders on ornery and finds comfort in the challenges that isolation brings.
A great deal of Appalachian culture is owed to that very isolation that is both bane and boon to our people. The Blue Ridge Mountains have always possessed a strange, almost eldritch power to seemingly slow time. The world beyond them may move at a breakneck pace, but Father Time holds little sway in King Coal’s kingdom. At times, the two almost seem at war. For while modern conveniences have made their way here, they’re often offset by a lack of fundamental social infrastructure — things our city-born brethren might take for granted — or they coexist with relics long discarded elsewhere.
Nestled within our hills, valleys, winding creeks, and forgotten backwoods corners are pockets of society that remain both connected to the modern world and strangely apart from it. These small slices of rural culture, now linked to the world wide web, remain remarkably unchanged in composition, financial prospects, and their knack for making do with whatever’s at hand.
For more than a hundred years, the people of Appalachia — my people — have endured economic hardship, pollution-induced disease, corrupt governments, and even violence. This is the birthplace of the Redneck Army, the beating heart of America’s coal industry, and an all-too-often forgotten chapter of the American Dream. Here, the UMWA and brave miners fought for the rights of all working people. Moonshiners thwarted revenuers. And the blood and sweat of Appalachia’s patchwork people helped fuel the American Industrial Revolution.
Now, the richest men and women in America conspire to steal away what’s left of our healthcare — cutting Medicaid and shuttering rural hospitals and clinics. These actions, whatever their so-called intent, will bring dire consequences. Less healthcare means more death. Fewer hospitals means more suffering. And fewer living Appalachians, when all is said and done, means that we have failed as a people.
Well, I say — if you intend to hand down a death sentence to the good people of Appalachia, you rotten bastards…
Then I shall have some words for you.
Fill your hands, old sons.
I’m Coyote Wallace. This is Dispatches from Appalachia. And today, we’re talking about The Dollars and the Dead: The Cruelty of Medicaid Cuts in Appalachia.
Learning the Land
Before one can begin to grasp the monstrosity of the proposed cuts to Medicaid and other government programs by the Trump administration — and what those cuts will do to the people of Appalachia — one must first understand the general layout of our region. The remoteness and near-impenetrability of our mountains have kept as many of us in as they have kept interlopers out. This rugged terrain has traditionally limited economic development and kept many aspects of early trade out of the region. The steep slopes, dense forests, treacherous soil, and broad-bottomed mountains have long disrupted efforts by the economically minded to build roads, railways, or other means of commerce.
Hell, the first stone road didn’t reach Wheeling, Virginia until 1811 — and the first road through Middlesboro, Kentucky wouldn’t exist until 1908.
Just in case you needed an idea of how slow progress can move in the mountains.
Many of the earliest settlements in these hills were supplied not by convoy or train, but by pack mule and flatboats that ferried goods up rivers that could turn treacherous in an instant. Such means of supply faced challenges both natural and criminal in origin, and it goes without saying that as many flatboat captains lost their lives to river pirates as they did to the churning waters.
Our isolation also gave King Coal — by which I mean the barons of the coal industry — plenty of room to operate. Here, sequestered from the eyes of the American public, the Appalachian people were starved, beaten, killed, and treated in ways unfit even for dogs. The coal industry was merciless in how it exploited men and plundered the land, and by keeping other economic opportunities out of the region, it only strengthened King Coal’s grip on our people.
Even as late as the ’40s and ’50s (and in some regions far beyond that), there were places without running water, electricity, or even the most basic of utilities. We are a people who still, in many cases, have grandparents who remember what it was like not to have indoor plumbing. Our region was once so starved for literacy, and so lacking in schools, that the brave Pack Librarians were dispatched to carry knowledge into the dark corners of our hills.
While the remote nature of our existence has brought many difficulties, it is also the crucible in which our culture was forged and tested. All of us who trace our roots back through the years in this region inevitably reach the point where our immigrant ancestors signed away their lives to King Coal. Forced to live in close quarters, and united by the dangers of the work and the cruelty of the paymasters, our ancestors’ cultures fused into a superheated melting pot — a microcosm of the American experiment itself. Tinker Irish shared tales of haints over loaves of Italian bread; proud Black Americans taught the banjo to Polish boys with big-eyed dreams; Welsh miners taught their German brethren the secrets of surviving the coal pits.
Our accent, which distinguishes us from both Yankee Bill and Johnny Reb, is itself the product of this cultural merger. Even the way we speak has been shaped by generations raised together in remote communities with their own rhythms, customs, and cadences.
We were made by the cruel hands of King Coal, and shaped by the isolation granted us by our mountains.
Here, with our twisting roads and stretches of darkness that may never know electric light, it can take more than an hour just to travel a few miles. Even GPS can’t reliably find an address.
Here, when seconds matter and time is of the essence, the Appalachian people already pay double — just to keep breathing.
Medicine in the Mountains
The Appalachian people, for all of our rough upbringings and hard-won self-reliance, are not without our flaws. The mortality rate from what is commonly known as the diseases of despair — drug overdose, suicide, liver failure from pills or drinking — is staggering in its scope. In these mountains, such conditions kill 36% more people than in any other region of the United States.
This depressing state of affairs is not new, nor is the disproportionate toll it takes some random fluke — as you shall see.
Compounding these diseases of despair is the fact that generations of coal industry labor, a lack of healthy food options, the absence of public health infrastructure, and limited tobacco awareness programs have left Appalachia with one of the highest rates of chronic disease in the nation. Stroke, heart disease, COPD, silicosis, and diabetes all run rampant in our communities. These illnesses tear through families. And the long-term care required to treat them traps people in poverty. That poverty, in turn, fuels even more chronic disease, creating a vicious cycle that feeds on the suffering of the poor.
But it is not only the withering touch of sickness that we in the mountains must endure.
Ever since the days of coal camps and pit ponies, even basic access to doctors and clinics has been a constant struggle. The same remoteness that once made it difficult to ship goods into our region also stymied the building of hospitals and doctors’ offices. And the coming of the modern era did not fix that — it only made the divide more obvious.
You see, Appalachia leads the nation in having the fewest specialty doctors per 100,000 people. As of this writing, we sit at a 65% lower rate of medical access than the rest of the country. Fewer doctors, fewer hospitals — fewer chances to live. For many Appalachian families, the nearest clinic or hospital may be hours away by car. Journeys for basic care cost both time and wages — and so, for many, those journeys simply never happen.
And if you need an ambulance? You will likely die.
You’ll see why that’s important in a moment.
The only thing that has served to mitigate some of this hardship is the fact that a people already battered and ignored by their own nation have found a lifeline in the Medicaid program. Here in my native Kentucky, one out of every three residents receives some form of Medicaid assistance. This help is vital — not just for the elderly seeking dignity in their golden years, but for the first-time mother sobbing through the night as her baby breathes through a ventilator.
Medicaid, flawed though it may be, has long been the thin wire holding countless Appalachians above the gaping maw of economic ruin.
And now wicked men have come to cut that wire — and let my people fall.
Death By A Thousand Cuts
When I sat down to write this piece, I thought right about here was where I would begin ripping into the Republican Party for this proposed cruelty. I intended to roast Mike Johnson for having no soul, to slather JD Vance in literary napalm and throw bricks made of words at The Orange King himself. I intended, with all fire and vigor and venom at my disposal to light into those who would build their fine mansions on the bones of my people. I would fill my pen with fire and scorch the whole foul lot for their inhumanity and callous natures.
They intend to cut more than 793 billion dollars from a program that saves Appalachian lives over the next ten years while loading it down with work requirements and every other conceivable measure meant to kick people off their healthcare. This is an act of cruelty that is difficult to imagine in its scope, and the cost will not be measured simply in voter dissatisfaction, but in death and despair that will echo for generations in these mountains.
They took our food stamps and made our children go hungry.
They took our jobs and gutted our unions so their corporate masters could line their pockets a little deeper.
Now, folks like Mitch McConnell propose that we shall ‘Get Over It’ when we are denied the basic human right of healthcare.
While you lot deserve the fire, I shall not give it to you, for I have something far more personal to answer your cuts with. I, like many of people, have long learned to carry our losses with us wherever we go. I can prove to your foul lot who believe we, the poor and forgotten, shall excuse your barbarity given enough time.
I hate doing this.
I hate you rotten bastards for making me do this.
Those that have followed my Dispatches From Appalachia know that my mother was very important to me, and she played a tremendous role in shaping me into the sort of person I am today. My mother was born in the coal camps of Wheelwright, Kentucky and she worked her whole life to climb out of that pit. She overcame poverty, abusive men, and a system that was not always kind to her. She taught me the importance of seeing beyond a man’s skin, how to be a gentleman around a lady, and the importance of standing up for the truth even when nobody else will.
My mother was the sort of woman that, even when we were low on money, would cook for all the kids in the neighborhood because not all the kids in my neighborhood got supper at night.
She loved horses and singing Dolly Parton songs badly and off key.
My mother, whose name was was Shelia by the way, Mr. McConnell, was the best goddamn person I have ever known in this world. Maybe I’m not objective in that matter, but I do believe it to be true regardless. She was not perfect, but her heart was good and there was no hate in her save for that of bullies and men who hit their wives or their horses. She had blond hair and green eyes that I see every day when I look at my Sprat.
I would walk through the fires of Hell itself just to hear her voice -one- time.
Do you know how she died, Mr. McConnell?
A hernia in her esophagus, just below the point where her breast bone was, ruptured inside of her at 3:19 am one foggy night in May.
Do you know what that entails, Mr. McConnell?
Do you conceive of what I am about to tell you?
I was awoken from my sleep by the sound of my stepfather beating on my door, his face pale and his eyes wide, as he begged me to call the ambulance because my mother was dying. I rushed to her house, the operator already on the line, and discovered a river of blood pouring out of every place in my mother that it could escape. She was still conscious you see, still awake and aware, and though the years had diminished her mind with dementia and other hardships — she knew she was in a bad way.
She was so scared, Mr. McConnell, so terribly scared. Like a child.
The nearest hospital was two towns away and had only three ambulances on call that night. All three were already out helping other people. The dispatcher told me the best thing I could do was wait by the road — so I could flag them down when they did come, and they wouldn’t overlook our driveway.
As I’ve said before, GPS is unreliable in our mountains, and that always adds time — especially when the men behind the wheel aren’t trained to know the names of our curvy backroads.
Forty-five minutes to an hour.
That’s how long it took for someone to get there to help my mother.
Do you understand what I’m telling you, sir?
Do you comprehend what it is — EXACTLY — that I am saying to you?
The best person I’ve ever known died because there are not enough hospitals, not enough ambulances, not enough doctors, and not enough nurses in these hills to take care of us all.
My mother died because men like you worry more about the dollar than they do about the graves filled by your greed.
You miserable bastards took her from me — as you’ve taken countless others — and now you propose to take even more.
You robbed my Sprat of the chance to know her grandmother.
You robbed me of the chance to show her that I became a writer.
You robbed my community of the light that my mother brought into the world.
And the only reason I’m not calling you what you really are is because she taught me not to speak that way when I’m trying to make an important point.
How does that make you Republicans feel?
Do you feel anything at all?
A Final Plea For Sanity
Today, even as I write this, there are men and women in wheelchairs being arrested in Washington. Yesterday, police were dispatched by the governor of West Virginia to break up protests as people grew angry with the impending losses. Our nation — one that survived both the scourge of slavery and the struggle of the Civil Rights Movement — now teeters on the brink of an abyss that heralds its own destruction. The very fabric of who we are, our values, and our capacity for empathy is under assault by those who would see the world remade in the image of the oligarch.
No one deserves to go through what I went through.
No one.
Red or Blue.
Our nation is not defined by the freedoms it grants, for freedom without responsibility to the less fortunate is only oligarchy under a more appealing name. Our nation is not defined by our accomplishments — what good is celebrating a man walking on the moon while children starve in the streets? We were not the first to end slavery. We were not the first to give women the right to vote. And we damned well weren’t the first to get rid of monarchs and royalty.
At its core, and at its very best, our nation is defined by our ability to empathize with and care for our neighbors. Be you Appalachian, Johnny Reb, Yankee Bill, a West Coaster, a Texan, or just a believer in the promise of the American Dream — we are defined by how we care for one another. The way we treat our sick, our poor, and our elderly is the measuring stick of our people.
Not guns.
Not Free Speech Absolutism.
Not wars won.
Not the size of our mighty military.
We are Americans — and we HELP.
Remember this warning well…
When it is your mother, your daughter, your sister, your brother, your father, or your lover, and you are waiting in the dark for someone to save them — you do not forget it when help does not arrive. You do not “get over it” when someone who could still be here isn’t anymore. You may believe that FOX News will insulate you — but I promise you, it shall not. You may believe that the Orange King inspires greater loyalty in the Appalachian heart than an Appalachian has for his own mother — but you are mistaken.
Do the right thing.
Block these cuts to Medicaid.
Save your own political careers — and maybe even your souls.
Because if you don’t, you’ll only make more people like me. And I promise you, with my last breath, I will be fighting you. I will be organizing against you. I will be in the streets spreading word of your misdeeds. I will be in the hollers with the haints and the howlin’ possums, ensuring your sins are known.
Men and women will spit on your graves for what you have stolen from them.
Children will grow up cursing your names for the parents you took from them.
Your cuts are an act of murder against my people — and we will not forget them.
We will never forget them.
We will never forget those taken from us by the likes of you.
Do you understand me?
Not ever.
Not for a month, a week, a day, an hour, a minute, or even a solitary second.
We will see you stripped of your powers.
We will see you cast down from your positions.
We will see that you harm not a single hair on a single head ever again for as long as you live.
We will fight you every step of the way — until the last breath is gone from the last set of Appalachian lungs.
“Get over it?”
Old Sons, we’ll put you under it before we get over it.
Solidarity Forever.
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