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Rural Pain, Republican Gain

How the Republican Party Is Killing Rural America and Why Democrats Are Blamed

Rural Pain, Republican Gain

How the Republican Party Is Killing Rural America and Why Democrats Are Blamed

An eye-opening look at how Republican policies have affected health outcomes in rural communities and why poor, rural white voters are turning to the Republican Party—not despite this harm, but because of it.

Over the last four decades, the health of rural Americans has been in free fall. Just as opioid and gun deaths have ripped apart rural communities, hospitals have closed at alarming rates, leaving millions desperately far from care. At the same time, voters in struggling rural communities have increasingly come to vote for the Republican Party.

In Rural Pain, Republican Gain, Michael E. Shepherd demonstrates that these two trends are closely connected. At both the federal and state levels, the Republican Party has increasingly enacted policies that worsen rural health. Rural voters are not indifferent to this development (quite the contrary), but they misassign blame, in part, because the Democratic Party is more commonly associated with health-related policy initiatives and has ownership of health as an issue area. Republican politicians can reap rewards from their own destructive policies by appealing to the shared grievances of rural people.

Shepherd draws on new, wide-ranging data, including in-depth studies of the opioid epidemic, hospital closures, and COVID-19. In so doing, he quantifies the harm of Republican policymaking and its disproportionate effect on rural communities, recasting how readers understand growing Republican support among less healthy, lower-income rural white Americans.


368 pages | 23 halftones, 23 line drawings, 12 tables | 6 x 9 | © 2026

Chicago Studies in American Politics

Political Science: American Government and Politics, Political Behavior and Public Opinion

Reviews

“In this utterly absorbing, important work, Shepherd explains why rural White voters support Republican politicians whose policies harm them. Although rural voters have attracted a great deal of attention from sociologists, journalists, economists, and political scientists in recent years, Shepherd offers the most well-developed theory and certainly the most comprehensive empirical analysis of White rural attitudes and voting behavior. In the process, he not only demolishes existing explanations but also helps us understand the nature of American politics in the present era. A masterclass in making the most out of available data and a true tour-de-force.”

Andrea Louise Campbell, Massachusetts Institute of Technology

"In this brilliant, revelatory book, Michael Shepherd explains why America’s rural electorate sides with Republicans even as they peddle deadly medicine. Rural pain may be Republicans’ gain, but it is American democracy’s loss."

Jacob S. Hacker, Yale University

“Optimists about democracy like to believe it will produce a virtuous circle: elected officials strive to govern well because voters will reward them for doing so. In this brilliant and troubling book, Michael Shepherd explores a different scenario: in an age of political distrust politicians can win by running against government, and when their own policies make things worse the voters reward them. A vicious circle supplants a virtuous one. All who care about the vitality of American democracy would do well to confront Shepherd’s sobering analysis.”

Paul Pierson, author of "Partisan Nation: The Dangerous New Logic of American Politics in a Nationalized Era"

Table of Contents

1. Introduction

Part I. Republican Policies and Rural Health
2. The Right Against Life
3. Snake Oil States

Part II. Race, Place, and the Rural Right
4. Under the Elephant: How the Rural Sick and Poor Became Republicans
5. Place and Prejudice: How Rural Identities Undermine Health

Part III. The Rural Health Spiral in Three Acts
6. Deaths of Deceit: The Politics of the Opioid Epidemic
7. Dying for the Donald: The Politics of the Rural Hospital Crisis
8. COVID Comes to the Countryside

9. Conclusion

Acknowledgments
Notes
Bibliography
Index

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