Diverse Stakeholder Perspectives on Rural Health Care Reform in a U.S. State That Rejected the Affordable Care Act: A Case Study


  • Molly Vaughan Prengaman Boise State University
  • Dorinda L. Welle University of New Mexico
  • Nancy Ridenour Barnes- Jewish College
  • Keith J. Mueller University of Iowa




Purpose:  This case study identifies rural health care stakeholder perspectives on the Affordable Care Act (ACA) and describes the health policy context in Idaho, the only state in the United States to reject Medicaid expansion yet develop a state-run health insurance exchange.

Sample: The sample included 20 rural health care stakeholders, including clinicians, elected officials, state agency administrators, health care facility administrators, and interest group leaders.

Method: A single-case study of stakeholder perspectives on the ACA and rural health care access in Idaho was conducted from 2014 to 2016. Data sources include qualitative interviews with 20 rural health care stakeholders and public documents relating to the ACA and rural health care from Idaho governmental and nongovernmental entities’ websites.

Findings:  Since the 2010 passage of the ACA, opposition to “Obamacare” became associated with a conservative stance on health care reform. However, in this case study, diverse health care stakeholders who criticized aspects of the ACA identified several components of the policy, including Medicaid expansion, as essential in ensuring access to rural health care. Some stakeholders called for federal legislation authorizing nurse practitioners to practice as independent primary care providers. However, the politics of medical sovereignty present challenges to this relevant strategy and to full implementation of Idaho’s Nurse Practice Act for increasing access to primary care in a rural state.

Conclusions: The case study approach can be effective in illuminating stakeholder perspectives and policy strategies that may fall outside of polarized health care policy debates. Examination of the state-level political context of rural health care must consider concurrent battles about state sovereignty over health care policy and professional-clinical battles about sovereignty over primary care.

Keywords: Affordable Care Act, case study, Idaho, rural health care policy, advanced practice nurses

DOI: http://dx.doi.org/10.14574/ojrnhc.v18i2.514    

Author Biographies

Molly Vaughan Prengaman, Boise State University

Associate Professor, School of Nursing 


Dorinda L. Welle, University of New Mexico

Assistant Professor, College of Nursing 

Nancy Ridenour, Barnes- Jewish College

Dean, Goldfarb School of Nursing & President, Barnes- Jewish College


Keith J. Mueller, University of Iowa

Department Head & Gerhard Hartman Professor in Health Management & Policy