Medicaid expansion was a key Obamacare pillar, one a number of red states opted out of.

https://www.kff.org/health-costs/issue-brief/rural-hospitals...

> Among rural hospitals in non-expansion states, median operating margins were 2.1 percent during the July 2021-June 2022 period and were -0.7 percent when excluding documented relief funds. In Medicaid expansion states, median operating margins dropped, but remained positive even after excluding documented relief funds.

A huge reason hospitals lose money is due to the amount of charity care they provide. There is a saying that "Reagan instituted universal healthcare in the US, he just didn't institute a way to pay for it." That is, during Reagan's time, laws were passed that required hospitals to provide emergency care regardless of an individual's ability to pay. But no laws were passed then that actually funded that mandate.

So in rural areas where you have more people in poverty, if they had health insurance hospitals would be better able to actually collect payment for the legally required services they provide.

Just over a dozen red states refused the Medicaid Expansion, which would have offered more federal health dollars to their states. Yes the Affordable Health Act was just a band-aid on our for profit health insurance system. Our country spends over 30% on health insurance administration before you count all the billing effort by the medical providers. We have out 27% without any insurance and many more with limited coverage. The money is already there this is a rare example where nationalizing would surely safe money. The thing that should be able to help even the better off is that it should eventually reduce the strain on our emergency rooms. No system would be perfect but our system is about as far as can be from supporting individual health.

The affordable care act and medicade are programs to pay hospital bills for people. Hospital income comes from someone paying hospital bills sent to people who get medical care. Since those programs pay the bills for the people who get treatment, the hospital gets its income.

A big drain on hospitals are treating uninsured people who they can't reliably collect payment for treatment from. Expanding insurance through public exchanges and wider employer healthcare requirements plus bringing more people on to Medicaid decreases the number of people who are uninsured. There's also the effect that if you catch issues with diseases sooner they're usually cheaper to treat for obvious reasons, same goes for chronic issues that may be poorly managed because the patient can't afford to go to a doctor regularly or keep up with their medication.