In Heartland: A Memoir of Working Hard and Being Broke in the Richest Country on Earth, Sarah Smarsh describes how Reagan-era policies pushed her family from working class to working poor, mapping their increasingly impoverished lives against the demise of the family farm, the defunding of public schools, and—as she explores in this adapted excerpt—the dismantling of public health care. 1

My childhood in Kansas happened to coincide with the moment that health-insurance and drug companies essentially merged with the nation’s for-profit hospital system, creating costs that were prohibitive for uninsured families like ours.2

In our parts, health care was rare not just because of escalating costs but because of our remote location. We didn’t put much faith in doctor visits, anyway. We told ourselves that we didn’t need doctors, but the truth was that we couldn’t afford them. If you had a real health emergency, you were liable to be dead before some small town’s ambulance made it down the muddy, sandy ruts of our dirt roads. But a decade-old dropper of stinging red iodine would fix most cuts, so we went on like everything was fine.3

By the time I was born, rural hospitals were closing and American health care had been transformed into a slick big business in the urban centers. Being the youngest of six, my dad was the only baby that Grandma Teresa gave birth to in a hospital rather than in the farmhouse where they were raised. But when I was a kid, the old ways of country doctors were still hanging on in places like ours—places that, I would later learn, much of the country thought endured only in movies and books.4

As an infant, one night I came down with a dangerously high fever. My parents rushed me miles along bumpy roads to the rural home of Dr. Joseph Stech, a small-town physician who still sometimes made house calls. Dr. Stech had delivered me at a big Wichita hospital, but as I grew up he was still charging a modest fee for a visit at his 19th-century office on Main Street in nearby Andale. He gave me all my immunization shots and prescribed penicillin when I got strep throat.5

We didn’t have health insurance, but my parents could afford Dr. Stech’s fees. When I came down with chicken pox the day before the Christmas play at school, I cried next to our kitchen telephone while he told Mom over our shared rural party line that I had to stay home.6

Once in a while, we’d drive past what to my eyes was a grand mansion on a hill, and my parents would say, “That’s where we took you when you were a baby and had a fever in the middle of the night.” No one remembered what Dr. Stech did to save me. For my family, the more important takeaway was that I just wasn’t meant to die that night.7

“The good Lord will call you home when He’s ready,” Grandpa Arnie liked to say. “When it’s your time, it’s your time,” people repeated. The Lord wasn’t ready, and it wasn’t my time.8

I would develop a habit of burning up, though. Until I was 2 or 3, Dad told me years later, severe fevers came and went. They didn’t rush me to Dr. Stech again or even to a Wichita hospital; the issue had ceased to seem an emergency, and every doctor visit costs money. Instead, they put me in a small tub of cold water.9

“We’d splash a little water on you, and every time you were good to go!” Dad said.10

I had lived, and that was all that mattered. The medical industry worked by naming ailments and prescribing medicine, but the sort of healing we knew operated in mystery. We didn’t know the word “placebo” but figured that’s all survival ever was, until God called you home. Mind over matter.11

But a few years down the road, people like us would face health epidemics that cried for professional care: obesity, diabetes, methamphetamine addiction, sepsis from what we called a “bad tooth” with infection at the root, abuse of opioids overprescribed by the same doctors who were supposed to help. When I was a young adult, I would see all those ailments inscribed on the bodies of my extended family: grooves and scabs on their faces, expanding waistlines, swollen feet, missing teeth, the erratic shakes of a body craving a Lortab fix. By then, the same forces of privatization that had all but shuttered state mental-health hospitals had compromised an entire system of general care to such an extent that even the middle class couldn’t afford treatment.12

What was still preventable in the 1980s would, in a couple of decades, become manifest; what was once treatable would become deadly. I’m not sure my immediate family’s brushes with death when I was a kid—Mom’s hemorrhage in childbirth, Grandma Betty’s collapsed lung, Dad’s chemical poisoning—would be survived today. Mom would have been less healthy going into labor, Grandma would have been sent home too soon for lack of insurance, Dad would have been given a cheaper and less effective treatment. The mortality rate for poor rural women, in particular, has risen sharply over my lifetime.13

Health insurance had been around for a long time, of course, but the power of that industry had swelled up fast, transforming access to care and all the costs that come with it. Grandma Betty would forget a lot about giving birth to Mom, but she always remembered how much she owed when she left the hospital: $12.14

“That was hard to come up with then,” Betty told me. “I handed them the money and told her, ‘You’re all mine now.’”15

That was at a military hospital in the 1960s. When I was in my 20s, it took me two years to pay off an emergency-room visit, and I had employer-based health insurance at the time.16

It’s a hell of a thing to feel—to grow the food, serve the drinks, hammer the houses, and assemble the airplanes for people with more money to eat or drink or live in or fly around in, while you and the people you know can’t afford to go to the doctor. Even though no one complained or maybe even realized it was a problem, I could feel that the people around me knew they were viewed as dispensable.17

While our family struggled to improve our situation with our intelligence, creativity, and grit, manual labor changed our bodies. Wrinkles and sunspots from years spent working in the fields beneath an unobstructed sun in the big Midwestern sky; limbs or fingers bruised, scarred, or lost altogether to big, churning equipment; back problems from standing on factory floors making motions as repetitive as the conveyor belt.18

The physical markers of our place and class were so normal and constant, from my vantage, that I never thought to question them: the deep, black bruises ever-present beneath my dad’s fingernails; the smoker’s rattle in Grandma Betty’s lungs; the dentures she’d had since her late 20s; the painful sunburns I sometimes got on my young corneas working outside against a hard slant of light.19

Occasionally, though, I detected something curious about my family’s bodies. Once, concerned, I rubbed a bump on Grandma Teresa’s nose. She explained it was where a doctor had cut off a bit of skin cancer, a common ailment among farmers out in the sun all day. Grandpa Chic’s face, too, was a map of where the sun had been every day of his life. Like Teresa, he was skinny and long-limbed. His overalls, which Teresa had washed for decades until they were worn thin, hung from his body like a sheet on the clothesline.20

Clothes didn’t hang from Grandpa Arnie but rather stretched across him. He was as tank-like as his tractors and combines. He was of average height but had the shoulders of a lineman, a bovine torso, and a round belly that threatened the snaps on the thin, brown plaid shirts he wore to threads. His hands were tremendous clamps of callouses and bruised fingernails and seemed too large even for his powerful arms. His hands handled rope with no gloves and swatted wasps on his shoulders. He wore sideburns on his wide jaw, and a fine patch of brown-gray hair swept across an otherwise bald head connected to a neck so thick Grandma Betty could never find collared dress shirts that fit around it. Most days he wore the top of his shirts undone to leave way for his neck, which I often studied.21

It didn’t look like other necks. Not like my mom’s, pale and smooth beneath long brown hair, or even my dad’s, darkened from work in the sun but still youthful. Grandpa Arnie’s neck was something else: serrated on the back, reddish-brown, with deep grooves like the rough sediment in creek embankments that revealed the geological strata of epochs. When he tilted his head back, his neck wrinkled into mounds of thick flesh.22

I rubbed his shoulders when I was at their farmhouse and he came in from work to sit at the table with instant iced tea. Almost every evening, I dug my thumbs into his or Grandma Betty’s or my parents’ shoulders, which always seemed to be aching. Once, while kneading the knots in Arnie’s enormous back, I asked about his neck.23

“Why does it look like that?”24

“Like what?” Grandpa Arnie said.25

“Like there are scars in it,” I said. Grandpa laughed and told me someone had accidentally hacked him on the back of the neck with an ax while chopping wood. I was so little that I didn’t realize he was joking. The real cause of the deep, jagged ruts, of course, was a lifetime on the Great Plains, pulling plows through fields in the hard sun and sand-filled wind or feeding cattle while stinging ice pellets rained down.26

People today would call us “rednecks,” but I didn’t hear that word much growing up. When I did, I understood it as an insult—a city person calling a country person backward. Or, occasionally, a country person calling another country person trashy.27

I had no idea about the word’s origins back then, and linguists still aren’t certain. It likely refers to a white field worker’s neck burned by the sun. In the early 1900s, striking coal miners took the term when they wore red bandannas around their necks in solidarity. And white-supremacist politicians in the South have used the word to pit poor whites against poor blacks.28

Today, the term is leveraged to disparage an entire class and place. It is printed on baseball caps, even on baby bibs sold at Walmart, and worn by people with seeming pride.29

As with other terms that have derogatory histories, reclaiming “redneck,” “trailer trash,” “hillbilly,” and so on is a sort of cultural self-defense, I guess. That is understandable enough. But if such a trend had existed when I was little, Mom wouldn’t have put me in a shirt with any of those words on it.30

When I got to be a little bigger, there was a hit country song on the radio called “Trashy Women.” Once, riding with Mom in her car, I sang along with the lyrics: “I like my women just a little on the trashy side.” The male singer went on about how he was raised in a sophisticated, well-to-do household but was turned on by poor women, by waitresses in tight clothes and too much makeup. Mom winced and told me not to sing to that song. She changed the station.31

We might have been born poor, and we might have been born female—two strikes against a body in the world. Mom might have looked like something that men wanted to possess, and I might have been an unwanted child—one more strike against each of us navigating an already perilous life. But Mom knew she wasn’t trash. And she knew her daughter wasn’t, either.32