Carolyn Sheridan, right, is watching the health insurance reform debate closely. As nurse director at Spencer (Iowa) Hospital, she has seen the financial impact of the uninsured on the bottom line. As clinical director of The AgriSafe Network, she knows the health impact on underinsured farmers.

"Less coverage usually means less preventive care, a later diagnosis, and a more negative prognosis for patients," she says. "It often means bad debt for hospitals."

Recent surveys underscore rural America's stake in the reform debate. A 2007 report by The Access Project shows that 33% of rural residents are self-employed, compared to 21% in urban areas. A total of 33% of farmers buy individual insurance vs. 8% of Americans.

As small business owners, farmers also struggle to insure employees. Over the last decade, premiums paid by small businesses jumped 100%. According to The Access Project, small business employees are twice as likely to be uninsured.

"Health reform is the most important issue for the majority of small businesses," says John Arensmeyer, CEO of Small Business Majority, Sausalito, California.

Two decades ago, the top 10 insurers covered about 27% of all insured Americans. Today, four companies cover about half of everyone with private insurance.

Wall Street expects insurers to keep the medical loss ratio as low as possible. Last year's PricewaterhouseCoopers report shows the average loss ratio fell from more than 95% in 1993 to about 80% in 2008.

"Insurance companies often deny coverage to individuals with preexisting conditions or charge high premiums and co-pays," Sheridan says.

Many policies exclude screenings and maternity care. "I was rejected on my husband's plan when I became pregnant," says Suzanne Caspell, Grinnell, Iowa, farmer.

After 60 years of debate, health reform has reached a strategic crossroads. In 1975 total health care spending was 8% of the economy; today it consumes about 16%. It's projected to rise to 20% by 2016.

A July survey of 200 Iowa and Nebraska small businesses by The Small Business Majority and Nebraska's Center for Rural Affairs shows 69% support a choice of a private or public health insurance plan.

Not-for-profit co-ops are an option. The Farmers Health Cooperative of Wisconsin, launched in 2004, is a potential model.

As more rural factory jobs are lost, the ranks of the uninsured are likely to swell. At the Wise County (Virginia) Fairgrounds last summer, 2,700 people from 16 states lined up at a cattle barn for free care given by Remote Area Medical volunteers. All were uninsured or underinsured.

Photography: Euvonne Sheridan