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.