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This Article examines trends in Appalachian child poverty and wellness in the context of the Affordable Care Act ("ACA"). Appalachia is a region with mercurial definitions and boundaries, which in its broadest iteration, includes all of West Virginia and spans parts of 12 other states: Maryland, Pennsylvania, New York, Ohio, Kentucky, Virginia, North Carolina, Tennessee, South Carolina, Alabama, and Mississippi. Child poverty has plagued Appalachia for decades. Nationally, child poverty in rural areas is higher overall than in cities. A 2017 report by the U.S. Department of Agriculture explained that the rural rate was nearly one-fourth (23.5%), while the urban rate was just over one-fifth (20.5%). The report also explained that pockets of certain states are classified as "persistent poverty counties," where the poverty rates run long and deep. Roughly 85% of those counties are in non-metro areas, and a significant swath of them are in Appalachia. Compounding its vulnerability to widespread poverty is Appalachia's persistently high concentration of child residents.