A lot more could certainly be done. But it all costs money and no one spends any more than they have to.

I worked on some coal mine reclamation projects when I was employed by one of the Southeastern Land Grant schools and I think we were able to improve some things -- particularly in the areas of topsoil salvage, spoil mixing (some rock types for reasons of texture and chemistry just naturally weather to a more desirable soil parent material), and (top)soil amendments. But it would admittedly have been much more expensive to implement all of the things that we recommended. And some of our recommendations were not politically popular (sewage sludge amendments). So, in the end, what you end up with are a lot of half-measures.

Bottom line: It's just damned hard to create a healthy vegetative cover with only bulldozed rock and a hydro-seeder. Mother Nature will eventually finish the job for you but on her own time. Meantime, you're living with a destroyed ecosystem, you've grossly increased rainfall runoff (which, in the narrow stream valleys characteristic of the Appalachian Region is just what you don't want to do) and you've created a lot of just plain ugly places.

Sure...

But why should I care?

I'm being a bit smarmy here sure, but I really dont know why I should care about mountaintops being scarred in the middle of nowhere. Isn't this just an aesthetic issue?

Well, I guess that depends on what you value. In my mind, it is rarely a question of simple aesthetics. The Appalachian corrider is, for instance, an important flyway for migratory songbirds -- songbirds that help to control insects in wood-producing forests in Appalachia or in New England or South America. It also happens that the Appalachian Highlands sit atop the sub-continental divide between the Atlantic and the Gulf and so essentially form the headwaters region for much of the freshwater runoff in the Southeastern US. So, there are water quality issues, as well.

But your question does, I think, reflect our attitude, as a society, about things that are "out of sight, out of mind." The coal-bearing portion of the Appalchians has been made, in effect, a national sacrifice zone. But that was well underway before anyone thought about Peak Oil or Climate Change and I expect that process to continue.

But why should I care?
I'm being a bit smarmy here sure,

No, you've already emotionally invested in seeing Fission Power be the "way to go", so you don't care.

in the middle of nowhere.
Your 'middle of nowhere' is someone else's somewhere.

Isn't this just an aesthetic issue?

No. Educating you on heavy metal issues is pointless however, as you have shown a desire to remain ignorant.