Ms. Connor is a mother of six children. A grandmother of twice as many. She was raised on a farm, knows the meaning of hard work and reads her Bible daily. Unexpectedly, she suffered a stroke at the top of her staircase and was found some time later at the bottom of it. She was rushed to the closest hospital 42 miles away. By the time she made it to the emergency room, she started to experience a second stroke. The urban hospital did its best, but she would not survive. Although this case would be classified as an expected mortality, her family was left wondering whether she might still be with them if she had had better access to stroke care closer to home. When it comes to stroke, the fourth-leading cause of death in the U.S., every second matters.
Rural America is at another critical moment, and families like the Connors need our help. To truly make rural America healthy again, the nation must commit to directing the bulk of the $50 billion federal Rural Health Transformation (RHT) funds straight to rural healthcare providers like rural health clinics and critical access hospitals.
Even though the RHT Program offers a tremendous opportunity to improve the health, stability and economic future of rural communities, it won’t be enough to make up for Medicaid cuts. In Illinois alone, there are 85 rural hospitals — nearly 30% operating at a deficit — and most patients are on Medicare or Medicaid.
It’s my understanding the RHT Program’s design is to clearly prioritize sustainable access to care, support providers, help with workforce development and facilitate the modernization of rural health delivery systems. Yet, I am joined by many rural hospital leaders who feel that unless the majority of RHT dollars reach the rural providers who deliver care daily, the program will fall far short of its transformative promise. I sure hope we are wrong.
We must remember that rural hospitals are not simply rural hospitals. They are economic anchors, emergency response hubs and essential sources of local stability. When a rural hospital closes or ends services, the entire community suffers:
- Loss of emergency and trauma access
- Increased maternal and infant health risks when OB service lines close
- Reduced chronic disease management
- Loss of jobs and tax base
- Decline in business investment and population retention
Unfortunately, far too many hospitals and systems like my own in rural communities are forced to face this decision frequently due to inadequate revenue generated from specialty services and/or declining populations. Direct investment in rural providers prevents these cascading harms and ensures that essential services remain available where they are most needed. In addition, direct funding aligns with the RHT Program’s intent.
The RHT Program authorizes states to use funds for:
- Payments to rural healthcare providers
- Workforce recruitment and retention
- Technology modernization, including telehealth, AI and remote monitoring
- Prevention and chronic disease management
- Training and technical assistance
- Improving IT infrastructure and cybersecurity
These uses could and should support direct patient care. To honor legislative intent, funding must strengthen rural health delivery and not be diverted toward nonclinical or distant private equity or venture capital-backed enterprises, such as Amazon, Berkshire Hathaway, JP Morgan and Walmart.
The following eight imperatives outline a clear path forward. Each depends on rural providers as the operational backbone; without stable, directly funded hospitals and clinics, none of these reforms can be implemented at scale.
- Develop a comprehensive rural workforce strategy. No transformation of rural healthcare is possible without a strong workforce. Key strategies include the expansion of rural primary care residency programs. Students from rural backgrounds are significantly more likely to practice in rural communities when linked to rural residencies, but we know physicians tend to practice where they train. And 98% of Medicare-funded residencies are in urban hospitals, leaving rural communities without a sustainable pipeline. Redirecting funding toward rural residency development is critical. We need to be more intentional about recruiting medical students from rural areas. Strengthening programs that identify, support and educate rural students increase long-term provider stability and improve local health outcomes.
- Increase primary care reimbursement. Primary care remains undervalued despite its vital role in a risk-based, prevention-focused health system. Competitive compensation is necessary to attract students who might otherwise pursue more lucrative specialties. We need to expand loan repayment and J-1 visa programs. Loan forgiveness tied to rural primary care service and more flexible visa pathways for international physicians can quickly strengthen rural workforces.
- Strengthen current hospitals that are keeping rural communities alive. Our Federally Qualified Health Centers (FQHCs) have long been a bedrock of support. FQHCs are the safety net for millions of rural residents. Enhanced funding sustains essential primary care, behavioral health and dental services. We must stabilize rural hospitals through targeted reimbursement reforms, such as increasing the share of Disproportionate Share Hospital (DSH) and 340B payments. Require large urban systems, especially those receiving specialty referrals from rural communities, to contribute financially or in-kind back to rural health.
- Go beyond the hospital and clinic walls. Rural communities face structural barriers that directly affect health outcomes. To help alleviate these challenges, funding should support Community Health Workers (CHW). CHWs strengthen prevention, patient navigation, communication with providers, data collection and chronic disease management while creating local jobs.
- Boost Rural Emergency Medical Services (EMS). Rural EMS is often under-resourced and understaffed. Policy action is needed to adequately fund and support rural communities with necessary measures like salary support, loan forgiveness and tax credits to help with EMS staff recruitment and the purchase of more ambulances.
- Expand broadband for underserved communities. Often cited as an opportunity for improvement, high-speed internet is essential for telehealth and virtual specialists, home monitoring technology, online education and digital literacy, and community economic development. It has been long argued that a national–state–private partnership, with income-based vouchers and community digital literacy training, is essential for success. This type of partnership would also lead to sustainable economic development.
- Include managed care plans as part of the solution. Medicaid managed care and Medicare Advantage play major roles in rural health, as more than two-thirds of states use Medicaid managed care; over half (55%) of Medicare-eligible seniors are in MA plans; rural areas have a higher share of older adults; and many rural residents are dual eligible for Medicare and Medicaid. These plans should be required to:
- Increase reimbursement to rural hospitals.
- Collaborate on joint rural health initiatives.
- Directly invest in social determinants of health.
- Work with state and federal agencies to strengthen local care capacity.
- Federal and state governments must take a more aggressive role in supporting rural healthcare hubs, such as rural health clinics, critical access hospitals, public health departments and community agencies. This coordinated model will enhance impact, build economies of scale and ensure rural residents receive more coordinated, integrated care.
If I can be so bold, I would also contend that these models maintain access to care when full inpatient services are unsustainable, preventing “care deserts.”
A call to action: fund allocation matters
The RHT Program offers the most significant opportunity in decades to help reverse the long decline in rural healthcare. But the path to success is contingent on the funds being given directly to actual rural providers.
The majority of RHT funds must reach rural providers who deliver care, sustain access and anchor their communities.
Strengthening rural hospitals, clinics and caregivers — while simultaneously investing in workforce development, broadband, economic revitalization, transportation and social determinants — creates a resilient ecosystem where rural Americans can thrive.
Rural Health Transformation is not just a healthcare initiative. Families like the Connors and others depend on the support. It should be viewed as a moral imperative to securing the future of our rural communities, to truly make rural America healthy again.
Damond W. Boatwright is president and CEO of Hospital Sisters Health System, a Catholic nonprofit with 13 hospitals and 130 care sites in Illinois and Wisconsin.
At Becker's 4th Annual CEO + CFO Roundtable, taking place November 2–5 in Chicago, more than 1,500 hospital and health system executives tackle decisions that determine whether organizations thrive or merely survive: protecting margins under cost pressure, choosing where to grow, renegotiating payer relationships, stabilizing the workforce and proving real ROI on technology. This is where leaders work through them together, face-to-face. Apply for complimentary registration now.
