WILLIAMSTON, N.C. — Two years after her brother’s death, Debra Pierce still wonders whether the 50-year-old would have survived his heart attack if her local hospital hadn’t closed.

“The sad thing is we’ll never know if he could have been saved that night or not, because we don’t have a higher level of care in this county,” Pierce said as she stood outside the mobile home where she last hugged her brother.

Emergency crews from a neighboring town worked on Stanley Sears for a half hour but couldn’t revive him for the long drive to the closest hospital, records show.

In the tall grass — which would be mowed if Sears were still alive — Pierce swiped through the photos on her phone. She stopped at a picture that showed Sears smiling. Pierce chuckled and then sighed: “Bless him.”

The local hospital had closed a year before Sears’ death, leaving behind a gutted healthcare system. Martin County does not have paramedics on its ambulances, and it can be 20 miles or more to the closest — and often overcrowded — emergency rooms.

The healthcare gaps in Martin County illustrate the finite reach of a $50 billion rural health fund that Republicans crafted to strengthen support for President Donald Trump’s signature tax and spending measure, the One Big Beautiful Bill Act, last year. Though the cash has not been doled out, Republican candidates in competitive midterm elections — including the closely watched battle for the congressional district that encompasses Martin County — are casting the fund as a lifeline that will shore up critical rural health services across America.

The money has been highly anticipated in North Carolina, where most residents live in rural counties. Pierce, a Republican who blames county officials for the hospital closure, said she has faith Trump will help them. “Old man’s doing his job up in there,” she said.

On paper, Martin County — home to about 22,000 people — looks like a top contender to receive at least some of the $213 million that’s been earmarked for North Carolina.

Yet County Manager Drew Batts said it won’t be the answer for his residents.

“The $50 billion is not something that is specifically going to help our situation,” Batts said as he walked into the shuttered hospital in April. “It’s not going to help us get this place reopened.”

Martin County won’t get direct relief from Trump’s rural health fund — because its hospital isn’t open. North Carolina is distributing the money among existing health and social service organizations. Plus, federal regulators on how much can be spent on construction and building renovations.

‘We Can Only Pray’

Martin General Hospital closed abruptly in 2023, surprising employees and shocking patients, who had to be wheeled out on stretchers and transported elsewhere to finish treatment. The closure even stunned local elected leaders, who say the company operating the county-owned hospital, Quorum Health, did not notify them it intended to shut down operations and file for bankruptcy. Quorum spokesperson Lisa Anderson said the company had told county commissioners of the hospital’s ongoing financial challenges.

Politicians have spent the years since trying to reopen the hospital, with county taxpayers pouring an estimated $2.9 million into maintenance, utilities, and other costs in the hopes of resuming operations, Batts said.

The county is now considering spending at least $1.5 million, he said, to create two higher-level paramedic units with quick-response vehicles, specially equipped with electrocardiogram equipment or other “advanced lifesaving support.”

Pierce said she is praying the county can add paramedics and reopen the hospital.

“There’s some answered prayers happening every day,” she said. “So, we can only pray and hope, you know?”

‘They Just Want To Not Die’

With its nine hospitals, the region’s largest health system is ECU Health, connected to East Carolina University. The system has become a de facto safety net for 29 counties. Batts and Brian Floyd, the Greenville-based system’s chief operating officer, have lobbied state and federal lawmakers, walking them through the shuttered hospital and asking for help.

“It’s a real healthcare crisis that has already proven itself to have lost lives that perhaps didn’t have to be lost,” Floyd said. “They just want to not die because there’s nowhere to go when you have an emergency.”

Eleisa Ann Evans drove 2½ hours from a small town near the Outer Banks on a recent evening so her aunt could get care at an ECU Health ER in Greenville. Once there, Evans said, staff told her to leave her 79-year-old aunt in the waiting room and wait outside because of capacity issues.

Evans said she was outraged at the way the staff treated her. She said she had been standing behind her aunt’s wheelchair while inside and “wasn’t using nobody’s chair.”

With Martin General gone, all the surrounding counties are “also in jeopardy,” Floyd said. “No one knows what to do” with that large of a healthcare “desert,” he said.

What healthcare is left in the county includes one urgent care center, run by a private company, and a nonprofit health clinic, operated by Agape Health Services, which accepts patients from five counties and plans to build another primary care clinic to meet demand.

ECU Health signed a letter of intent to reopen Martin General as a rural emergency hospital that would provide outpatient care as well as an ER. Under the terms of the deal, Martin County would pay to refurbish the hospital, and the North Carolina General Assembly would have to give ECU Health $210 million, of which $150 million would pay for the construction of a new inpatient tower at ECU’s Beaufort Hospital.

The health system, through its affiliate , won a portion of North Carolina’s $213 million first-year payout from the rural fund. But the federal money can’t be used to reopen Martin General, Floyd said.

The five-year Rural Health Transformation Program is slated to be delivered in $10 billion annual increments to states, which applied and competed for the money.

North Carolina’s plan creates a that allots money to six large regional leads, including nonprofits such as Access East. Those hubs will distribute money to local entities and coordinate broad initiatives such as improving primary care and fortifying the healthcare workforce, as well as developing “digital solutions,” according to the state’s .

An Election Issue

The lack of emergency care in the region has emerged as a top talking point in a close U.S. House race between Rep. Don Davis, a Democrat who represented the district when Martin General closed and is seeking his third term, and Republican Laurie Buckhout.

The rural health fund was added at the last minute in 2025 to win votes for the One Big Beautiful Bill Act, which is expected to reduce federal Medicaid spending by more than $900 billion over a decade — cuts that are projected to hit rural hospitals and clinics especially hard. Rural health executives say the fund won’t come close to offsetting those losses.

Matt Mercer, a spokesperson for the North Carolina Republican Party, called the rural fund a “once in-a-generation opportunity” for the state.

But U.S. Sen. Thom Tillis, who was one of three Republican senators to vote against the bill — and who announced shortly before the final vote that he planned to retire from Congress — warned of devastating consequences ahead for healthcare in his state.

Buckhout, who declined an interview, plans to attack Davis — a vulnerable incumbent whose district was recently redrawn to favor GOP candidates — for voting against the bill.

“Martin County lost its hospital on his watch, and he still opposed the funding meant to help communities like it,” Buckhout campaign spokesperson Stephen Gallagher said in a statement to ºÚÁϳԹÏÍø News. The campaign did not respond to additional queries about her plans for healthcare access, if elected.

Davis, who signed from lawmakers in support of North Carolina’s rural health fund application, said the money “is essentially putting a band-aid on a much, much broader situation that needs dire help.” He has that would increase Medicaid reimbursements for rural hospitals, though it has not moved forward.

During recent testimony on Capitol Hill in Washington, ECU Health CEO Michael Waldrum said his system expects to lose a billion dollars over the next 10 years from the looming Medicaid cuts.

Overnight Waits for Emergency Care

The region’s emergency rooms offer a stark glimpse of a healthcare system in crisis.

Martin General’s ER treated annually before it closed, according to state data. A sign still hangs in the staff break room showing that 23 patients were seen in the ER the day it closed.

ECU Health, which owns all but one of the rural hospitals around Martin General, reported a 132% increase in its daily ER visits since the hospital’s closure. The company’s nearly 1,000-bed hospital in Greenville, about 40 minutes from Williamston, is the state’s only Level 1 trauma center east of Raleigh.

The Greenville hospital’s median patient ER wait and treatment time was nearly 4½ hours, according to the most . That’s longer than 96% of thousands of hospitals reporting nationwide. The wait times “don’t reflect poor care,” ECU Health spokesperson Brian Wudkwych said in an emailed statement. He said the system’s ERs treat nearly 300,000 patients annually.

While the system has seen an increase in Martin County patients, the wait times primarily stem from shortages of inpatient and behavioral health beds, Wudkwych said.

Floyd, the ECU Health chief operating officer, said many rural patients who arrive at the system’s ERs have multiple chronic conditions that require longer visits. Often doctors start treating one problem and then find the patient’s “blood sugar is out of control, your hypertension is far out of control,” he said.

ECU staff encourage people who are not too sick to skip Greenville and, instead, seek care at one of the system’s community hospitals, which aren’t as busy, Floyd said.

A security officer guarded the Greenville emergency department’s doors on two nights in April. The “capacity notice” sign near the entrance meant family members of patients had to wait in cars or on benches outside.

“We’ve only been here six hours,” Tonya Miles said after bringing her mother for a potential blood clot in her leg. The family had left the day before after waiting for two hours, because her mom “wasn’t prepared” for such a delay in treatment, Miles said.

On another evening, Olivia Lewis said she had brought her mother two nights previously and left without care after their wait stretched from 10:30 p.m. to 7 a.m.

“She tore off her hospital bracelet and said: ‘I’m out. I’m done,’” she said. Now, they were back.

On a recent Friday in Martin County, Vannessa Little was sitting at a McDonald’s with her kids just down the street from the closed hospital. Little pointed to one of her girls and wondered how her care would have been different if the hospital had been open.

Her daughter, then 6, suffered severe burns over 30% of her body in 2024, and the journey to treatment was “just crazy,” Little said. An ambulance arrived at her Williamston home from neighboring Bertie County to transport them to ECU’s Greenville ER.

“That was a long time,” Little said of the 30-mile drive. The girl was ultimately airlifted more than 100 miles to Chapel Hill. Little said she hadn’t heard of Trump’s rural health investment. “The only changes that people are making is they’re taking away everything.”

She voted against Trump in 2024 and said she didn’t think she would vote this year.

“It’s a waste of my time.”

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“They’re the folks that work at restaurants. They’re the teacher’s aides,” said Starr, a registered nurse who became Open Door’s chief executive more than six years ago. Those patients, he said, are “really the heart and soul of rural America.”

He said if his remote health centers don’t get a share of the billions of dollars Congress earmarked to transform health care in rural America, patients may soon lose services. About 50% of Open Door’s 60,000 patients are on Medicaid, the joint state and federal insurance program that, together with the related Children’s Health Insurance Program, covers with low incomes or disabilities.

When Congress approved the One Big Beautiful Bill Act last summer, it cut nearly $1 trillion from Medicaid over the next decade. Now, Starr hopes the $50 billion Rural Health Transformation Program, which was part of the same bill, will help keep his patients covered.

Yet, small community health care providers, such as Open Door, may find they are sharing the billions with an army of corporate giants before it reaches their patients.

Months after federal leaders announced that all 50 states won first-year awards, ranging from $147 million for New Jersey to $281 million for Texas, state plans reveal that a heavy dose of prescribed spending will go to companies that can increase the use of electronic health records, strengthen cybersecurity, and improve state and health system technology platforms.

And at least four large-scale coalitions of companies are now pitching multipronged services to the states. Many of the companies already work with regional health systems and states through Medicaid contracting or mobile and telehealth operations.

How those services will help improve the health care of rural Americans at places such as Open Door remains an open question.

States Stare Down Reporting Deadlines

Federal regulators were “really interested in seeing digital health investments” when they crafted the five-year rural health program rules last year, said Maya Sandalow, an associate director at the Bipartisan Policy Center, a think tank based in Washington, D.C. She co-authored a recent report on how the 50 states plan to invest in technology, including modernizing health care infrastructure and expanding virtual care options such as telehealth and remote patient monitoring.

“The rural health fund isn’t really designed to directly replace or offset the lost Medicaid funding,” Sandalow said, noting that the federal staffers in charge of the program — money that could help rural hospitals and clinics pay for patient care — at 15% of the total funding awarded to a state.

Federal regulators also established tight reporting deadlines, forcing states to move quickly.

States must file progress reports and obligate all first-year funding , according to the Centers for Medicare & Medicaid Services, the federal agency overseeing the program. States could see their awards decreased or terminated at any time if they fail to follow federal requirements, according to the .

As of early April, CMS had not approved or had only partially approved some state budgets, including those of Wyoming, Colorado, and Vermont, according to state officials. CMS spokesperson Catherine Howden, who declined to say which states still needed revised budgets approved, said the agency does not provide “state-by-state updates.”

In Alaska, the budget is approved but the state has not announced when it will release full grant proposals and awards, said Tricia Franklin, program coordinator for Alaska’s rural health transformation.

“Early summer was the target,” Franklin said. But the response from vendors and applicants has been “much greater than expected, so it may take us a little longer.”

Working with consulting companies is an established way for states to “quickly and effectively” meet federal deadlines and roll out grant money, said , national director for population health at the Milbank Memorial Fund, a nonprofit focused on state health policy work.

Upgrading Technology, Modernizing Rural Health

Science Applications International Corp., a Fortune 500 government contractor, pulled together the . SAIC does a variety of technology work such as cybersecurity and engineering support. The alliance also includes Walgreens and Mission Mobile Medical, which turns RVs into primary care clinics. A data analytics company, a telemedicine and software company, and a company that helps place medical graduates in health systems are also part of the coalition.

The SAIC alliance offers “an ecosystem” of companies that can coordinate the work states have promised, said , SAIC’s Rural Health Transformation Program lead and a former chief information officer for the Virginia Department of Health. Each of the companies has representatives focused on the rural program, he said.

A lack of digital infrastructure — such as electronic health records at different clinics and hospitals that can talk to one another — has been a consistent barrier for rural medical care teams, said the Bipartisan Policy Center’s Sandalow.

“The funding hasn’t always been there in order for rural areas to create the infrastructure that’s needed to fully adopt remote patient monitoring, telehealth, artificial intelligence in ways that will really be supportive,” Sandalow said. “It takes things like updating infrastructure, changing workflows.”

Sandalow’s found that Maine and Utah are investing in cybersecurity; Indiana, Missouri, and New Mexico plan to modernize their electronic health records; Oklahoma plans to buy hardware and software, subsidize subscriptions, and give technical support to rural providers; and states such as Arizona and South Carolina will use funds to create telehealth hubs or buy remote patient monitoring equipment.

Federal regulators, when creating the rural program’s spending rules, also said no more than 5% of a state’s total funding awarded could be used to replace electronic medical records systems that already meet federal standards. Sandalow said that means states will focus on enhancements and upgrades to their current systems.

Gainwell Technologies, which operates the systems for dozens of state Medicaid programs, is spearheading . Rushil Desai, a Gainwell senior vice president, said states’ detailed spending plans are “changing in real time.”

Maine’s Medicaid plan contracts with Gainwell, and the state’s initial application listed four contracts worth more than $16 million over five years for the company. The state confirmed it has received federal approval for only its first year of spending, which includes a to implement changes to the state’s Medicaid claims system.

James Lomastro, a senior-care advocate in rural Massachusetts with the nonprofit , said he worries that large vendors and health systems will get the state’s transformation dollars.

Clinics, home care agencies, and nursing homes that “actually provide day-to-day support in the community are mostly on the margins” of state discussions about how to spend the money, he said. A spokesperson for Massachusetts’ Executive Office of Health and Human Services, Olivia James, said state officials would “ensure that everyone has a seat at the table” with training, financial incentives, and direct investments.

Arizona’s rural fund budget, which is $167 million for the first year, allocates for medical diagnostic equipment and technology upgrades, including to electronic health records, specifically for rural health care facilities.

But it also for county public health departments, said Pima County Public Health Director Theresa Cullen. The approved budget includes up to $4 million for grants to support community health workers.

“In these rural communities, you need to be present,” Cullen said.

Alina Czekai, director of the CMS rural health transformation office, said her team plans to visit all 50 states. She spoke at the National Rural Health Association’s policy conference in Washington, D.C., in February and told the audience that her team wants “the money to go to rural communities, rural providers, rural patients.” The association’s members include rural hospitals and clinics, which are expected to suffer big losses under the Medicaid cuts.

In California, Open Door’s Starr said he provided input on his state’s initial application, which won $234 million in first-year funding, but he is not clear on what the next steps will be for getting money from the program.

For his patients, Starr said, money is needed for technology upgrades. After all, he said, updated electronic health systems could operate seamlessly and store the documentation needed to keep a patient enrolled in Medicaid.

Updated technology could be exactly what Open Door and other area clinics need to “help keep people covered,” Starr said.

ºÚÁϳԹÏÍø News senior correspondent Phil Galewitz and rural health care correspondent Arielle Zionts contributed to this report.

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HAY SPRINGS, Neb.— The sun was just warming the horizon as Mark Pieper left his house near his cattle ranch on a crisp February morning.

It’s not unusual for the rancher to wake up early to tend to livestock, but at 5:45 a.m. this day his cattle wouldn’t come first. For the past 3½ years, three days a week, Pieper has made an early-morning commute to get dialysis at the nearest hospital.

Pieper lives outside Hay Springs, which has 599 residents, according to a sign at the edge of town. He makes sure not to forget his chocolate-brown cowboy hat before starting up his pickup truck for the half-hour drive to Chadron.

That February morning was one of his last dialysis sessions there before the hospital shuttered the service at the end of March.

“I guess I’ll just bloat up and die in a month,” Pieper remembered thinking when he learned the center was closing, eliminating the only option near his home.

He needs dialysis to survive after cancer treatment damaged his kidneys.

Pieper and 16 other patients relied on Chadron Hospital for the life-sustaining therapy that filters waste and fluid from their blood — a job their failing kidneys could no longer do. Treatment lasts about four hours.

The closure is just one example of the long decline of health care services in rural America, where people have higher rates of many chronic conditions but less access to care than elsewhere.

The Trump administration promised to address this problem, when it launched the $50 billion federal Rural Health Transformation Program in September. It may not be enough to stop the trend.

“[President Donald] Trump says he is going to help the rural health care,” Pieper said. Dialysis “is one thing that we really need here.”

Some patients have moved to live closer to care, including several nursing home residents. Their new facilities may be farther from their families.

Others are making long drives to dialysis centers. Pieper eventually found treatment in Scottsbluff, which, with about 14,000 residents, is the biggest city in the rural Panhandle region of western Nebraska. The hour-and-a-half drive will triple his time on the road to more than nine hours each week.

Jim Wright and his wife reduced their drive time — but are spending more money — by renting a small home near Rapid City, South Dakota, and living there on weekdays so he can get dialysis. Wright said he understands that rural hospitals face financial challenges.

“But we’re talking about something that’s lifesaving. It’s not a matter of, ‘Oh, I would like to be there’” getting treatment, he said. “It’s a case that if you don’t, you die.”

An Influx of Money That’s Out of Reach

Jon Reiners, CEO of the independent, nonprofit Chadron Hospital, wrestled with the decision to end dialysis services. He and several patients said that the closure was announced as the $219 million the state will receive in first-year funding from the .

But the five-year program is aimed at exploring new, creative ways to improve rural health, not to help existing services stay afloat. States can use only up to 15% of their funding to pay providers for patient care.

At least 11 states — Nebraska is not among them — have mentioned using funding for rural dialysis programs, according to a ºÚÁϳԹÏÍø News review of applications. Their ideas include starting a mobile dialysis unit and helping people get treatment at home or in long-term care facilities.

Reiners said Chadron Hospital lost $1 million a year on its dialysis service due to low reimbursement rates that didn’t cover operational costs.

The facility is a critical access hospital, a designation that allows certain small, mostly rural hospitals to get increased reimbursement rates for their Medicare patients. While most of the affected patients were on Medicare, the critical access program doesn’t cover outpatient dialysis, Reiners said.

Reiners said the hospital worked for more than a year to find solutions, such as reaching out to four private companies to potentially take over the center. But he said they all passed after realizing they would lose money.

Nephrologist Mark Unruh said the dialysis closure in Chadron reflects a wider trend of staffing and funding challenges.

“You do end up in situations where you have people who are displaced like this, and it’s just sad,” said Unruh, chair of the Internal Medicine Department at the University of New Mexico.

People in rural America face significant disparities in kidney health and treatment, published in 2024 in the American Journal of Nephrology. They’re and face after diagnosis, according to data from the National Institutes of Health.

The best way to address this is to focus on prevention, Unruh said. He pointed to a that helps primary care doctors in rural and other underserved areas prevent end-stage renal failure.

Another idea, Unruh said, is boosting the rate of kidney transplantation for rural patients. He’s looking at whether it’s helpful to “fast-track” tests patients need to get approved for a transplant by scheduling all of them over a couple of days to limit travel time.

Unruh said the U.S. health system also needs to recruit more staff who can train patients and their caregivers to administer dialysis at home.

Exploring the Option of Home Dialysis

Rural dialysis patients are more likely than urban ones to get home dialysis, according to . In 2023, the rate was nearly 18% for rural patients and about 14% for urban ones.

One type of home dialysis requires surgery to get a catheter placed in the abdomen and . The other kind requires . The nearest facility to Chadron that offers training for the first option is in Scottsbluff. The nearest that offers training for the latter kind is three hours away in Cheyenne, Wyoming.

Pieper said doctors told him he’s not a candidate for home dialysis or a transplant. The Panhandle has a nonprofit, rural transit system, but its schedule won’t work for Pieper. He said that leaves him with no choice but to get treatment in Scottsbluff, a 200-mile round trip.

It takes Linda Simonson even longer — more than four hours round trip — to drive her husband, Alan, from their ranch to his treatment in Scottsbluff.

Linda sat in the waiting room with a yellow legal pad during one of Alan’s final treatments in Chadron. The paper was scrawled with phone numbers of politicians to call and driving distances to dialysis centers in the region. She said facilities closer to their ranch either don’t have room for new patients or lack good spots along the route to take a driving break in bad weather.

“It’s just unreal,” she said.

She said even if Alan took a bus, she’d have to ride along to support him during the trip and his treatment.

Jim and Carol Wright, the couple staying near Rapid City on weekdays, said they can’t afford to rent a second home forever. Their weekly commute is already taking a physical and emotional toll. They said they’ll eventually have to move to a bigger city, giving up the house they love in the scenic Nebraska National Forest.

Carol said she feels for the dialysis staffers in Chadron, who are wonderful.

“It just doesn’t seem right to sacrifice one unit that’s so vital,” she said while standing next to a pile of moving boxes stacked inside their rental.

The Wrights wrote letters to politicians and hospital leaders to share their concerns and ideas for keeping the unit open, including using the federal rural health funding.

Simonson said she spoke with aides for the governor and her state representatives but none of the leaders called her back.

“It feels like they don’t know that we exist at this end of the state,” she said.

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It’s one of the many parts of the 25-bed rural hospital that need updating, former CEO Ron Wiens said.

He said the hospital, an essential service in its namesake town of nearly 800 residents in the state’s sprawling north-central high plains, needs at least $1 million for deferred maintenance, including a failing HVAC system. But the facility has struggled to make payroll each month and can’t afford to make all the fixes, Wiens said.

Built by farmers and ranchers in 1965, Big Sandy Medical Center began with nine beds. Today, a similar community effort — donations and grants to plug financial holes each year — keeps it afloat.

Wiens, who recently left his position at the hospital, said he wishes Big Sandy could get funding from Montana’s share of the $50 billion federal Rural Health Transformation Program to renovate the hospital and direct payments to help secure its future. The state received more than $233 million in its first-year award.

But the hospital may not get the kind of help he sought.

That’s because the five-year program focuses on new, creative ways to improve access to rural health care, not on directly funding services and renovations. And Montana is one of at least 10 states whose leaders say projects launched under the federal program could lead rural hospitals to cut services so they can continue to afford to offer emergency and other essential care.

Congressional Republicans created the fund as a last-minute sweetener to their One Big Beautiful Bill Act, signed into law last summer. The funding was intended to offset disproportionate fallout anticipated in rural communities from the law, which is expected to slash Medicaid spending .

includes programs to make it easier for rural residents to get medical care and live a healthy lifestyle. For example, it says funding can be used to start community gardens, train paramedics to make home visits, open school-based clinics, or bring mobile clinics to rural areas.

rural Montana hospitals can receive payments for implementing recommendations, “including right-sizing select inpatient services” to match demand. In some cases, it says, right-sizing might mean “downsizing.” The state says hospitals will have input and recommendations will be specific to each facility.

“That’s what has all the hospitals on pins and needles, words like restructuring, reducing inpatient beds. Everybody is going, ‘What is this going to look like?’” Wiens said.

The Montana Department of Public Health and Human Services declined to answer questions about how it will carry out its right-sizing efforts.

A Lifeline of Care

Big Sandy cattle rancher Shane Chauvet doesn’t want any services cut.

He credits Big Sandy Medical Center with saving his life after a flying piece of metal nearly cut off his arm during a windstorm a few years back.

“I looked over, saw it coming, and whack!” Chauvet recalled.

His wife drove him to the hospital, where they frantically pounded on the ER door while Chauvet’s blood pooled on the ground.

Because of the storm, staffers worked on Chauvet with no power and no ability to summon a helicopter. He was then taken by ambulance 80 miles through intense rain and hail to a larger hospital.

Chauvet understands the state’s plan doesn’t call for eliminating emergency care, but he worries that reducing other services would set off a downward spiral for the hospital and his town.

In Oklahoma, realigning clinical services could mean “shutting down service lines,” to the federal program. And in Wyoming, any facility that receives funding must agree to “reduce unprofitable, duplicative or nonessential service lines,” .

Monique McBride, business operations administrator at the Wyoming Department of Health, said the department interprets right-sizing as helping rural hospitals provide essential services — such as emergency departments, ambulance services, and labor and delivery units — while maintaining long-term, financial stability.

“This might involve limiting some elective procedures that could be done at lower cost in higher-volume facilities. The main distinction here is time-sensitive emergencies vs. ‘shoppable’ services,” she said.

A New Lease on Life?

Seven of the 10 states — Nebraska, North Dakota, Tennessee, Kansas, Nevada, South Carolina, and Washington — where rural hospital service cuts are on the table say they’ll help pay for hospitals to convert to Rural Emergency Hospitals. The recently created federal designation requires hospitals to halt inpatient services and offers enhanced payments to help them maintain emergency and outpatient care.

At least 15 additional states wrote that they’ll use the federal funding to right-size, evaluate, or adjust services — which could mean adding or taking away services, or transitioning them to a telehealth or outpatient setting.

Brock Slabach, chief operations officer of the National Rural Health Association, said, “There’s a proper concern from rural hospital administrators that this funding is not going to where it was intended.”

He said cutting services that lose money could backfire in the long run. For example, he said, halting labor and delivery care might drive more people out of small towns, further reducing hospitals’ patient numbers and revenue.

The type of hospital services that states will assess matters, said Tony Shih, a senior adviser at the Commonwealth Fund, a nonprofit focused on making health care more equitable.

“If the end result is that high-margin services are taken away from local hospitals with nothing given back in return, it can be financially harmful,” he said.

Shih noted that states’ plans to add more outpatient care could prove beneficial for patients. It’ll take time to know which states help stabilize rural hospitals, he said.

Rural hospital leaders say they know which changes would keep their facilities open and that states shouldn’t suggest or mandate service cuts and other changes on their behalf.

Josh Hannes, who oversees rural health policy at the Colorado Hospital Association, said “top-down” directives won’t work.

He said the association’s members believe they can find efficiencies and are eager to collaborate. But “a state agency shouldn’t be making those determinations,” he said.

Hannes said members are worried Colorado’s plan to classify rural health facilities as a “hub, spoke, or telehealth node” will compel service reductions. The classification will help determine “which services are sustainable locally and which are best provided regionally or through telehealth,” .

Spokespeople for the Colorado and Oklahoma health departments said no facility will be forced to end services. But Oklahoma spokesperson Rachel Klein said some facilities might choose to do so as part of a broader effort to make sure they’re meeting community needs while remaining financially stable.

“A hospital might shift certain services to a nearby regional provider with higher patient volume and specialized staff while expanding other local services,” such as primary, outpatient, or community-based care, she said.

Wiens and Darrell Messersmith, CEO of Dahl Memorial Hospital in the southeastern Montana town of Ekalaka, said they worry the only way hospitals will get their share of funding is to cut services or become Rural Emergency Hospitals that don’t offer inpatient services.

“I would hate to see things shift toward a pack-and-ship facility,” Messersmith said. “Right now, we function quite well as an inpatient facility.”

Not all Montana health leaders are worried.

Ed Buttrey, president and CEO of the Montana Hospital Association, said he thinks his state’s plan could help rural hospitals become financially sustainable and survive Medicaid cuts. Buttrey is also a Republican state lawmaker.

Chauvet, the Big Sandy rancher, said his perspective on whether remote towns like his should have a hospital is forever changed because of his accident.

“I always would say, ‘Oh, they’re nice to have,’ but now I look at the hospital and say, ‘That’s essential to our community,’” he said.

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But plans to spend those nine-digit awards aren’t all warmly received.

At least one group of Republican state lawmakers appears to have scuttled an initiative preapproved by federal officials. And at least one hospital association persuaded its state health leaders to alter who greenlights spending. Other critics are taking a more cautious approach.

That’s because the Centers for Medicare & Medicaid Services, which manages the five-year Rural Health Transformation Program, says states could lose money if they make major changes to the plans approved in their applications. Changes could also delay states’ ability to get projects rolling in time to show the agency that they’re meeting progress deadlines.

“During the application period, states were advised to only propose initiatives and state policy actions that the state deemed feasible,” said CMS spokesperson Catherine Howden, who noted that the agency will work with states case by case.

The recent pushback reflects “tension” over state plans — which were approved by the federal government — from state lawmakers and health leaders who want more input amid tight deadlines, said Carrie Cochran-McClain, chief policy officer of the National Rural Health Association, the largest organization representing rural hospitals and clinics.

Cochran-McClain said many states must pass a bill to allow federal dollars to be spent and added that because the program rolled out so quickly “there’s important work that still needs to be done in some states between the legislatures and the governors.”

State lawmakers want to have a say, she said, in “how the funding is being allocated — how the implementation will go.”

Congressional Republicans created the program as a last-minute sweetener to include in their One Big Beautiful Bill Act, signed into law last summer. The funding was intended to offset concerns about the anticipated in rural communities from the law, which is expected to slash Medicaid spending by nearly $1 trillion over a decade.

CMS officials announced first-year funding — ranging from $147 million for New Jersey to $281 million for Texas — on Dec. 29, after scoring applications. Federal officials will begin evaluating progress in late summer and announce 2027 allocations at the end of October.

A chorus of critics say the program won’t make up for harm caused by Medicaid cuts.

The program is “a complete sham,” Sen. Ron Wyden (D-Ore.) said at a rural policy conference in February.

Medicaid, a joint federal-state program for low-income and disabled Americans, serves nearly , and many rural hospitals depend on it to stay afloat.

But the rural health program tilts toward seeding innovative projects and technologies, not shoring up rural hospital finances. States can use only up to 15% of their funding to pay providers for patient care.

That hasn’t stopped some federal officials and lawmakers from framing the program as a rural hospital rescue.

For example, the White House , “President Trump secured $50 billion in funding for rural hospitals.”

Now that applications have been approved, some state Republican lawmakers — who are than Democrats are — and hospital associations are upset that the political rhetoric doesn’t match what they see.

They’re also lobbing criticisms at specific aspects of their states’ plans, including the proposed projects, what’s not included, and the spending approval process.

In Wyoming, lawmakers didn’t just criticize an initiative from their state’s application. They moved to kill it.

State Rep. John Bear, a Republican, said he and other lawmakers declined to fund “BearCare,” a proposed state-sponsored health insurance plan that patients could use only after medical emergencies. But they did approve other aspects of the rural health program.

The Wyoming Department of Health won’t “proceed with BearCare without express legislative authority to do so,” said spokesperson Lindsay Mills.

While Wyoming lawmakers removed an initiative from their state’s rural health plan, a group in Ohio wants to add something.

Ohio Rep. Kellie Deeter and other Republican lawmakers to use the maximum allowed funding for provider payments — 15% — to support 13 independent, rural hospitals.

“We understand that the rural transformation fund is not designed to be given directly to prop up hospitals,” Deeter said. “We just want to capitalize on the mechanism of the fund that can be utilized for that purpose.”

Those hospitals “operate with very, very narrow margins, and it’s just difficult and, frankly, unsustainable,” she added.

Ken Gordon, a press secretary responding for the governor’s office and the state health department, said, “It’s still very early in this process, and many details are being worked out.”

State lawmakers around the country are also trying to ensure the federal program’s dollars benefit rural areas.

In North Dakota, Rep. Bill Tveit, a Republican who lives in a town with about 2,000 residents, that would have required the state to reserve its funding for programs located more than 35 miles from urban areas and small cities.

During a hearing, lawmakers appeared sympathetic to Tveit’s concerns but quickly shot down his idea.

State Sen. Brad Bekkedahl said the North Dakota health department already committed to prioritizing funding for the most pressing rural health needs. He also said he’s concerned any significant changes could cause the state to lose funding because CMS already reviewed and approved the plan.

Meanwhile, Republican lawmakers in Michigan and North Carolina have criticized their states’ definitions of “partially rural” or “rural,” saying that counties that include urban population centers could take money from lower-density counties, according to and .

Lawmakers aren’t the only ones speaking out.

The Colorado Hospital Association to state lawmakers denouncing how the state created its plan and two of its proposed initiatives.

“Not only were Colorado’s rural hospitals’ recommendations disregarded,” president and CEO Jeff Tieman wrote, but the plan includes ideas “they actively oppose and believe will harm the communities they serve.”

The department responded to one of the association’s concerns by adding rural health leaders to the .

Meanwhile, and Nebraska, some health groups are upset that their states’ plans lack specific funding streams for rural hospitals.

Lauren LaPine-Ray, who oversees rural health policy at the Michigan Health & Hospital Association, predicted the state’s rural hospitals will compete with other organizations, such as academic centers and health clinics, for funding. She said about 65% of the group’s rural members have never applied for a state grant before.

“The rural hospitals, the ones that really need the funding the most, will not be well equipped to apply for and pull down these dollars,” LaPine-Ray said.

Jed Hansen, executive director of the Nebraska Rural Health Association, said the federal funding won’t go to “rural hospitals, rural clinics, and rural providers in a meaningful way.”

“Rural Health Transformation will not save a single hospital in our state,” he said. “I don’t think it will save a hospital nationally.”

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The state could tackle rural health issues long into the future by investing its awards from the Rural Health Transformation Program, the director of Wyoming’s health department, Stefan Johansson, told state lawmakers.

But it’s unclear whether the maneuver will pass muster with the federal government.

If approved, Wyoming’s Rural Health Transformation Perpetuity fund could provide $28.5 million for the state to spend every year, presented to lawmakers.

Wyoming would spend the money on scholarships for health students and incentive payments to help keep small hospitals and rural ambulance services afloat.

“I have lots of questions. It seems very clever,” said Kevin Bennett, director of the South Carolina Center for Rural and Primary Healthcare. “It’s a wild idea.”

Bennett said the big question is whether the federal Centers for Medicare & Medicaid Services, which manages the new program, will approve of Wyoming’s plan.

If it does, he said, “it’s really an interesting way to keep things going” — one with potential benefits as well as risks.

Congressional Republicans created the Rural Health Transformation Program as a last-minute sweetener in their One Big Beautiful Bill Act last summer. The funding was intended to offset concerns about the anticipated in rural communities from the new law, which is expected to reduce Medicaid spending by nearly $1 trillion over the next decade.

Since 2010, 152 rural hospitals in the U.S. have , according to the Sheps Center for Health Services Research at the University of North Carolina. The guidelines for the federal rural health program say states can use only 15% of their funding for direct payments to providers, including hospitals.

CMS officials on Dec. 29 after scoring states’ applications. States had until Jan. 30 to submit revised budgets and other documents that align with their grant awards. CMS has until March 1 to review and approve the updated material.

Wyoming — the least populous state, with about 588,000 residents — will receive $205 million in the program’s first year, $5 million more than it asked for.

States must spend each year’s grants by the end of the following fiscal year, . If they don’t, unused money will be . The final deadline for all spending is Oct. 1, 2032, with leftover funds being returned to the federal government.

Given those rules, “how do you square that with squirreling money away in an account?” state Rep. Ken Pendergraft, a Republican, asked during a hearing on Wyoming’s plan.

Johansson said that depositing the federal grants into the perpetuity fund counts as expending them.

He said that CMS called in December to specifically ask questions about the fund and that he believes the agency has formally approved it. But “the devil’s always in the details,” he said, as the state works with CMS during the budget review period.

Emails obtained by ºÚÁϳԹÏÍø News through public records requests show CMS told officials in some states in early November that the grant money can’t “fund an endowment, capital fund, or other vehicle resembling an investment fund with the purpose of generating income.”

Wyoming officials that the perpetuity fund won’t be making or keeping any profit.

“All program income from these investments will directly fund” rural health programs, they wrote.

CMS spokesperson Catherine Howden did not directly comment on whether Wyoming’s perpetuity idea is allowed. Instead, she said states must follow regulations related to the program and federal grants.

The Trump administration gave states a mandate to spend their money by fall 2032, but on projects that will continue to help rural patients even after the federal program ends.

The perpetuity fund would ensure just that, said Patrick Hardigan, dean of the College of Health Sciences at the University of Wyoming.

“Rather than spend out now,” Hardigan said, “we would have this available to help fund us over a longer time period.”

The state health department has already presented lawmakers with to create the perpetuity fund and approve other parts of its rural health plan.

The legislation says Wyoming would put 80% of this year’s award — $164 million — and 69.5% of the funding it receives over the next four years into the fund. The state treasurer’s office would invest the fund in equities, including stocks. The health department plans to spend 4% of the fund’s money — in line with its expected return — each year, .

About 41% of the annual fund distribution would be spent on incentive payments for qualifying small hospitals, the bill says. The assistance could include one-time grants, medical debt relief for patients, and ongoing payments to offset fixed costs. This funding could amount to 2.5% to 10% of these hospitals’ annual operating expenses, in Wyoming’s application.

Bennett said it’s unclear whether all those types of payments are allowed under the federal rules.

“I think that states will try to do a lot of creative things like this, and CMS will approve or not on a case-by-case basis,” he said.

The bill says around 27% of annual spending would go to incentive payments to encourage coordination or consolidation among rural ambulance services. The funding could be ongoing or grants that help pay for ambulances, communications equipment, and regional dispatch services.

But these incentives would come with . Hospitals and ambulance services could receive payments only if they reduce “unprofitable, duplicative or nonessential” services and participate in “cost-containment arrangements,” such as regional collaborations and shared services.

About 22% of the annual spending would provide scholarships to help Wyomingites afford nursing, behavioral health, emergency medical services, and physician education. In exchange, recipients would have to work in the state for five years.

The remaining spending, around 11%, would be for scholarships to help doctors in training afford medical school, residency programs, and fellowships if they agree to work in an “underserved” Wyoming county for five years. The state health department would prioritize scholarships for people pursuing family medicine, obstetrics, or other high-demand specialties.

Johansson told Wyoming lawmakers that CMS could claw back money if a future state legislature decides to spend the fund in ways not allowed under the federal rural health program. He said this “check and balance” could last for decades.

“I can’t predict the future,” Johansson said, but “I think they have the authority to go look at the appropriate use of those funds through their audit parameters.”

Other states proposed funds in their applications, but Wyoming’s appears unique, according to a ºÚÁϳԹÏÍø News review of state applications.

For example, Kentucky wants to create a rural health endowment to continue its work once the federal program ends. But it would be backed by charitable donations, not seed money and investments from the federal funding.

Several states mention putting some of their federal award money into what they call rural health “catalyst funds.” But these funds, sometimes augmented with private contributions, would be invested in rural health technology.

Bennett said he’s never heard of a state investing any other federal health grant the way Wyoming wants to.

He said that in setting aside significant portions of its Rural Health Transformation Program awards, Wyoming would have much less money for rural health care in the short term in exchange for an ongoing revenue stream that could last decades.

“Everything has trade-offs,” Bennett said.

The Wyoming House Appropriations Committee unanimously approved the bill on Feb. 12, sending the legislation to the House floor.

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During a January White House roundtable touting the first grants to states under a new $50 billion rural health fund, Centers for Medicare & Medicaid Services Administrator Mehmet Oz called the idea “pretty cool.” Later that day, Sen. Bernie Sanders, the independent from Vermont, said it is decidedly . And obstetricians and others chimed in on social media to express alarm, with one political activist calling it a “.”

The disparate responses highlight how excitement over the tech-heavy ideas states pitched in their applications for the federal Rural Health Transformation Program conflicts with the reality that there simply aren’t enough health workers to serve patients in many rural communities. Now, as states prepare to spend their first-year awards, tension is mounting, and nowhere is that strain more visible than in Alabama.

Oz has lauded the state’s proposal to invest in the relatively new technology of robotic ultrasounds.

“Alabama has no OB-GYNs in many of their counties,” Oz said, sitting with President Donald Trump and Cabinet members. The dearth of care, , prompted the proposal to use robots for ultrasounds on pregnant women.

Britta Cedergren directs the and has a firm grip on reality: “No one is using autonomous robots.”

While robotic ultrasounds are a “really neat technology,” she said, they are not yet being used in the state. Instead, clinicians providing obstetric care lean on phone consultations and — when equipment and internet are available — telehealth.

The goal, she said, is to “support places where there is no care.”

Cedergren is part of multiple state maternal and fetal health groups and works daily with doctors, hospitals, and first responders. While enhanced technology is vital for patient care, it’s not a replacement for a well-trained workforce and a coordinated care and data system, she said.

In 2024, the most recent year for which data is available, Alabama’s infant mortality rate was per 1,000 live births. The nationwide rate was 5.5 per 1,000 live births, according to released by the Centers for Disease Control and Prevention.

Hospital-based obstetric unit closures, which often lead to a loss of health care providers who can care for expectant mothers and their babies, are a long-standing, ongoing trend in rural America. But Alabama’s loss of services has been particularly profound.

In 1980, 45 of the state’s 55 rural counties had hospital-based obstetric services. By 2025, , according to state data. And the losses aren’t slowing. Five hospital obstetric units closed in 2023 and 2024, including in three rural counties: Monroe, Marengo, and Clarke.

, a professor at the University of Minnesota School of Public Health, found that closures in remote areas in preterm births, a leading cause of infant mortality.

“People will be pregnant and give birth in communities all over the place,” she said. “You have to be able to get to a place where you can be cared for.”

Nearly all 50 states’ applications for the Rural Health Transformation Program declared workforce shortages and maternal health needs as priorities, but only Alabama proposed using robots to fill the gap. The rural fund, which Congress created as a last-minute sweetener in Trump’s One Big Beautiful Bill Act last summer, encouraged states to be creative, be innovative, and pitch tech solutions.

Alabama was awarded $203 million for the first of the program’s five years. Among nearly a dozen , the state’s application included bolstering its rural workforce as well as improving maternal and fetal health.

Mike Presley, a spokesperson for the , which is overseeing the plan, said no one was available for an interview about telerobotic ultrasounds.

LoRissia Autery, an obstetrics and gynecology specialist in rural Alabama northwest of Birmingham, said the robots won’t decrease maternal and infant mortality. There are nuances, she said, to doing ultrasounds.

Many of her patients have high-risk pregnancies with diabetes, high blood pressure, and hepatitis C, she said. She said she worries about the kind of care that will be given to her patients, many of whom drive an hour or more to get to her, if robots are used instead of a trained specialist.

“It takes away just the care that we need to have for women,” said Autery, who co-founded . The clinic includes three doctors, draws patients from five counties, and could use an additional physician to meet the demand, Autery said.

“Probably for the past six or seven years, we’ve been putting out feelers trying to find a fourth partner,” Autery said. “It’s difficult for a variety of reasons.”

In his social media remarks to Oz, Vermont’s Sanders called the lack of rural health care providers in the U.S. an “international embarrassment.”

“In the richest country on earth, we need more doctors, nurses, dentists and mental health counselors, not more robots,” Sanders wrote on the social platform X.

At least one country is using robots paired with trained workers to decrease deaths.

In the remote Canadian village of La Loche, Julie Fontaine operates an ultrasound robot at a clinic with two on-site nurse practitioners and rotating doctors. She said patients like the robot because it saves them the time and expense of traveling to a bigger regional health care facility six to seven hours away.

“When people come in, they’re like, ‘Wow, like, technology these days,’” said Fontaine, a member of the in northern Saskatchewan. “It’s something they’ve never seen before or even used.”

When working with patients, Fontaine connects the robotic ultrasound machine to a tele-sonographer at a control station in Saskatoon. The sonographer then remotely operates a robotic arm on the machine. A radiologist, who can be anywhere, reads the scan’s report and sends it back to the family doctor in La Loche, said Ivar Mendez, a neurosurgeon and the director of Canada’s . Most babies in Canada, he said, are delivered by family doctors or midwives, not specialists.

“The most important thing is the identification of a high-risk pregnancy early enough so you can intervene,” said Mendez, who added that the robotic ultrasound is “as good as the in-person ultrasound” but can’t be used when a patient needs a more invasive vaginal ultrasound. The mortality rate for mothers and newborns in the north, site of the La Loche clinic, is 20 to 25 times greater than in the rest of the nation, he said.

“One of the reasons is that there’s no availability of prenatal ultrasonography in those communities, so pregnant women have to travel to cities and they’re put up at hotels,” he said.

In a , Mendez and his team at the University of Saskatchewan examined 87 telerobotic ultrasounds and found that 70% of the time, the robotic ultrasound made travel for care unnecessary. Nearly all the patients said they would use the robot again.

The same robotic ultrasound technology was in the U.S.

Nicolas Lefebvre, chairman and chief executive of the robot’s creator and manufacturer, AdEchoTech, said the company has “U.S. maternity-specific projects that are currently under preparation.” The average price of a robot will be $250,000 to $350,000, according to AdEchoTech’s U.S.-based business development consultant.

Using robotic ultrasounds is one part of Alabama’s proposed maternal and fetal health initiative, according to the . Acknowledging loss of hospital obstetric units, officials said they planned to connect smaller rural providers and health care facilities that lack “high-quality maternal and fetal health services” to regional care hubs that can provide the services digitally, including through telerobotic ultrasound.

For their workforce initiative, state officials proposed training programs for doctors, emergency services, and nurse-midwives.

The estimated required funding for the maternal and fetal health initiative is . Alabama officials proposed for their workforce initiative over five years.

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But there are strings attached.

In late December, President Donald Trump’s administration announced how much all 50 states would get under its new Rural Health Transformation Program, assigning them to use the money to fix systemic problems that leave rural Americans without access to good health care. Now, the clock is ticking.

Within eight months, states must submit revised budgets, begin spending, and show the money is going to good use. Federal officials will begin reviewing state progress in late summer and announce 2027 funding levels by the end of October.

The money — divided into unique allocations for each state, ranging from $147 million for New Jersey to $281 million for Texas — represents the first $10 billion installment from the five-year, $50 billion program. Congress created the fund as a last-minute sweetener in Trump’s One Big Beautiful Bill Act last summer to offset the anticipated in rural communities from the statute’s nearly $1 trillion in Medicaid spending cuts over the next decade.

Federal officials crafted the fund to give states “space to be creative,” Mehmet Oz, administrator of the Centers for Medicare & Medicaid Services, said on a call with reporters after announcing the funding Dec. 29. “Some states will fail, and we will learn from that.”

The money was divided according to a complicated formula.

In 2026, each state will receive an equal $100 million share for the first half of the money, plus additional funding from the second half. Oz’s staff steered payouts from the second portion based on each state’s rural score, as well as results from a “technical” scoring system for project proposals.

Within hours of the announcement, academics and researchers began to parse the awards to better understand why some states received more than others, including whether the awards reflected any partisanship or political favoritism.

At first glance, total awards do not appear to favor states governed by either Republicans or Democrats. But teased out the amount awarded for each state’s technical score, which is the part determined by the discretion of agency officials.

The analysis was performed at the University of North Carolina’s Cecil G. Sheps Center for Health Services Research, which specializes in rural health. A ºÚÁϳԹÏÍø News review of the Sheps Center data found that states with Republican governors tended to receive more money for the parts of their application based on the technical score. Democratic-controlled states crowded the bottom quarter of those technical score awards.

Overall, though, the state awards reveal wild variation in how much money each state will get per rural resident, almost a hundredfold difference between the top and bottom.

In an emailed statement to , a spokesperson for Arizona’s Democratic Gov. Katie Hobbs accused the administration of shortchanging rural residents in the state, which was awarded $167 million this year from the program.

CMS spokesperson Chris Krepich said in an emailed statement to ºÚÁϳԹÏÍø News that “politics played no role in funding decisions.”

On the December call, Oz pushed states to start working on policy actions championed by the administration — such as approving presidential fitness tests and restricting food benefits — that could require legislative approval.

Half of states promised to mandate the presidential fitness test, Oz said. Many states also proposed food waivers under the Supplemental Nutrition Assistance Program, known as SNAP, which would limit low-nutrition items such as soda. He also said some states promised to teach health care professionals about nutrition. And others confirmed they will repeal certificate-of-need laws, which require companies to prove that new health facilities they want to open are necessary.

Krepich said CMS’ new Office of Rural Health Transformation is hiring program officers to serve as point people for three or four states. Many states are setting up their own offices to oversee the new funding.

Oz highlighted Alabama’s “big maternity initiative with robotics doing ultrasounds” and said states are tackling issues ranging from behavioral health to obesity.

A ºÚÁϳԹÏÍø News review of state “” and “” released by CMS shows that many states plan to address the workforce challenges in rural areas. Delaware, for example, plans to use its funding to create the state’s first four-year medical school with a rural primary care track.

A third of states said they want to improve electronic health records, and every state mentioned telehealth.

Many state legislatures to distribute the funding to their state offices. Meanwhile, state officials are hiring staff, , and .

“I’m excited about what’s next,” said Terry Scoggin, former interim chief executive of the Texas Organization of Rural & Community Hospitals, or TORCH. Texas was awarded the biggest allocation. The money will bolster a rural hospital funding bill Republican Texas Gov. Greg Abbott signed last year, Scoggin said.

More than two dozen cash-strapped rural hospitals in Texas to clinics since 2005, a nationwide trend that hit the Lone Star State particularly hard. The state has the largest rural population in the United States. Texas’ allocation amounts to about $66 per rural resident, . By contrast, Rhode Island was granted about $6,300 per rural resident.

Scoggin said he has “a ton of concerns” about companies taking the money instead of it helping rural hospitals and residents. “I was blown away about how many for-profit companies reached out.” The companies have also called rural hospitals and asked to work with them to apply for state money, he said.

The awards should be judged on how they benefit rural residents because “the stated goal of the program is to improve rural health,” said Paula Chatterjee, an assistant professor of medicine at the University of Pennsylvania who co-authored on the transformation fund.

Researchers at the Sheps Center conducted the analysis to estimate how much money states received from the technical score, which is the portion of funding based on the quality of their proposals and state policy actions that align with “Make America Healthy Again” priorities.

New Mexico won the least amount of technical funding, with less than 10% of its award based on the discretionary metrics. Alaska won the largest technical award, according to the Sheps Center data.

Texas, Nebraska, New Hampshire, and Hawaii rounded out the top five recipients of technical funding. In addition to New Mexico, the other lowest technical awards went to Michigan, New Jersey, Arizona, and California.

Mark Holmes, director of the Sheps Center, declined to comment on whether he saw any political bias in the awards but said the nuance in the final portion of discretionary awards based on technical scores is important because those dollars can be redistributed and potentially clawed back in future years.

“We can be fairly certain that every state will get at least a slightly, if not a vastly, different amount next year based on this re-pooling and reallocation piece,” Holmes said.

States now have a limited time to show they’re using the money effectively to secure future funding.

But they can’t start spending yet. CMS followed standard grant procedures and is requiring each state to submit revised budgets before they can draw down money, Krepich said.

States have until Jan. 30 to resubmit their budgets, and CMS then has 30 days to respond, according to the standard . Under that timing, some states may not have cash in hand until March.

“CMS is working closely with states to complete this process as efficiently as possible,” Krepich said.

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Since the Nov. 5 deadline passed for states to apply for their shares of the new $50 billion federal Rural Health Transformation Program funding, officials at the Centers for Medicare & Medicaid Services have declined to publicly release the applications. Federal officials are using those submissions, most of them more than 100 pages long, to decide how to divide the money among states. They’ve pledged to announce the allocations by Dec. 31.

ºÚÁϳԹÏÍø News is working to collect and post complete application materials, by state, here and will update this repository as new materials, released in response to public records requests, arrive.

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Federally recognized tribes can’t directly apply for a share of the rural health fund — only states can. And states aren’t required to consider tribes’ needs. But state applications for the five-year payout show some states with significant Native American populations did so anyway.

Workforce development, technology upgrades, and traditional healing are a few of the initiatives specifically aimed at Native American communities that some states included in their applications, which were due to the Centers for Medicare & Medicaid Services on Nov. 5. The fund was a late addition to the One Big Beautiful Bill Act in response to worries about the harm the spending reductions in Republicans’ bill would have on rural hospitals’ finances.

Some states, , Nevada, , are also considering setting aside 3% to 10% of their federal payouts to distribute among tribes. Washington proposed setting aside $20 million per year.

Federally recognized tribes have direct relationships with the U.S. government, but state governments also allocate resources to tribes and can create policies that support tribal priorities. States and tribes share concerns about the effect that the massive GOP budget bill, which President Donald Trump signed into law in July, will have on the U.S. health system. The law is expected to reduce federal Medicaid spending by nearly $1 trillion and increase the number of uninsured by , according to KFF, a health information nonprofit that includes ºÚÁϳԹÏÍø News.

Catherine Howden, a CMS spokesperson, said that states are required to develop their applications in collaboration with key stakeholders, including the state governments’ tribal affairs offices or tribal liaisons, as well as “Indian health care providers, as applicable.” But these entities do not include tribal governments or official tribal representatives.

Tribes can apply for Rural Health Transformation Fund subgrants through their states. But during a recent call with federal health officials, tribal leaders expressed frustration about being regarded as just another stakeholder in the issue rather than sovereign nations. Tribal sovereignty guides most government-to-government consultations over proposed federal actions that would have a substantial effect on tribes.

“Even in a scenario where tribal consultation is required, the quality and quantity of that tribal consultation on a state-by-state basis is all over the place,” said Liz Malerba, director of policy and legislative affairs for the United South and Eastern Tribes Sovereignty Protection Fund, which advocates for tribal nations from Texas to Maine. Malerba is a citizen of the Mohegan Tribe.

Federal policy works better when tribal nations are directly eligible for funding that supports essential services in their communities, Malerba said, adding that tribal leaders are concerned that the reach of the program into their communities will vary considerably.

There are and Native American and Alaska Native people in the U.S. The population faces a lower life expectancy and when compared with other demographics. The Indian Health Service, the federal agency responsible for providing health care to Native Americans and Alaska Natives, has been by Congress.

ºÚÁϳԹÏÍø News analyzed how 12 states with significant Native American populations took tribes into account as they developed plans for the pot of federal money.

, , , and were among the states that held tribal consultations or listening sessions ahead of the Nov. 5 application deadline.

In states that did not initiate input from tribes, some Native American leaders made sure their voices were heard in other public hearings. Jerilyn Church, CEO of the Great Plains Tribal Leaders’ Health Board, said she attended an October public meeting in South Dakota because she felt it was important for state leaders to consider how they could use the program’s resources on reservations. There are nine federally recognized tribes in the state, and Native American people make up 9% of the population.

“I felt like we needed to help be that advocate,” said Church, a citizen of the Cheyenne River Sioux Tribe.

In the proposed initiatives included in its rural fund application, South Dakota such as improved telehealth and funding for doula programs. It also said the state will continue meeting with the Great Plains tribal health board throughout the five-year funding cycle.

In Oklahoma — where more than 14% of the population is Native American, a higher share than in most other states — tribal representatives were invited to weigh in with the rest of the public when the state was gathering information for its application, the details of which have not been publicly released.

“We’ve welcomed input from any Oklahoman,” said state health department spokesperson Erica Rankin-Riley.

North Dakota in the Rural Health Transformation Program and included initiatives such as expanding physician residency slots with tribal-specific rotations and opportunities for farm-to-table food distributions. But that would have pledged 5% of its federal allotment to tribes. There are five federally recognized tribes in the state, and Native Americans make up nearly 5% of the population.

Some states did include proposals to fund high-priority initiatives for tribes.

for the rural fund included an initiative focused on improving health among Native American communities. Its goals include investing in workforce development for tribes, better care coordination between tribes and rural hospitals, and $2.4 million annually to support Washington State University’s rural health education programs, including its Indigenous health program.

included integrating Indigenous traditional healing in Alaska Native village clinics. It would include offering traditional-healing house calls, hands-on training for healers, and traditional-medicine training for health care providers and staff, according to the application.

One of would support the state’s nine federally recognized tribes in improving health outcomes. The state estimates the initiative would require $20 million per year, or 10% of the Rural Health Transformation Program award.

Whether or not states identified funding for tribes or included tribal priorities in their proposals, tribes will be eligible to apply to their states for subgrants of the Rural Health Transformation Program money. While larger tribes that have more resources, such as grant writers and staff to implement programs, could benefit, smaller tribes may struggle to produce competitive applications.

Church said that the Great Plains Tribal Leaders’ Health Board will know the fruits of its labor when states are notified of their rural health fund allotments by the end of the year.

“Hopefully the work that we did, the advocacy that we did, and the outreach,” Church said, “will result in resources getting to our tribes.”

ºÚÁϳԹÏÍø News South Dakota correspondent Arielle Zionts contributed to this report.

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