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Health Affairs This Week places listeners at the center of health policy’s proverbial water cooler. Join host Jeff Byers, editors from Health Affairs Publishing, and guests as they discuss health policy’s most pressing news and trends.
Hello and welcome to Health Affairs This Week. I'm your host, Byers. We are recording on 06/03/2026. This month, we have an insider event on June 23 on antitrust and health care and beyond. Speakers include Lee Moore Dathney, Katherine Gudixson, and Nathan Hostert.
Jeff Byers:Please check the show notes to learn more, and we have a great July event planning on Supreme Court cases, again, with Sarah Rosenbaum. So check that out in the show notes. Today on the pod to discuss rural health care, we have Sarah Jane Tribble from KFF Health News. Sarah, welcome to the program.
Sarah Jane Tribble:Good to be here. Thank you for having me.
Jeff Byers:We're talking about the Rural Health Transformation Fund. So it provides $50,000,000,000 over five years for states to improve care in rural communities. Rural care is honestly not a topic we touch much on here at Health Affairs This Week. So, like, looking out, what's the state of rural care today?
Sarah Jane Tribble:Yeah. So let me let set the stage for you just a little bit. So according to the census, about one in five Americans live in rural America. And the population tends to be older, agriculture employs less than 5% of the workforce. So it's not automatically what you think of farmers and so forth.
Sarah Jane Tribble:There's a lot of transitioning from the historical reliance on manufacturing and farming and energy production into other things. I wanna note that rural America is also not a monolith. It's not a bunch of just one Caucasians out there. There's also growth and different people of color. And there has been some population growth in rural America too.
Sarah Jane Tribble:But it's also higher poverty rates overall in rural America than their urban counterparts, often working poor, people who are working double shifts, or they're working manufacturing, or they're working fast food, or retail stores. So there's a lot of working poor in rural America. And people tend to live with more chronic diseases, and they tend to die younger in rural America. There's a mortality challenge in rural America in more recent years, which is really very different than it was decades ago. I know we're here to talk about health care and the $50,000,000,000 fund.
Sarah Jane Tribble:So let me also mention that for healthcare in rural America, resources are limited in many places. Rural hospitals have been closing over the decades. It's something Congress has really tried to address with different initiatives and different rules. But more than 100 hospitals have closed since 2010, or converted more than 153 have closed or converted since 2010. And even if they don't close out, they'll lose services like maternal services and delivering babies.
Sarah Jane Tribble:I'll stop there. So I think that kind of paints some of the picture real quick.
Jeff Byers:Yeah, so like rural America is not a monolith. And one of the things I kind of wonder about, like you mentioned a lot of working poor, is there also a lot of affluence in rural areas?
Sarah Jane Tribble:Yeah, I mean, during the pandemic, we found a lot of younger people moving to rural America because they could do their remote jobs, right? So there are pockets of a lot of affluence in rural America. Actually, was just down North Carolina for my most recent story, somebody and mentioned to me, if you go out to this area along the coast, you're gonna see a completely different picture than you see right here next to this health clinic, because those are people coming in and they're buying second homes and so forth. So you're seeing that in some areas of rural America too.
Jeff Byers:Yeah. Yeah. I just that was interesting to note with your not a monolith comment that takes all kinds. So how does the Rural Health Transformation Fund work to improve the conditions of the population of what you said that live with more chronic disease?
Sarah Jane Tribble:So it has a lot of built in initiatives in it. But before I start talking about the $50,000,000,000 fund, let me give a little bit of background on where it came from. And some of your listeners may know this, but the big HB1 debate, the big beautiful bill, as many people call it from
Jeff Byers:Heard about it.
Sarah Jane Tribble:Yeah, that you may recall had a lot of Medicaid cuts in it, right? So at the time when nearly a trillion dollars was going to be reduced in Medicaid spending over a decade, that's what the bill ended up doing, to win over some senators, some Republican senators, there was a lot of talk about hospital closures in rural America. And so they put in this sweetener. I And remember sitting with a group of rural experts at the weekend that this was happening. And we first heard it was gonna be like 15,000,000,000, and then we heard it was gonna be like 25,000,000,000, and then it landed on 50,000,000,000.
Sarah Jane Tribble:And so that was put in at the last minute to win over votes from some very important rural senators. With that in mind, when you ask the question about what the transformation fund does, it doesn't replace the Medicaid funding. And it wasn't meant to actually. I was recently talking to Kevin Bennett. He is in South Carolina and the former president of the National Rural Health Association.
Sarah Jane Tribble:And Kevin has a saying that he's used, and I love this. It's like, they're getting this $50,000,000,000 injection, rural providers are, and rural America is, at the same time, they've just had their leg cut off with Medicaid. And so it's like having your leg amputated and being given a two to three minute start in a race at the same time and seeing how you're gonna do. So that's sort of the context of the spending. But the question you asked me about how it transforms rural care is also sort of an exciting thing to talk about because there's incentives in there for the states to kind of change and improve their infrastructure and help rural providers in different ways.
Sarah Jane Tribble:Then also a real focus on technology and innovation in this as well.
Jeff Byers:So when you bring up this as an opportunity for states to change their infrastructures to help manage Medicaid populations, is that what you were saying?
Sarah Jane Tribble:In some cases, it will help them manage their Medicaid populations.
Jeff Byers:Goal
Sarah Jane Tribble:But
Jeff Byers:also of infrastructure in general?
Sarah Jane Tribble:Yeah. So if you think about the way health care works in general, like you go into your doctor's office and you may have a portal that you work on and there's electronic health records. Or you may want to do a telehealth call with your provider to get into the doctor sooner than waiting. It might be more convenient. All those kinds of things can be addressed with these rural health care dollars.
Sarah Jane Tribble:So there's money states are setting aside to improve telehealth. There's money states are setting aside to improve their claims processing systems in some cases when you look at their plans. Maya Sandelow at the Bipartisan Policy Center is one of the researchers who's really looked at the infrastructure and technology aspect of this. And when I was talking to her, she said this really great thing that really resonated with me. And that is that a lot of times these rural health clinics and providers, their electronic health records maybe aren't connected to another system.
Sarah Jane Tribble:So they need sort of that basic funding, a shot in the arm of funding, really, to get up to speed in other places. Now, isn't every place in rural America. Some are really on top of technology. But like I was in Alabama for a story. I did a story on a hospital that didn't have a central operating system, and the nurses were using two different electronic health records, one for the ER and one for inpatients.
Sarah Jane Tribble:That was just adding to their workload and really making it difficult for them to just focus on the patients. So those kinds of things are the things that I think there's money set aside for and states are really focusing on saying, hey, we know this is a problem, we want to fix it.
Jeff Byers:And we'll go into some of the policy shifts and challenges in a second, but I wanted to also step back again real quick of that you know, storytelling matters, narrative matters. From a storytelling perspective, we're talking you said one in five Americans live in a rural area. That's more than what I would have thought. I I saw some stat that said 13% of the population. If we're looking at, like, 20, that's, you know, still a fair amount of people.
Jeff Byers:When you're trying to talk about your stories, for someone that might live in DC or Boston or, you know, a metropolitan area, how might you illustrate or frame the health needs of a rural population that, like, can make them understand what what's, like, challenging about it or what's not challenging or what's different than, like, being able to walk to a hospital or an urgent care center?
Sarah Jane Tribble:To me, it's a really great question. And, you know, the difference in the numbers is really funny because it's a big conversation between among statisticians and who focus on rural because there's like 15 plus different designations of rural in the federal government. So the Census Bureau will have a different number than say, the economic bureau over here and so forth. Needless to say, there's a lot of people in rural America. And something that Mehmet Oz, who, you know, the administrator of CMS, which is the agency in charge of this $50,000,000,000 program and in charge of Medicaid, has said repeatedly when he talks about the $50,000,000,000 program, is lessons learned in rural America with this money can be applied to urban America.
Sarah Jane Tribble:Because the reality is people are people, right? Humans are humans, and we all suffer the same sort of challenges in our healthcare, right? There's plenty of people who are working with diabetes and living with obesity in urban areas as well as rural areas, so lessons learned. The most striking difference though, that I like to bring home when I'm writing about this is sort of a access to resources, transportation, telecommunication needs are often very different in rural America than they are in urban areas. I've covered places like East Cleveland, right, where there's a lack of resources and people don't have transportation to get to the hospital.
Sarah Jane Tribble:But that transportation doesn't take as long to get to the hospital when you're in East Cleveland and you can go to a massive place like the Cleveland Clinic for care within fifteen minutes. But if I'm sitting in rural North Carolina, and I interviewed a woman who drove two and a half hours to get to the emergency room at ECU Health in Greenville, North Carolina recently, and she wanted to take her aunt in. Two and a half hours because her insurance wasn't covered someplace else, and she wanted the level one trauma center. It was just that much further. Or, you know, I did stories recently where I had to go back to people's houses because they simply didn't have good enough internet connections to do an interview, or really even cell service to do interviews.
Sarah Jane Tribble:Those aren't as common challenges in urban areas. So those are some of the stories that really need to be lifted up.
Jeff Byers:You wrote an article for KFF Health News called Big Companies Position Themselves for Payday from 50,000,000,000 Federal Rural Fund. It touches on modernizing infrastructure in rural areas and digital health options. We've talked about this already a little bit, but is there a generalized status? I mean, we're already talking about, like, the difference in telecommunications needs and, like, how can this fund move these technology infrastructure forward more?
Sarah Jane Tribble:Yeah, I mean, think what states are doing is they're really looking at the systems they have in place and they're saying, how can we improve these systems? And they are also at the same time putting out, there are a handful of states already putting out grant proposals and things for nonprofits to apply for. There's a focus on making sure rural providers have access to this money, or companies that work with rural populations have access to the money. States are really writing that into their roles. And I will say that CMS's Deputy Director, Kate Sapra, of the Office of Rural Health Transformation, which was created last fall to help manage this fund, She said recently on stage that she really wants to make sure this money goes to rural America.
Sarah Jane Tribble:So when states are looking at how to spend the money on infrastructure, they're also at the same time looking at, well, once we spend it on this technology, is it going to help rural Americans?
Jeff Byers:And I would that is a great segue for me to give a shout out to. If you're listening to this today, it will be published on June fifth, Friday. We have a free event on June 8 with Kate Sapra and Catherine Orenstein on rural health transformation and age friendly care. That's at June 8, 2PM eastern time. Also check the show notes out.
Jeff Byers:It's free to join. Hope you'll join us. With that, back to the program. What does this kind of denote for like policy shifts when we're looking at this Rural Health Transformation Fund? You know, what can we glean from this of where we're going in either rural care or urban care?
Sarah Jane Tribble:So the other aspect about the Rural Health Transformation Plan from the federal level is when you look at the application the states had to fill out last fall, there were some policy incentives. So it was a complicated formula on how much money each state got. They were supposed to apply for 200,000,000 a year, basically. And then states were then graded and rated with a panel of review experts and given money based on their morality and their initiatives. And included in that were policy initiatives that are very MAHA, MAGA friendly.
Sarah Jane Tribble:And so you'll see states getting incentives, financial incentives for saying, we are going to vote and put in place the presidential fitness test. That's a really easy one to understand. We are going to make sure our SNAP benefits are very healthy and eliminate coverage of unhealthy foods in the SNAP benefits.
Jeff Byers:Yeah, every millennial, by the way, when you mention the presidential fitness test, just like went back to their elementary school days.
Sarah Jane Tribble:I couldn't get up the rope all the way. I shouldn't say that on something national. But it was really hard for me as a little grade schooler to get all the way up the rope to the ceiling in the gym.
Jeff Byers:It's hard. Well, that's neither here nor there, But yeah.
Sarah Jane Tribble:That's part that was part of the test. Right?
Jeff Byers:I you know, I don't think I did that. I think we had to, like, do pull ups and Yeah. There was, like, a you reached to a certain amount. Do you remember that apparatus? Yeah.
Jeff Byers:Yeah. And then I can't remember where I never did a rope in gym class.
Sarah Jane Tribble:Okay. We had push ups too. So Yeah.
Jeff Byers:Push up. That reminds yeah. Anyway
Sarah Jane Tribble:It's really easy to understand how you would think that makes you healthy, right?
Jeff Byers:Yeah.
Sarah Jane Tribble:Yeah. And so that's sort of fun to talk about. But at the same time, having a bunch of kids do push ups is probably not going to move the needle on, you know, whether somebody has chronic diseases later in life. It's really hard to track that, right, from a medical standpoint, outcome standpoint. But there are required outcomes in these plans.
Sarah Jane Tribble:Like the CMS wants to make sure they're spending their money and they're seeing results in rural America. And that's something that, you know, as journalists we wanna watch.
Jeff Byers:And, you know, we'll get to the challenges real quick, but off mic as before we were prepping for this call, you mentioned that there's a little bit of fun in some of these proposals. So like, you know, healthcare is not a fun topic for a lot of people at all times. So like, what what can you tell us?
Sarah Jane Tribble:Yeah. Yeah. So I mean, one of the big incentives here is for innovative ideas. Right? And so you're seeing things like sort of moonshot ideas, like drones that are going to be taking medications to people in Alaska.
Sarah Jane Tribble:Alabama wants to have telerobotic ultrasounds to help offset maternal health care problems. Delaware is gonna do its first sort of rural focused medical school, right? And so states are going, okay, we have workforce challenges in rural America. We have maternal health problems in rural America. What innovative ideas can we apply for that?
Sarah Jane Tribble:And it's really been, there are really some fun activities out there. I was really doubtful about the telerobotic ultrasounds, so I pitched a story on it. I was like, how does that work in Alabama where there's not even, there's a lot of broadband deserts, high speed internet deserts in Alabama. But then I talked to some doctors up in Northern Canada, and they are really making it work and seeing improvements in health outcomes for pregnant women. They hire community healthcare workers in the villages and then have a sonogram reader elsewhere in an urban area.
Sarah Jane Tribble:So it can actually work. And so those are the sort of fun ideas and challenging ones too at the same time that are being proposed.
Jeff Byers:Sarah, as we wrap up, what should listeners be on the lookout for next steps? Like, what are the challenges in this area? And is there any, like, reporting or past articles you want to direct listeners to?
Sarah Jane Tribble:Thanks for asking. I I love all the people I've talked to. When I go out to these rural communities, I always want to let their voices up. And those are all on kffhealthnews.org. We have a rural health payout page that has all the stories focusing on this with a map that includes state applications.
Sarah Jane Tribble:We did public records requests and requested all 50 states for their applications. And so if you wanted to look at that, we have that there. Going forward, there are some deadlines the states have to meet. At the end of August, they file their first annual reports on their plans, which should be really interesting because they're just now getting the money out. States have to have all the money obligated from the first year of funding by the end of October.
Sarah Jane Tribble:And at the end of October is also when the federal government announces the next round of funding for next year. If states get the same amount of funding next year or if they lose some because they didn't make enough progress. So those are all some of the things from watching a future standpoint.
Jeff Byers:Yeah. Well, we'll be sure to put a link into the show notes on that page so listeners can check that out. Sarah Jane Tribble, thanks again for joining Health Affairs This Week today. If you, the listener, enjoyed this episode, send it to the Montana rancher in your life, and we will we will see you next week.
Sarah Jane Tribble:Thanks so much, Jeff.