Here it is, just two days from Election Day. I can’t wait for it to be Wednesday, I must admit. I don’t even live in a swing state, and the amount of calls, texts, emails, and mailers flooding into my life feels like an all-out assault. And yet, I feel a sense of pride, solidarity, and even camaraderie when it comes to voting—especially this year. I hope you do, too, and I hope that if you haven’t voted early, you’re planning to do whatever is needed to show up at the polls and make sure your vote counts on Nov 3.
This one really matters, for all of us. It may matter even more if you live in a rural area. Now, I’ve spent the last 24 years of my life living in a major metropolitan area. I really am a city girl. However, I spent my first 18 years growing up in a rural community, and since moving to California I’ve had the good fortune of spending a lot of time traveling around to different places, hearing what people in rural and frontier communities have to say, and learning what makes it difficult for them to access health and social services. I’ve spent a lot of my career working to figure out what we might be able to do about it.
It’s for this reason that rural health care has been on my mind so much the last two years, and why I think it matters so much for this election. This administration has spent a lot of effort bragging about how much they are doing to improve rural health care access. (So many Republican voters live in rural areas, a point that is not lost on this administration.) But what’s the reality? Who are they really helping? Let’s explore. Share with your rural friends—and encourage them to vote.
The Brag
As I’m sure you remember, in July 2025 Trump signed into law the One Big Beautiful Ugly Bill, HR1. That bill is estimated to cut federal Medicaid spending by more than $900,000,000,000 over ten years, including an estimated $137,000,000,000 in rural areas. I’m spelling out those billions because I think it helps to see how many zeros we’re really talking about here. Recognizing that this will be devastating for people who live in rural areas and already have limited options for healthcare, the bill also created the Rural Health Transformation Program, designed to award $50 billion in state grants from 2026 to 2030 to reinforce and expand rural health care. In December 2025, the federal Centers for Medicare & Medicaid Services (CMS) announced the first Rural Health Transformation awards to all 50 states, averaging $200 million in 2026 (range $147 million to $281 million), with $10 billion available each year through 2030. Dr. Oz, who runs CMS, called it “an extraordinary milestone for rural health in America.”
This sounds great. It really does. Of course, Dr. Oz framed it as a limited-time increase of nearly 50% over the roughly $19 billion in federal Medicaid funding currently going to rural America. (He conveniently left out the $137 billion in cuts his administration is about to start overseeing.) In the press release CMS sent out bragging about $104 million they were granting to the state of Mississippi, he said Trump made a “historic commitment to rural America.” The press release notes that Democrats unanimously opposed the law that made this investment possible. (It conveniently leaves out the fact that Democrats were opposing, among other things, the $911 billion in cuts to Medicaid that the law would also put in place.)
The thing is, there are great things about the Rural Health Transformation Grants. In 2026 every state in the U.S. got at least $100 million to support rural health projects. This is money that will make a real difference. However, despite Senate Majority Leader John Thune (R-SD) going on Fox News to proclaim “Rural hospitals are going to be fine,” the reality is the math doesn’t work. In fact, just last month Dr. Oz toured a hospital in Blair, Nebraska to brag about discuss the $218 million investment Nebraska would be receiving under the program, and he got an earful from hospital leaders about their concerns that not enough money from the program is actually going to rural hospitals. Wait, huh?
What the fund can’t do (or isn’t doing)
It’s not designed to prop up hospitals. The statute allows provider payments to be made with the funds, but the administration chose to cap this at 15% of the funding received. Funds also can’t be used to provide payments for clinical services that insurance can reimburse, even if the insurance reimbursement rate is too low to cover the hospital’s cost. Ultimately, the fund is not intended to backfill financial gaps. To put a Nebraska point on it, Jed Hansen, the executive director of the Nebraska Rural Health Association, was quoted in KFF Health News as saying, “Rural Health Transformation will not save a single hospital in our state.”
It’s not awarding money proportional to need. More money is not going to states that have the highest rural mortality rates, or states losing the most hospital beds. States got a $157 per rural resident average award in 2026, but how much support your state got depends on where you live. Texas got about $66 per rural resident. Rhode Island got $6,305. The technical scoring rewarded states with policies most closely aligned with RFK Jr’s “Make America Health Again” priorities, with the lowest technical scores going to New Mexico, Michigan, New Jersey, Arizona and California (all of which have Democratic governors—likely not a coincidence).
The Reality: The math doesn’t work.
Let’s look at some simple numbers. This doesn’t require calculus.
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Nearly 1 in 4 rural residents in the United States use Medicaid for health insurance.
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All the money in the Rural Health Transformation Program could, at best, offset about 37% of the cuts to Medicaid in rural areas.
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Under HR1, most cuts to Medicaid persist for at least 10 years, while the Rural Health Transformation Fund expires in five.
Regardless of funding to rural hospitals, people are rapidly losing insurance. Affordable Care Act enhanced subsidies expired on January 1 of this year. By February 2026, marketplace enrollment had fallen from 21.8 million to 19.2 million, and premium payments rose 114% on average to keep the same plan. Plus, under the new Medicaid work requirements, people are already starting to lose insurance – or will, once their state begins complying with the requirements by the Jan 1, 2027 deadline. Some states have already started. Let’s take Nebraska: they began enforcing Medicaid work requirements May 1 of this year. So while Dr. Oz is visiting a hospital in rural Blair to talk about the new investments the federal government is making, the Nebraska Hospital Association is already reporting that some people are going without the care they need as they are losing coverage.
More Reality: For rural folks, less care is near home.
HR1 is still too new for anyone to know exactly how it’s going to play out. Most of the Medicaid cuts haven’t even started yet, so much of the noise is about what people predict will happen, not what’s already happening. But what we do know is that HR1 is exacerbating an already dismal and worsening picture for health care systems in rural US communities, and the Rural Health Transformation Program isn’t going to be enough to offset the further damage.
Nationally, Chartis counts 206 rural hospitals in the US closed or converted since 2010. Of those that remain open, over 40% are operating at a deficit, and more than 300 have dropped obstetrics from the services they offer. There are many, many examples of rural hospitals closing their labor and delivery units, which aren’t big money makers—but boy, are they important if you’re planning to have a baby and want to make sure that neither the mother nor the baby dies in childbirth. In a rural area, if your regional hospital closes their labor and delivery unit you might have to literally drive hours for care when you’re having pregnancy complications or go into labor.
All of this isn’t just about Medicaid. Fees for the H-1B visa, one of the main ways foreign-trained physicians come to the US and practice medicine, increased 100x from under $1,000 to $100,000 (plus existing fees) on September 21, 2025 thanks to the Trump administration’s proclamation to combat “systemic abuse” of the visa program. In June of this year that fee was vacated, and the administration renewed their intention to collect the higher fees on September 18 (though it remains blocked by the June ruling). On September 30th it was vacated yet again. In August the Department of Homeland Security proposed a very specific fee of $103,265 through changing the federal rules (trying to avoid further rulings that these fees aren’t permitted under the current rules) – public comment has closed but as of now this is just a proposed rule and hasn’t yet gone into effect. If it does, it won’t just cover people trained in other countries, but also international graduates of U.S. schools who apply to change their status without leaving the country. So in fact, this latest effort is a further expansion of the visa fees required.
OK, but what does it all mean? Why am I talking about this here? Nearly 20 million Americans live where foreign-trained physicians are at least half of practicing doctors. Simply put, immigrants are the backbone of clinical staff in hospitals throughout the US, but especially in rural areas. If those hospitals can’t afford to bring in foreign-trained doctors to work, then there won’t be enough doctors. And without enough doctors, hospitals cut services, and sometimes close.
Rural voters aren’t buying it.
Here’s the good news – as of a poll in August, at least, it didn’t look like rural voters were buying the brag of the Rural Health Transformation Program. A KFF/AP poll of 2,241 rural voters found that 54% disapproved of Trump on health care and largely saw his policies as hurting costs, Medicaid, and local availability of care. 92% said Medicaid is important locally. 66% worried about affording health care.
What you can do:
First, especially if you live in a rural area, look at KFF’s Health News’ tracker and check how much your state is receiving under the Rural Health Transformation Program, and what their plans are for spending the funds. If you don’t like what you see and you’re worried about healthcare access in your region, reach out to state representatives and express your concern.
Second, VOTE. If you haven’t already, make sure you get there before the polls close on Tuesday. Stay in line, rain or shine. You’ve got this.
Third, send this to every rural resident you know, and encourage them to read and vote, too. We’re all in this together.
As for me, I already voted—early, because I’m in San Antonio, TX right now for the annual conference of the American Public Health Association. But I’m taking off early on Tuesday to do some election protection work in Bexar County. I’m volunteering with Help Texas Vote, connected with 866ourvote.org, a non-partisan organization and very impressive operation. If this is something that might interest you in the future, make sure to look them up.
In a democracy, voting is everything. We need to protect everyone’s right to vote. Make sure you exercise those rights and speak your mind with your votes!