Kopplin, a physician assistant who works with seniors, low-income people, and mental health patients in the rural Black Hills, shared her thoughts at a meeting hosted by state officials.

South Dakota’s leaders did a “good job of diving in” and asking questions to get “deeper at the root of the problem,” she said.

Kopplin later told KFF Health News how one of her rural patients recently missed two appointments because of a broken-down car and no access to public transportation.

Nationwide, health care workers like Kopplin and thousands of others — from patient advocates to technology executives — flocked to town halls or online portals during the seven weeks state leaders had to craft and submit their applications for the Rural Health Transformation Program to the federal Centers for Medicare & Medicaid Services. That deadline was Nov. 5.

“We will give $50 billion away by the end of the year,” CMS Administrator Mehmet Oz said Nov. 6 at a Milken Institute event in Washington. He said all 50 states had submitted applications.

The program will “allow us to right-size the health care system,” Oz said, adding that innovations from the rural work “will spill over to suburban and urban America as well.”

Among applications and summaries publicly shared by states, themes include workforce development, telehealth, and access to healthy food. In Kansas, leaders want to build a “Food is Medicine” program. Wyoming officials propose a new program called “BearCare,” a state-sponsored health insurance plan that patients could use only after medical emergencies.

But many health policy experts and Democrats are raising alarms that the Republican-backed program will become a “slush fund.” Critics worry it will fail to reach the small-town patients they say need it most, especially as states face nearly a trillion dollars in Medicaid spending reductions over the next decade. Medicaid, a joint federal-state program, serves nearly 1 in 4 rural Americans.

“The status quo is tremendous distress in rural communities,” said Heather Howard, a professor of the practice at Princeton University and director of the university’s State Health and Value Strategies program, which is tracking the rural health fund. The new funding won’t be enough to offset the Medicaid losses, she said.

Congressional Republicans added the five-year, $50 billion Rural Health Transformation Program as a last-minute sweetener to President Donald Trump’s massive tax-and-spending legislation. The move helped win support for the One Big Beautiful Bill Act from conservative holdouts who worried that the Medicaid cuts in the bill would harm rural hospitals in their states.

In Montana, which hosted an online public forum before submitting its application, a nonprofit director pitched youth peer support as a way of battling high suicide rates. A registered nurse asked state leaders to “think maybe even bigger” and consider statewide universal health care.

And in Georgia, a technology-focused chain of primary care clinics that serves seniors proposed expanding its operations into that state in its online public comment. A rural grant writer asked for “safe and stable housing.”

The law says half of the $50 billion will be divided equally among all states with an approved application. The rest will be doled out according to a points-based system. Of the second half, $12.5 billion will be allotted based on each state’s rurality. The remaining $12.5 billion will go to states that score well on initiatives and policies that, in part, mirror the Trump administration’s “Make America Healthy Again” objectives.

Top Senate Democrats have raised alarms about the rural health program. They include Ron Wyden of Oregon and Tina Smith of Minnesota, who called on a federal watchdog agency to investigate the fairness and implementation of the fund. Taylor Harvey, a Wyden aide, said the Government Accountability Office has confirmed it will investigate.

According to the federal statute, no less than a quarter of states with an approved application may share the second half of the funding each fiscal year, CMS spokesperson Catherine Howden said. The agency plans to publish summaries of approved state projects, according to CMS guidance.

A handful of conservative-leaning states — including Texas, Arkansas, Louisiana, and Oklahoma — have already instituted regulatory and legislative initiatives, such as prohibiting “non-nutritious” foods in benefit programs, that garner additional points in the program application process.

Michael Chameides, a county supervisor in rural New York, said he fears the money could “be used in ways that would hurt certain states or reward certain states.” Chameides is also the communications and policy director with the Rural Democracy Initiative, a national advocacy organization that released a rural action report last month.

Edwin Park, a research professor at Georgetown University’s Center for Children and Families, said federal lawmakers gave Oz and his agency “really excessive discretion” when awarding the money.

Federal administrators have added rules that aren’t within the statute that created the program, Park said. For example, its application guidelines say states cannot use more than 15% of their funding to pay providers for patient care — payments that are expected to take a hit due to the Medicaid cuts.

Georgetown’s health policy experts and Democrats aren’t the only ones with concerns. Some Republicans and small hospitals in Ohio worry the money will go to large health systems instead of smaller, independent hospitals that serve people within their rural communities.

CMS’ Oz repeated the idea of getting “big hospitals to adopt smaller institutions” at the Washington gathering after applications were filed. He used similar language at a rural health summit hosted by South Dakota-based Sanford Health. “How do we get big hospitals to adopt smaller hospitals? Not to take them over, but to keep them viable by giving them good telehealth services, specialty support, radiology support,” he said at the October event.

Sanford owns or manages dozens of hospitals and hundreds of clinics and long-term care centers, as well as a health insurance company. The system reported about $81 million in operating income during the first six months of fiscal year 2025, according to a recent bond rating report.

Last year, Sanford opened a “command center” for its systemwide telehealth initiative. It launched a telehealth expansion in 2021 and offers virtual care for 78 medical specialties, Sanford President and CEO Bill Gassen said.

“We’ve tried to imagine, what if that number doubles?” Gassen said. The startup costs for telehealth are high, he said, and the rural fund could be a unique opportunity “for us to make virtual care available to more patients, to more communities, to more hospitals and health systems across the country.”

Gassen, who is set to chair the American Hospital Association in 2027, said Sanford leaders have met with state and federal officials, including Oz, whom he’s known for years, and Chris Klomp, a top deputy at CMS and a senior adviser to Health and Human Services Secretary Robert F. Kennedy Jr.

The word “telehealth” appears 36 times in the rural health program’s 124-page application guidelines. But Don Robbins Jr., chief executive of a small hospital on the Illinois-Kentucky border, chuckled at the idea of using the funding for that purpose.

Robbins, whose 25-bed Massac Memorial Hospital averages five to seven patients in its beds each day, said his hospital does not regularly offer telehealth. Even if it did, he said, patients living more than a mile outside of town couldn’t use it because they don’t have a good internet connection.

The small hospital reported a $31,314 loss in September, Robbins said. “I think if we get anything out of it,” Robbins said of the rural health program, “we’ll be lucky.”

Kopplin, the physician assistant who attended the South Dakota meeting, is cautiously optimistic about the rural health fund. She views it as a wonderful chance for states to test out ideas and learn from what works and what doesn’t.

But “in a lot of ways this bill is going to be a band-aid approach” for rural health, she said. “It’s not really going to fix the problem.”

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WASHINGTON — Nationwide, states are racing to win their share of a new $50 billion rural health fund. But helping rural hospitals, as originally envisioned, is quickly becoming a quaint idea.

Rather, states should submit applications that “rebuild and reshape” how health care is delivered in rural communities, Centers for Medicare & Medicaid Services official Abe Sutton said late last month during a daylong meeting at Washington, D.C.’s Watergate Hotel. Simply changing the way government pays hospitals has been tried and has failed, Sutton told the audience of more than 40 governors’ office staffers and state health agency leaders — some from as far away as Hawaii.

“This isn’t a backfill of operating budgets,” said Sutton, CMS’ innovation director. “We’ve been really clear on that.”

Rural hospitals and clinics nationwide face a looming financial catastrophe, with President Donald Trump’s massive tax-and-spending law expected to slash federal Medicaid spending on health care in rural areas by $137 billion over 10 years. Congressional Republicans added the one-time, five-year Rural Health Transformation Program as a last-minute sweetener to win the support of conservative holdouts who worried about the bill’s financial fallout for rural hospitals.

Yet, the words used by CMS Administrator Mehmet Oz and his agency’s leaders to describe the new pot of cash are generating tension between legacy hospital and clinic providers and new technology-focused companies stepping in to offer new ways to deliver health care.

It’s “what I would call incumbents versus insurgents in the rural space,” said Kody Kinsley, a senior policy adviser at the Institute for Policy Solutions at the Johns Hopkins School of Nursing.

Applications are due Nov. 5. The money will be awarded to states by the end of the year and distributed over five years.

Half of the $50 billion will be divided equally among all states with an approved application; the other half will go to states that win points. Of the second half, $12.5 billion will be allotted based on a formula that calculates each state’s rurality. The remaining $12.5 billion will go to states that score well on initiatives and policies that mirror the Trump administration’s “Make America Healthy Again” objectives.

The application identifies specific policy goals such as implementing the Presidential Fitness Test and restrictions to food assistance, as well as broader investment strategies around remote care services, data infrastructure, and consumer-facing technology tools, which CMS identified as “symptom checkers and AI chatbots.”

In September, after CMS officials released the application, Republican members of Congress from states with Democratic governors called for fairness, concerned their states might direct the money to urban areas. In a letter to Oz and Health and Human Services Secretary Robert F. Kennedy Jr., they said the money “will serve as a lifeline for rural and at-risk hospitals in our communities that are already struggling to keep their doors open.”

Smaller hospitals fear they will get “a tiny little slice” of each state’s share, said Emily Felder, who leads the health care practice at Brownstein Hyatt Farber Schreck, a law firm whose clients include rural hospital systems.

“There’s a lot of frustration,” Felder said.

But Kinsley, who was previously North Carolina’s secretary of health and human services, said using this money only to shore up a balance sheet “is really just throwing good money after bad.” In contrast, he said, insurgents such as technology-driven startups can offer new strategies.

One of those companies vying for funding is Homeward Health, a Silicon Valley-based company that contracts with Medicare managed care insurers. Using artificial intelligence analytics, Homeward helps patients get care in their home and with local providers.

The company manages the health of 100,000 rural Michigan patients enrolled in insurance, said Homeward co-founder and chief executive Jennifer Schneider. The company was a sponsor for the Watergate summit. It also has ongoing meetings with Oz and his team, Schneider said.

“They’re doing their job, and they’re talking to a lot of people in the ecosystem and really eager to learn from those of us that have been in the system,” Schneider said. “We’re one of many in that position.”

KFF Health News requested an interview with Alina Czekai, director of the newly created Office of Rural Health Transformation. CMS spokesperson Alexx Pons said the agency was “unable to accommodate facilitation of any interview.”

Instead, CMS provided an emailed statement from Oz saying the program “will help states and communities reimagine what’s possible for rural healthcare.”

Brock Slabach, chief operations officer of the National Rural Health Association, the largest organization representing rural hospitals and clinics, said the money would best be used to help pay for transformation that isn’t “sexy” or “revolutionary.”

“If what we end up with is we have a wearable for every rural patient, I don’t think that’s transformational,” Slabach said, referring to digital health monitors such as fitness-tracking watches.

Slabach, a onetime small-hospital chief executive and an unofficial adviser to hundreds of rural facilities nationwide, named a few ideas for the money — including paying for capital improvements such as electronic health records or equipment, loan repayment programs to aid workforce development, and creating “SWAT” teams that rescue rural hospitals on the brink of closure.

More than 150 rural hospitals have closed nationwide since 2010 — a statistic cited by CMS’ Sutton that is well known among industry watchers. The Sheps Center at the University of North Carolina, which compiles the closure data, also released a guide to help states calculate how rural they are for their applications.

State applications will be reviewed by a panel, with some reviewers from within the government but others outside it, said Kate Sapra, acting deputy director of the Office of Rural Health Transformation, speaking at the Watergate.

“We will train them in the scoring criteria,” Sapra said, adding that the panelists will not be coming from “your state” and will need to fill out conflict-of-interest forms. A portion of money each state gets will be reevaluated annually based on the progress it makes on its goals and priorities, according to CMS.

States are creating stakeholder groups, asking for public comment, and working with their health agencies. Some, such as Mississippi and New Mexico, are hiring consultants.

In Montana, a collection of health providers and associations proposed a list of ideas for the cash, including creating a loan repayment fund for rural clinicians to try to ease worker shortages.

“It’s one-time money, and it’s a little bit of money,” said David Mark, a doctor who is the CEO of One Health, which has clinics dotted across eastern Montana and Wyoming. A state could receive a minimum of $100 million a year for five years if all 50 states have applications approved.

“How do you accomplish goals of a health care system transformation with an infusion of money like that?” Mark said.

Neither Montana nor Wyoming — vast, rural states — sent leaders to the Watergate summit, according to a copy of the attendees list. In the afternoon, attendees could rotate among planning tables and meet with corporate sponsors such as the electronic health records behemoth Epic and the emergency services company Global Medical Response.

Wyoming Department of Health Deputy Director Franz Fuchs confirmed his state did not send representatives to the event, because they were “stretched with other commitments.” Montana, Wyoming, and other states submitted an optional letter of intent signaling they will apply for the funds. CMS did not respond to questions about how many and which states have submitted letters.

During the Watergate event, hints of brewing competition among states began to surface.

“I think Arkansas’ application is going to be better than yours,” seasoned political adviser Jack Sisson said with a smile during a morning panel.

The audience laughed. Sisson, who recently left his job as health adviser for Arkansas Gov. Sarah Sanders, had interrupted Michael Hendrix, policy adviser to another Republican governor, Tennessee’s Bill Lee.

“See, this is the kind of friendly competition that CMS is hoping for,” Hendrix said. He grinned, thanked Sisson, and added, “I look forward to us both winning.”

KFF Health News Montana correspondent Katheryn Houghton contributed to this report.

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Un poste naranja y una señal de “¡Atención!” al costado de una carretera marcan el lugar donde está enterrado un cable de fibra óptica.

“Tienen necesidades de atención médica, pero carecen de las habilidades digitales necesarias”, dijo Waiters, quien trabaja como navegadora digital para una organización sin fines de lucro de Alabama. Su trabajo ha consistido en regalar computadoras y tabletas, a la vez que imparte clases sobre cómo usar internet para el trabajo y necesidades personales, como el banco y la salud. “Es como un espacio extraño”.

Esas historias ahora tienen un sabor agridulce.

Wakers forma parte de una red de navegadores digitales en todo el país, cuyo trabajo para acercar a otros al mundo digital se financió, en parte, a través de un programa federal de $2.750 millones que canceló abruptamente su financiación esta primavera.

La suspensión se produjo después de que el presidente Donald Trump publicara en su plataforma Truth Social que la Ley de Equidad Digital era inconstitucional y prometiera “¡no más ayudas a la conciencia pública basadas en la raza!”.

La ley detalla exactamente a quiénes debería beneficiar el dinero, incluyendo hogares de bajos ingresos, residentes mayores, algunas personas en cárceles, estadounidenses de zonas rurales, veteranos y miembros de minorías raciales o étnicas.

Políticos, investigadores, bibliotecarios y defensores afirmaron que la desfinanciación del programa, junto con otros cambios en las iniciativas federales de banda ancha, pone en peligro los esfuerzos para ayudar a los residentes rurales y desfavorecidos a participar en la economía moderna y llevar una vida más saludable.

“Se podían ver vidas cambiando”, dijo Sam Helmick, presidente de la Asociación Americana de Bibliotecas, recordando cómo ayudaron a abuelos en Iowa a consultar recetas médicas en línea o a trabajadores despedidos de fábricas a llenar solicitudes de empleo.

La Ley de Equidad Digital forma parte de la amplia ley de infraestructura de 2021, que incluyó $65.000 millones para construir infraestructura de internet de alta velocidad y conectar a millones de personas sin acceso a internet.

Este año, el Congreso impulsó una vez más un enfoque moderno para ayudar a los estadounidenses, exigiendo a los líderes estatales que priorizaran las tecnologías nuevas y emergentes a través de su Programa de Transformación de la Salud Rural, de $50.000 millones.

Un análisis de KFF Health News reveló que casi 3 millones de personas a lo largo del país viven en zonas con escasez de profesionales médicos y donde los servicios modernos de telesalud suelen ser inaccesibles debido a las malas conexiones a internet.

El análisis reveló que en unos 200 condados, principalmente rurales, donde persisten las zonas sin cobertura, los residentes viven con mayor riesgo de enfermedad y mueren antes, en promedio, que las personas del resto del país. El acceso a internet de alta velocidad se encuentra entre una serie de factores sociales, como la alimentación y una vivienda segura, que ayudan a las personas a llevar una vida más saludable.

“Internet proporciona esta capa adicional de resiliencia”, afirmó Christina Filipovic, quien dirige la investigación de una iniciativa del Institute for Business in the Global Context de la Universidad de Tufts. En 2022, el grupo de investigación descubrió en 2022 que el acceso a internet de alta velocidad se correlacionaba con una menor mortalidad por covid-19, especialmente en áreas metropolitanas.

Durante la pandemia de covid, los legisladores federales lanzaron un programa de subsidios financiado por la ley de infraestructura. Esta ayuda, denominada Programa de Conectividad Asequible, buscaba conectar a más personas con sus trabajos, escuelas y médicos. En 2024, el Congreso no renovó la financiación del programa de subsidios, que había inscrito a unos 23 millones de hogares de bajos ingresos.

Este año, el secretario de Comercio de Estados Unidos, Howard Lutnick, renovó y retrasó la iniciativa de construcción de la ley de infraestructura —conocida como Programa de Equidad, Acceso e Implementación de Banda Ancha (BEAD)— tras anunciar planes para reducir las cargas regulatorias. Más de 40 estados y territorios han presentado propuestas finales para extender internet de alta velocidad a zonas desatendidas bajo las nuevas directrices de la administración, según un panel del Departamento de Comercio.

En mayo, la financiación de la Ley de Equidad Digital se canceló pocos días después de la publicación de Trump en Truth Social. Si bien muchos estados recibieron fondos para planificar sus programas en 2022, la siguiente ronda de financiación, destinada a que los estados y las agencias implementaran los planes, se había otorgado en gran medida, pero no distribuido.

En cambio, los reguladores federales, incluida la Administración Nacional de Telecomunicaciones e Información (NTI), la agencia federal que supervisa la implementación de la Ley de Equidad Digital, notificaron a los beneficiarios que las subvenciones serían canceladas.

Se crearon y administraron con “preferencias raciales inconstitucionales”, según la carta.

En Phoenix, Arizona, las autoridades se enteraron en enero de que la ciudad recibiría $11,8 millones para aumentar el acceso a internet y enseñar alfabetización digital, pero recibieron un correo electrónico el 20 de mayo indicando que todas las subvenciones, “excepto las destinadas a Entidades Nativas”, habían sido canceladas.

“Es una pena”, declaró la alcaldesa de Phoenix, la demócrata Kate Gallego. El dinero, afirmó, habría ayudado a 37.000 residentes a obtener acceso a internet.

En julio, los líderes demócratas de Georgia enviaron una carta a Lutnick y al entonces administrador interino de la NTIA, Adam Cassady, reclamando la restitución de los fondos, señalando que el recorte federal ignora la intención del Congreso y vulnera la confianza pública.

La creadora de la ley, la senadora Patty Murray (demócrata por Washington), declaró durante una conferencia de prensa en línea en mayo que los gobernadores republicanos de 2024 apoyaron la ley y su financiación cuando cada estado promocionó la finalización de sus planes de equidad digital requeridos y solicitó recursos.

“No puedo creer que no haya gobernadores republicanos que se unan a nosotros para luchar contra esto”, declaró Murray, y agregó que “la otra vía es a través de los tribunales”.

Los 50 estados desarrollaron planes de equidad digital luego de meses de grupos focales, encuestas y períodos de consulta pública. La directora de Equidad Digital de la NTIA, Angela Thi Bennett, durante una entrevista en agosto de 2024 con KFF Health News, afirmó que la “participación comunitaria deliberada” de los líderes federales y estatales para brindar banda ancha a las comunidades desatendidas fue “la mayor demostración de democracia participativa que nuestro país haya visto jamás”.

No fue posible contactar con Thi Bennett para que comentara sobre este artículo. El voceru de la NTIA, Stephen Yusko, afirmó que la agencia “no podrá atender” una solicitud de entrevista con Thi Bennett y no respondió a las preguntas para este artículo.

Caroline Stratton, directora de investigación del Instituto Benton para la Banda Ancha y la Sociedad, afirmó que la financiación de la ley permitió a los estados dotar de personal a sus oficinas; identificar programas de internet de alta velocidad existentes, incluyendo los que operan en otras agencias estatales; y crear planes para subsanar las deficiencias.

“Esto motivó a la gente a investigar”, explicó Stratton, para ver si las agencias del estado ya estaban trabajando en planes de mejora de la salud y para preguntarse si el trabajo en banda ancha podría contribuir y “ayudar activamente a mejorar la situación”.

Las solicitudes de subvenciones estatales incluían objetivos para promover el acceso a la atención médica. En Mississippi, el plan consiste en una iniciativa para mejorar la salud de la universidad estatal y otra agencia, explicó Stratton.

Si bien los estados debían crear programas que ayudaran a poblaciones específicas cubiertas, algunos modificaron el lenguaje o agregaron subcategorías para incluir a otras poblaciones. El plan de Colorado incluía a inmigrantes y a personas sin hogar.

“En todos los estados, hay una pérdida”, afirmó Angela Siefer, directora ejecutiva de la Alianza Nacional para la Inclusión Digital. La organización sin fines de lucro, que recibió casi $26 millones para colaborar con organizaciones de todo el país, pero no recibió fondos, presentó una demanda el 7 de octubre para obligar a Trump y al gobierno a distribuir el dinero.

“La brecha digital no ha terminado”, declaró Siefer.

La subvención de la organización se había planificado para apoyar a los navegadores digitales en 11 estados y territorios, incluyendo a Waiters. Su empleador, la organización sin fines de lucro Community Service Programs of West Alabama, esperaba recibir una subvención de $1,4 millones.

En los últimos dos años, Waiters dedicó horas a recorrer las carreteras rurales de Alabama para llegar a los residentes. Ha distribuido 648 dispositivos (computadoras portátiles, tabletas y tarjetas SIM) y ha ayudado a cientos de clientes mediante 117 clases de habilidades digitales de dos horas en bibliotecas, centros para personas mayores y programas de desarrollo laboral en Tuscaloosa, Alabama, y sus alrededores.

Personas de “todas las razas, edades y niveles económicos” que no “encajaban en nuestra típica categoría minoritaria” recibieron ayuda gracias a su trabajo, afirmó Waiters. Dijo que Trump y su administración deberían saber “cómo se ve realmente la situación para la gente a la que sirvo”.

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“They have health care needs, but they don’t have the digital skills,” said Waiters, who is a digital navigator for an Alabama nonprofit. Her work has involved giving away computers and tablets while also teaching classes on how to use the internet for work and personal needs, like banking and health. “It’s like a foreign space.”

Those stories are now bittersweet.

Waiters is part of a network of digital navigators across the country whose work to bring others into the digital world was, at least in part, propped up by a $2.75 billion federal program that abruptly canceled funding this spring. The halt came after President Donald Trump posted on his Truth Social platform that the Digital Equity Act was unconstitutional and pledged “no more woke handouts based on race!”

The act lists exactly whom the money should benefit, including low-income households, older residents, some incarcerated people, rural Americans, veterans, and members of racial or ethnic minority groups. Politicians, researchers, librarians, and advocates said defunding the program, along with other changes in federal broadband initiatives, jeopardizes efforts to help rural and underserved residents participate in the modern economy and lead healthier lives.

“You could see lives change,” said Sam Helmick, president of the American Library Association, recalling how they helped grandpas in Iowa check prescriptions online or laid-off factory workers fill out job applications.

The Digital Equity Act is part of the sweeping 2021 infrastructure law, which included $65 billion to build high-speed internet infrastructure and connect millions without access to the internet.

This year, Congress once again pushed for a modern approach to help Americans, mandating that state leaders prioritize new and emerging technologies through its $50 billion Rural Health Transformation Program.

A KFF Health News analysis found that nearly 3 million people in America live in areas with shortages of medical professionals and where modern telehealth services are often inaccessible because of poor internet connections. The analysis found that in about 200 mostly rural counties where dead zones persist, residents live sicker and die earlier on average than people in the rest of the country. Access to high-speed internet is among a host of social factors, like food and safe housing, that help people lead healthier lives.

“The internet provides this extra layer of resilience,” said Christina Filipovic, who leads the research for an initiative of the Institute for Business in the Global Context at Tufts University. The research group found in 2022 that access to high-speed internet correlated with fewer covid deaths, particularly in metro areas.

During the covid-19 pandemic, federal lawmakers launched a subsidy program paid for by the infrastructure law. That aid, called the Affordable Connectivity Program, aimed to connect more people to their jobs, schools, and doctors. In 2024, Congress did not renew funding for the subsidy program, which had enrolled about 23 million low-income households.

This year, U.S. Commerce Secretary Howard Lutnick revamped and delayed the infrastructure law’s construction initiative — known as the Broadband Equity, Access, and Deployment Program, or BEAD — after announcing plans to reduce regulatory burdens. More than 40 states and territories have submitted final proposals to extend high-speed internet to underserved areas under the administration’s new guidelines, according to a Commerce Department dashboard.

In May, the Digital Equity Act’s funding was terminated within days of Trump’s Truth Social post. While many states in 2022 had received money to plan their programs, the next round of funding, designated for states and agencies to implement the plans, had largely been awarded but not distributed.

Instead, federal regulators — including the National Telecommunications and Information Administration, the federal agency overseeing implementation of the Digital Equity Act — notified recipients that the grants would be terminated. The grants were created and administered with “unconstitutional racial preferences,” according to the letter.

In Phoenix, officials learned in January that the city was slated to get $11.8 million to increase internet access and teach digital literacy, but they received an email May 20 stating that all grants, “except for grants to Native Entities,” had been terminated. “It’s a shame,” said Phoenix Mayor Kate Gallego, a Democrat. The money, she said, would have helped 37,000 residents get internet access.

Georgia’s Democratic leaders in July sent a letter to Lutnick and NTIA’s then-acting administrator, Adam Cassady, urging reinstatement of the money, noting that the federal cut ignores congressional intent and violates public trust.

The act’s creator, Sen. Patty Murray (D-Wash.), said during an online press conference in May that Republican governors in 2024 supported the law and its funding when each state touted completing its required digital equity plans and asked for resources.

“I cannot believe there aren’t Republican governors out there that are going to join with us to fight back on this,” Murray said, adding “the other way is through courts.”

All 50 states developed digital equity plans after months of focus groups, surveys, and public comment periods. NTIA Digital Equity Director Angela Thi Bennett, during an August 2024 interview with KFF Health News, said the “intentional community engagement” by federal and state leaders to deliver broadband to unserved communities was “the greatest demonstration of participatory democracy our country has ever seen.”

Thi Bennett could not be reached for comment on this article. NTIA spokesperson Stephen Yusko said the agency “will not be able to accommodate” a request for an interview with Thi Bennett and did not respond to questions for this article.

Caroline Stratton, a research director at the Benton Institute for Broadband & Society, said the act’s funding allowed states to staff offices; identify existing high-speed internet programs, including those operating within other state agencies; and create plans to fill the gaps.

“This sent folks out looking,” Stratton said, to see whether agencies in the state were already working on health improvement plans and to ask whether the broadband work could contribute and “actively help move the needle.”

State grant applications included goals to promote health care access. In Mississippi, the plan consists of the state university and another agency’s health improvement plan, Stratton said.

While states were required to create programs that would help specific covered populations, some states modified the language or added subcategories to include other populations. Colorado’s plan included immigrants and “individuals experiencing homelessness.”

“In every state, there’s a loss,” said Angela Siefer, executive director of the National Digital Inclusion Alliance. The nonprofit, which was awarded nearly $26 million to work with organizations nationwide but did not receive any funds, filed a lawsuit Oct. 7 seeking to force Trump and the administration to distribute the money.

“The digital divide is not over,” Siefer said.

The nonprofit’s grant had been planned to support digital navigators in 11 states and territories, including Waiters. Her employer, the nonprofit Community Service Programs of West Alabama, expected to receive a $1.4 million grant.

In the past two years, Waiters spent hours driving the roads of rural Alabama to reach residents. She has distributed 648 devices — laptops, tablets, and SIM cards — and helped hundreds of clients through 117 two-hour digital skills classes at libraries, senior centers, and workplace development programs in and around Tuscaloosa, Alabama.

People of “all races, of all ages, of all financial backgrounds” who did not “fit into our typical minority category” were helped through her work, Waiters said. Trump and his administration should know, she said, “what it actually looks like for the people I serve.”

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“It is almost impossible to explain what it takes to keep a child alive who should be dead,” said Fabrello, whose son, Ysadore Maklakoff, experienced a rare brain condition called acute necrotizing encephalopathy at 9 months old.

Through North Carolina’s Medicaid program, Maklakoff qualifies for a large slate of medical care in the family’s home in Chapel Hill. Fabrello said she works with staffing agencies to arrange services. She also learned to give the care ordinarily performed by a doctor, skilled nurse, or highly trained therapist because she often can’t get help.

Now, broad cuts to North Carolina Medicaid will make finding and paying for care even more difficult.

Nationwide, states are scrambling to close budget shortfalls and are eyeing Medicaid, generally one of a state’s biggest costs — even before President Donald Trump’s hulking tax-and-spending law decreases federal spending on Medicaid by about $1 trillion over the next decade.

North Carolina and Idaho have already announced plans to cut Medicaid payments to health care providers, including hospitals, doctors, and caregivers.

In Michigan and Pennsylvania — where lawmakers have yet to pass budgets this year — spending on Medicaid is part of those debates. In Washington state, lawmakers approved cuts to the program that will not affect who is eligible, said Hayden Mackley, a spokesperson for the state’s Office of Financial Management.

Medicaid is government health insurance for people with low incomes or disabilities and both state and federal dollars pay for the program.

North Carolina’s Medicaid agency announced it will institute on Oct. 1 a minimum 3% reduction in pay for all providers who treat Medicaid patients. Primary care doctors face an 8% cut and specialty doctors a 10% drop in payments, according to the North Carolina Department of Health and Human Services.

Fabrello said her son’s dentist already called to say the office will not accept Medicaid patients come November. Fabrello fears dental work will become another service her son qualifies for but can’t get because there aren’t enough providers who accept Medicaid coverage.

Occupational and speech therapy, nursing care, and respite care are all difficult or impossible to get, she said. In a good week, her son will get 50 hours of skilled nursing care out of the 112 hours he qualifies for.

“When you say, ‘We’re just cutting provider rates,’ you’re actually cutting access for him for all his needs,” Fabrello said.

Shannon Dowler, former chief medical officer for North Carolina Medicaid, said that reduced payments to dentists and other providers will lower the number of providers in the state’s Medicaid network and result in “an immediate loss of access to care, worse outcomes, and cause higher downstream costs.”

The imminent cuts in North Carolina “don’t have anything to do” with the new federal law that cuts Medicaid funding, Dowler said.

“This is like the layers of the onion,” she said. “We are hurting ourselves in North Carolina way ahead of the game, way before we need to do this.” North Carolina alone is projected to lose about $23 billion in federal Medicaid dollars over the next decade.

More than 3 million North Carolinians are enrolled in Medicaid. Deadlocked state lawmakers agreed to a mini budget in July to continue funding state programs that gave the Medicaid agency $319 million less than it requested. Lawmakers can choose to reinstate funding for Medicaid this fiscal year, Dowler said.

“We all hope it changes,” Dowler said, adding that if it does not, “you’re going to see practices dropping coverage of Medicaid members.”

Each year since at least 2019, North Carolina’s Medicaid agency has asked for more money than it received from the state legislature. A variety of federal resources, including money provided to states during the covid-19 pandemic, helped bridge the gap.

But those funds are gone this year, leaving the agency with a choice: Eliminate some optional parts of the program or force every provider that accepts the public insurance to take a pay cut. The state opted mostly for the latter.

“It’s a difficult moment for North Carolina,” said Jay Ludlam, deputy secretary for North Carolina Medicaid. The cut in the budget is “absolutely the opposite direction of where we really want to go, need to go, have been headed as a state.”

For Anita Case, who leads a small group of health clinics in North Carolina, the cuts make it harder to take care of the “most vulnerable in our community.”

Western North Carolina Community Health Services’ three clinics serve about 15,000 patients in and around Asheville, including many non-English-speaking tourism workers. Case said she will look at staffing, services, and contracts to find places to trim.

Idaho has about 350,000 people enrolled in Medicaid. This month, state leaders there responded to an $80 million state budget shortfall by cutting Medicaid pay rates 4% across the board.

The broad cuts have raised backlash from nursing home operators and patient advocacy groups. Leaders of one nursing home company wrote in a recent op-ed in the Idaho Statesman newspaper that 75% to 100% of the funding at their facilities comes from Medicaid and the cuts will force them to “to reduce staff or accept fewer residents.”

Idaho Department of Health and Welfare spokesperson AJ McWhorter said the state faced tough choices. It forecasted 19% growth in Medicaid spending this year.

The Idaho Hospital Association’s Toni Lawson said the financial strain will be greatest at about two dozen small hospitals — ones with 25 or fewer beds — that dot the state. Lawson, the organization’s chief advocacy officer, said one hospital leader reported they had less than two days’ cash on hand to make payroll. Others reported 30 days’ cash or less, she said.

“Hopefully, none of them will close,” Lawson said, adding that she expects labor and delivery and behavioral health units, which often lose money, to be the first to go because of this latest state reduction in payments. Several hospitals in mostly rural areas of the state closed their labor and delivery units last year, she said.

Nationwide, Medicaid makes up an average of 19% of a state’s general fund spending, second only to K-12 spending, said Brian Sigritz, director of state fiscal studies for the National Association of State Budget Officers.

States generally had strong revenue growth in 2021 and 2022 because of economic growth, which included federal aid to stimulate the economy. Revenue growth has since slowed, and some states have cut income and property taxes.

Meanwhile, spending on Medicaid, housing, education, and disaster response has increased, Sigritz said.

In North Carolina, Fabrello has been unable to work outside of caring for her son. Her savings are almost exhausted, Fabrello said, and she was on the brink of financial ruin until North Carolina began allowing parents to be compensated for caregiving duties. She’s received that income for about a year, she said. Without it, she worried about losing her home.

Now, if the state reductions go through, she faces a salary cut.

“As parents, we are indispensable lifelines to our children, and we are struggling to fight for our own survival on top of it,” Fabrello said.

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KFF Health News has partnered with InvestigateTV to tell the stories of residents whose health care falls into the gap. InvestigateTV’s Caresse Jackman and KFF Health News’ Sarah Jane Tribble take viewers to Alabama, Idaho, and West Virginia to explain why those connectivity gaps persist.

Explore the full investigation here.

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The cuts are “just a little astonishing,” said Carole Johnson, who previously led the Health Resources and Services Administration. She left the agency in January with the administration change and has described the sweeping staff cuts as a “big threat” to the agency’s ability to distribute billions of dollars in grants to hospitals, clinics, nonprofits, and other organizations nationwide.

Since February, about a quarter of workers at HRSA — including analysts, auditors, scientists, grant managers, and nursing consultants — have left, according to a KFF Health News analysis.

The agency, headquartered in a nondescript gray-and-glass office building tucked into side streets in Rockville, Maryland, employed about 2,700 staffers in early 2025. Employees worked behind the scenes to manage and monitor thousands of projects nationwide that fund primary health providers, HIV/AIDS treatment and prevention, maternal and child care programs, rural hospitals, and workforce training.

On the ground, HRSA’s grants have helped create telehealth initiatives for mothers in rural New Mexico, funded workforce training for Indigenous nurses in South Dakota, and supported Healthy Start programs for expectant mothers and babies in places like rural Georgia.

Ryan Alcorn, a co-founder and the chief executive of GrantExec, a company that helps organizations match and apply for funding, said every American benefits from the programs HRSA’s funding supports: “When the safety net fails, hospitals become overwhelmed, unpaid costs rise, and premiums go up for everyone.”

Several former HRSA leaders, who have been in touch with employees, confirmed the magnitude of the cuts estimated by KFF Health News. Johnson said she believes the actual number of workers lost is larger.

More than 700 workers were fired or chose to leave from February through the end of June. The analysis is based on data from the HHS employee directory, which may not include workers who opted out of being listed, and may not be an exact count of the worker roster, which is in flux.

Johnson, who is now a senior fellow at the Century Foundation, and several other former employees interviewed by KFF Health News said they are concerned that specific programs will be eliminated, but also that reduced staffing could affect ongoing program oversight. The agency’s workforce ethos, Johnson said, is one in which “if there were two people left at HRSA, they would work around the clock to try to get the money out.”

For at least one program, revealed during a tense moment on Capitol Hill in July, money to help low-income and minority students has already stopped flowing to colleges and universities. The Scholarship for Disadvantaged Students program, established through congressional legislation, helped schools pay for students to train to become dentists, physician assistants, midwives, and nurses — all of whom are in short supply in rural and some urban areas. Candice Chen, acting associate administrator of HRSA’s health workforce bureau, confirmed the agency “did have competitions that were canceled.”

When U.S. Rep. Diana DeGette (D-Colo.) asked whether they were canceled by the Trump administration, Chen paused before speaking again: “Well, the funding decisions were made across the administration.”

Asked about the canceled funding, officials from several schools declined to comment. Patrick Gonzales, a spokesperson for the University of Texas-Rio Grande Valley, said in an emailed statement that the school is “helping students navigate this transition with clarity and care.”

U.S. Sen. Angela Alsobrooks (D-Md.) has called for Health and Human Services Secretary Robert F. Kennedy Jr.’s resignation or firing, “whichever one comes first,” saying there was “no defensible answer” to eliminating thousands of workers across federal agencies.

In April, nearly a dozen Democratic senators sent a letter to Kennedy demanding answers about the mass firings, noting HRSA is the “primary agency tasked with improving access to health care for vulnerable populations.”

HHS did not respond to the senators’ letter. Kennedy and the Department of Health and Human Services “has refused to answer basic questions about why the administration conducted mass firings in this office,” said Sen. Lisa Blunt Rochester (D-Del.).

President Donald Trump’s proposed fiscal 2026 budget eliminates HRSA as well as some of its programs, including grants to rural hospitals, workforce training, Ryan White HIV/AIDS programs, and emergency medical services for children. HRSA spokesperson Andrea Takash said in an emailed response that HHS is “undertaking organizational changes that support multiple goals while ensuring continuity of essential services.”

HRSA continues to process new funding announcements and awards for the health centers, workforce programs, child and maternal health initiatives, and “many more of our critical programs and services,” Takash said.

HRSA’s largest bureau supports thousands of community health centers that serve over 31 million people nationwide. Before the end of September, the agency’s grants are still scheduled to pay out billions more to health clinics and other organizations nationwide.

Cuts to health centers could come under more scrutiny because their funding has “a lot of bipartisan” support, said Celli Horstman, a senior research associate at the Commonwealth Fund, a health research nonprofit. HRSA’s funding, which includes Section 330 grants, goes to “keeping the doors open” at federally qualified health centers nationwide, Horstman said.

An additional 42% of health center funding comes from Medicaid, a federal and state insurance program that covers people with low incomes and those with disabilities, she said. Congress recently voted to reduce Medicaid funding.

Joe Stevens, spokesperson for the Virginia Community Healthcare Association, said health centers are rethinking “how they do business” because of the Medicaid cuts and the increased administrative challenges faced when processing their HRSA grants, which have been more challenging to obtain since February. Virginia’s health clinics treat about 400,000 people annually, Stevens said.

“It’s a system that’s been in place for 50-plus years, and this is the first time they’re having issues receiving their funds,” he said, noting that clinics now must also provide an itemized list of how the money is to be used after grants have been approved.

“Our health centers are understaffed, so having somebody to have to enter that information every two weeks is just more time,” Stevens said.

For months, HRSA staff across all departments have worked through changes to their technology systems and transitioned work to others as employees left their jobs. Workers have continued to process grants despite an executive order that froze federal funding and a March announcement that HHS would lay off 10,000 workers and shut down entire agencies — including HRSA.

One former employee said that, at this point, “all we’re doing now is keeping the lights on.”

Michael Warren, who left the agency in June, ran HRSA’s Maternal and Child Health Bureau. Warren described the bureau’s staffing cuts as “substantial.” The bureau awarded more than $628 million in grants between Oct. 1, 2024, and July 22, 2025, to programs that included providing block grants to states and funding home visiting programs, through which trained staffers work with families with young children.

Warren, who is now the chief medical and health officer for the March of Dimes, said America faces a crisis as one of the “most dangerous places in the world to give birth among other high-income countries, and that shouldn’t be the case.”

With tears brimming, Warren said his former employees “wake up every morning, they work all day, and they go to sleep every night thinking about what they can do for mothers, children, and families.”

Methodology

For this article, KFF Health News calculated workforce reductions at the Health Resources and Services Administration using public information from the Department of Health and Human Services directory posted online. We compared the number and type of employees listed with HRSA in February to those in early July. Our employee totals exclude people listed as interns, fellows, student trainees, or volunteers. The directory is not an official count of HRSA employees, but it offers detailed snapshots of trends so far this year. Reporters also cross-checked the estimates with former employees.

We’d like to speak with current and former personnel from the Department of Health and Human Services or its component agencies who believe the public should understand what’s happening within the federal health bureaucracy. Please message KFF Health News on Signal at (415) 519-8778 or get in touch here.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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The Rural Health Transformation Program calls for federal regulators to hand states $10 billion a year for five years starting in fiscal year 2026.

But the “devil’s in the details in terms of implementing,” said Sarah Hohman, director of government affairs at the National Association of Rural Health Clinics.

“An investment of this amount and this style into rural — hopefully it goes to rural — is the type of investment that we and other advocates have been working on for a long time,” said Hohman, whose organization represents 5,600 rural health clinics.

People who live in the nation’s rural expanses have more chronic diseases, die younger, and make less money. Those compounding factors have financially pummeled rural health infrastructure, triggering hospital closures and widespread discontinuation of critical health services like obstetrics and mental health care.

Nearly 1 in 4 people in rural America use Medicaid, the state and federal program for low-income and disabled people. So, as Senate Republicans heatedly debated Medicaid spending reductions, lawmakers added the $50 billion program to quell opposition. But health advocates and researchers doubt it will be enough to offset expected cuts in federal funding.

Senate Majority Leader John Thune, a Republican from South Dakota, which has one of the largest percentages of rural residents in the nation, led the push to pass the budget bill. His website touts support for strengthening access to care in rural areas. But his office declined to respond on the record to questions about the rural health program included in the bill.

Sen. Susan Collins, a Republican from Maine who introduced an initial amendment to add the rural program, also did not respond to a request for comment. On July 15, Sen. Josh Hawley, a Republican from Missouri, introduced a bill to reverse future cuts to Medicaid and add to the rural program.

Michael Cannon, director of health policy studies at the Cato Institute, a libertarian think tank headquartered in Washington, D.C., said the money was set aside because of politics and not necessarily for rural patients.

“As long as it’s a government slush fund where politics decides where the money goes, then there’s going to be a mismatch between where those funds go and what it is consumers need,” Cannon said.

The nonpartisan Congressional Budget Office estimates federal Medicaid spending will be reduced by about $1 trillion over the next decade.

“These dollar amounts translate to actual people,” said Fredric Blavin, a senior fellow and researcher at the Urban Institute, a Washington D.C.-based think tank that focuses on social and economic research.

Most states expanded their Medicaid programs to cover more low-income adults under the Affordable Care Act. That has lowered medical debt, improved health, and even reduced death rates, Blavin said.

By 2034, about 11.8 million people are expected to lose their health insurance from this bill, said Alice Burns, an associate director for KFF’s Program on Medicaid and the Uninsured. And she said the Medicaid rollback may have an outsize impact on rural areas.

In rural areas, federal Medicaid spending is expected to decline by $155 billion over 10 years, according to an analysis by KFF, a health information nonprofit that includes KFF Health News.

If the goal of the rural program was to transform rural health care, as its name suggests, it will fall short, Burns said. The $50 billion rural program distributed over five years won’t offset the losses expected over a decade of Medicaid reductions, she said.

In Kansas, Holton Community Hospital Chief Executive Carrie Lutz said she doesn’t “feel that the sky is falling right now.”

Lutz, whose 14-bed hospital is on the northern plains of the state, said she is bracing for the potential loss of Medicaid-covered patients and limits to provider taxes, which nearly all states use to get extra federal Medicaid money.

The reduction in provider taxes has been delayed until fiscal year 2028, Lutz said, but she still wants her state’s leaders to apply for a portion of the rural program funding, which is expected to be distributed sooner.

“Every little penny helps when you’ve got very negative margins to begin with,” Lutz said.

The program’s $50 billion will be spread over five years and may not be limited to bolstering rural areas or their hospitals. Half of the money will be distributed “equally” among states that apply to and win approval from the Centers for Medicare & Medicaid Services. The law’s current language “raises the possibility” that a small state like Vermont could receive the same amount as a large state like Texas, Burns said.

States are required to submit a “detailed rural health transformation plan” by the end of this year, according to the law.

The law says states should use the funds to pursue goals including improving access to hospitals and other providers, improving health outcomes, enhancing economic opportunity for health care workers, and prioritizing the use of emerging technologies.

Mehmet Oz, a Trump appointee leading Medicare and Medicaid, will determine how to distribute the other half, or $25 billion, using a formula based on states’ rural population and need. The law says the money is to be used for such things as increasing use of robotics, upgrading cybersecurity, and helping rural communities “to right size their health care delivery systems.”

Spokespeople for CMS did not respond to a list of questions.

Kyle Zebley, senior vice president of public policy at the American Telemedicine Association, said there is “a pretty significant degree of discretion” for the White House and the Medicare and Medicaid administrator in approving state plans.

“We will urge states to include robust telehealth and virtual care options within their proposals going up to the federal government,” Zebley said.

Alexa McKinley Abel, government affairs and policy director for the National Rural Health Association, said that while the law calls for states to create and submit plans, it’s unclear what state agencies will perform the task, McKinley Abel said.

“There are a lot of gaps around application and implementation,” she said, noting that an earlier version of the bill called for state plans to be developed in consultation with federally funded state offices of rural health.

But those offices are proposed to be eliminated in Trump’s federal budget, which will face congressional approval in the fall. McKinley Abel said her organization supports state offices of rural health helping develop the plans and working with states to disburse the money, “since they intimately know the rural health community.”

Hohman, with the rural health clinic association, said she is not sure money from the transformation program will even reach her members. About 27% of the patients treated at rural health clinics are enrolled in Medicaid, she said.

“There’s just some confusion about who actually gets this money at the end of the day,” Hohman said. “What is it actually going to be used for?”

KFF Health News senior correspondent Phil Galewitz contributed to this report.

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The Commerce Department, which runs the massive Broadband Equity, Access, and Deployment Program, announced new rules in early June requiring states — some of which were ready to begin construction later this year — to solicit new bids from internet service providers.

The delay leaves millions of rural Americans stranded in places where health care is hard to access and telehealth is out of reach.

“This does monumental harm to rural America,” said Christopher Ali, a professor of telecommunications at Penn State.

The Biden-era program, known as BEAD, was hailed when created in 2021 as a national plan to bring fast internet to all, including millions in remote rural areas.

A yearlong KFF Health News investigation, with partner Gray Media’s InvestigateTV, found nearly 3 million people live in mostly rural counties that lack broadband as well as primary care and behavioral health care providers. In those same places, the analysis found, people live sicker and die earlier on average.

The program adopts a technology-neutral approach to “guarantee that American taxpayers obtain the greatest return on their broadband investment,” according to the June policy notice. The program previously prioritized the use of fiber-optic cable lines, but broadband experts like Ali said the new focus will make it easier for satellite-internet providers such as Elon Musk’s Starlink and Amazon’s Kuiper to win federal funds.

“We are going to connect rural America with technologies that cannot possibly meet the needs of the next generation of digital users,” Ali said. “They’re going to be missing out.”

Republicans have criticized BEAD for taking too long, and Commerce Secretary Howard Lutnick vowed in March to get rid of its “woke mandates.” The revamped “Benefit of the Bargain BEAD Program,” which was released with a fact sheet titled “Ending Biden’s Broadband Burdens,” includes eliminating some labor and employment requirements and obligations to perform climate analyses on projects.

The requirement for states to do a new round of bidding with internet service providers makes it unclear whether states will be able to connect high-speed internet to all homes, said Drew Garner, director of policy engagement at the Benton Institute for Broadband & Society.

Garner said the changes have caused “pure chaos” in state broadband offices. More than half the states have been knocked off their original timeline to deliver broadband to homes, he said.

The change also makes the program more competitive for satellite companies and wireless providers such as Verizon and T-Mobile, Garner said.

Garner analyzed in March what the possible increase in low-Earth-orbit satellites would mean for rural America. He found that fiber networks are generally more expensive to build but that satellites are more costly to maintain and “much more expensive” to consumers.

Commerce Secretary Lutnick said in a June release that the new direction of the program would be efficient and deliver high-speed internet “at the right price.” The National Telecommunications and Information Administration, the Commerce Department agency overseeing BEAD, declined to release a specific amount it hopes to save with the restructuring.

The NTIA also declined to respond on the record to questions about program revisions and delays.

More than 40 states had already begun selecting companies to provide high-speed internet and fill in gaps in underserved areas, according to an agency dashboard created to track state progress.

In late May, the website was altered and columns showing the states that had completed their work with federal regulators disappeared. Three states — Delaware, Louisiana, and Nevada — had reached the finish line and were waiting for the federal government to distribute funding.

The tracker, which KFF Health News saved in March, details the steps each state made in their years-long efforts to create location-based maps and bring high-speed internet to those missing service. West Virginia had completed selection of internet service providers and a leaked draft of its proposed plan shows the state was set to provide fiber connections to all homes and businesses.

Sen. Shelley Moore Capito (R-W.Va.) praised removal of some of the hurdles that delayed implementation and said she thought her state would not have to make very many changes to existing plans during a call with West Virginia reporters.

West Virginia’s broadband council has worked aggressively to expand in a state where 25% of counties lack high-speed internet and health providers, according to KFF Health News’ analysis.

In Lincoln County, West Virginia, Gary Vance owns 21 acres atop a steep ridge that has no internet connection. Vance, who sat in his yard enjoying the sun on a recent day, said he doesn’t want to wait any longer.

Vance said he has various medical conditions: high blood sugar, deteriorating bones, lung problems — “all kinds of crap.” He’s worried about his family’s inability to make a phone call or connect to the internet.

“You can’t call nobody to get out if something happens,” said Vance, who also lacks running water.

KFF Health News, using data from federal and academic sources, found more than 200 counties — with large swaths in the South, Appalachia, and the remote West — lack high-speed internet, behavioral health providers, and primary care doctors who serve low-income patients on Medicaid. On average, residents in those counties experienced higher rates of diabetes, obesity, chronically high blood pressure, and cardiovascular disease.

The gaps in telephone and internet services didn’t cause the higher rates of illness, but Ali said it does not help either.

Ali, who traveled rural America for his book “Farm Fresh Broadband: The Politics of Rural Connectivity,” said telehealth, education, banking, and the use of artificial intelligence all require fast download and upload speeds that cannot always be guaranteed with satellite or wireless technology.

It’s “the politics of good enough,” Ali said. “And that is always how we’ve treated rural America.”

Fiber-optic cables, installed underground or on poles, consistently provide broadband speeds that meet the Federal Communications Commission’s requirements for broadband download speed of 100 megabits per second and 20 Mbps upload speed. By contrast, a national speed analysis, performed by Ookla, a private research and analytics company, found that only 17.4% of Starlink satellite internet users nationwide consistently get those minimum speeds. The report also noted Starlink’s speeds were rising nationwide in the first three months of 2025.

In March, West Virginia’s Republican governor, Patrick Morrisey, announced plans to collaborate with the Trump administration on the new requirements.

Republican state Del. Dan Linville, who has been working with Morrisey’s office, said his goal is to eventually get fiber everywhere but said other opportunities could be available to get internet faster.

In May, the West Virginia Broadband Enhancement Council signaled it preferred fiber-optic cables to satellite for its residents and signed a unanimous resolution that noted “fiber connections offer the benefits of faster internet speeds, enhanced data security, and the increased reliability that is necessary to promote economic development and support emerging technologies.”

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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Chief rural health correspondent Sarah Jane Tribble explains how millions of rural Americans live in counties with doctor shortages and where high-speed internet connections aren’t adequate to access advanced telehealth services. A KFF Health News analysis found people in these “dead zones” live sicker and die younger on average than their peers in well-connected regions.

KFF Health News has partnered with InvestigateTV to tell the stories of residents whose health care falls into the gap. You can view the full investigation here.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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