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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Robert F. Kennedy Jr. on Sept. 4, 2025, in a Senate hearing

At a September Senate hearing, Health and Human Services Secretary Robert F. Kennedy Jr. boasted about a rural health initiative within  President Donald Trump’s “One Big Beautiful Bill Act.”

“It’s going to be the biggest infusion of federal dollars into rural health care in American history,” Kennedy said, responding to criticism from Sen. Bernie Sanders (I-Vt.). Sanders said the law would harm patients and rural hospitals.

Kennedy was referring to the law’s five-year, $50 billion Rural Health Transformation Program, HHS spokesperson Emily Hilliard said. GOP lawmakers have made similar claims about the program.

The fund was added to the bill at the last minute to secure support from Republican lawmakers who represent rural states. Some were concerned about how the bill’s Medicaid cuts would harm rural America, where more than 150 hospitals have stopped offering inpatient services or been shuttered completely since 2010, according to the Cecil G. Sheps Center for Health Services Research at the University of North Carolina.

“The transformation fund was really talked about in the context of saving rural hospitals that would be facing these significant Medicaid cuts,” said Carrie Cochran-McClain, chief policy officer at the National Rural Health Association. Medicaid is the joint state-federal health insurance program that primarily covers low-income people and those with disabilities.

So is Kennedy right in his description of the rural health fund as a historic cash infusion, or does it fail to acknowledge critical context?

The Rural Health Transformation Program

Trump’s tax and spending law is expected to reduce federal Medicaid spending in rural areas by at least $137 billion by 2034, according to an analysis by KFF, a health information nonprofit that includes KFF Health News. The Congressional Budget Office predicts the law will increase the overall number of uninsured patients by 10 million by 2034.

Rural health facilities disproportionately rely on Medicaid reimbursement to stay afloat. In 2023, 40.6% of children and 18.3% of adults under age 65 from rural areas and small towns were enrolled in Medicaid, according to the Center for Children and Families at Georgetown University. In metro areas, the rates were 38.2% and 16.3%, respectively.

The Trump administration argues that rural hospitals cannot rely on “legacy” funding sources like Medicaid and Medicare due to the programs’ reimbursement structure, which ties payments to the number of services provided, a model that’s not financially sustainable for rural facilities with typically low patient volumes.

“Distinct from these other programs, the Rural Health Transformation Program is designed to provide a flexible source of investment” to promote innovation, efficiency, and sustainability, the White House wrote in a memo.

Here’s how it works. States can propose projects spearheaded by state agencies, health care providers, consultants, and vendors aimed at various purposes, such as improving technology, access to care, and workforce recruitment.

States can use only 15% of their transformation program funding for provider payments and can direct money to non-rural areas, according to KFF.

Half of the $50 billion will be evenly divided among states whose applications are approved — regardless of their rural and overall populations — according to the “Notice of Funding Opportunity” for the program.

The other half will be awarded based on “the transformative possibilities” of states’ grant proposals; how much they’ve committed to aligning their health policies with the Trump administration’s; and data on their rural population, rural health facilities, uncompensated care, and other measurements.

The application deadline is Nov. 5.

The Big Picture

Michael Meit, director of the Center for Rural Health and Research at East Tennessee State University, said the rural health community is excited about the innovations the new program might foster, but he’d “love for it to happen in the absence of these cuts that are going to devastate our rural health system.”

“It’s not going to fill the hole,” Meit said.

KFF estimates that the rural health fund’s five-year, $50 billion investment is a little over a third of the expected loss of federal funding in rural areas that will be spread over 10 years. According to that analysis, Medicaid cuts over that period would tally at least $137 billion in rural areas.

That number doesn’t account for other reductions stemming from the same law, such as cuts to the ACA Marketplaces or the health system revenue loss expected from an increase in the number of people without insurance. 

These factors are important to note because the rural health program is a temporary initiative, while reductions in federal spending are long-term.  

Another issue is the difference in the program’s spirit. The rural health fund is focused on transforming the rural health care system — not providing continued funding to keep facilities open or making up for lost Medicaid funds. Even if the money triggers successful innovations, there are doubts that those will happen in time to prevent rural health facilities from closing.

“There’s a real misperception that somehow these funds are going to be able to save rural America or save rural hospitals,” Cochran-McClain said.

Joseph Antos, a health policy expert and senior fellow emeritus at the conservative-leaning American Enterprise Institute, said Kennedy’s comment is something “politicians say when they want to ignore the rest of the policies.”

“What they wanted was to say that they were creating a new program,” Antos said. “Well, this is a very inefficient way to distribute a relatively very small amount of money to hospitals that will incur much larger bad debt over the coming years, thanks to the cuts in Medicaid.”

One Caveat

Experts said that when viewed outside of mandatory programs like Medicare and Medicaid, the $50 billion rural health fund does appear to be unrivaled, especially for a limited, five-year program.

Several mentioned the Hill-Burton Act as another program that significantly boosted rural health care. The law provided loans and grants that modernized or built 6,800 health facilities, many of which were in rural areas, from 1946 to 1997, according to the Health Resources and Services Administration.

Incomplete funding data makes it difficult to account for inflation, said Kelsey Moran, an assistant professor and health economist at the University of Miami.

But she estimated that, during the life of the program, it spent $47 billion in 2024 dollars when using the Consumer Price Index, or $109 billion when using the CPI’s medical care index. The medical index has a higher inflation rate because health prices have risen more than overall prices.

Our Ruling 

Kennedy said the rural health fund is “going to be the biggest infusion of federal dollars into rural health care in American history.”

The statement contains an element of truth because the new program could be the most significant one-time investment in rural health funding.

But it ignores critical facts and context that create a different impression.

Federal contributions to rural areas from Medicaid and Medicare easily dwarf this program’s $50 billion mark. The new fund offers states flexibility in how they can allocate resources, meaning there’s no guarantee that all the new funding will go to rural Americans’ health care. The program comes at the same time rural areas are expected to lose far more from Medicaid cuts and an increase in uninsured patients than what the rural health fund infusion can backfill.

Experts say the rural health fund’s cash infusion is canceled out by other parts of Trump’s tax and spending law that call for cuts and policy changes.

We rate this statement Mostly False.

Our Sources

“Watch: Sanders, RFK Jr. Get Into Testy Exchange Over COVID Vaccine, CDC Director’s Firing,” CBS News, Sept. 4, 2025.

“$50B Rural Health ‘Slush Fund’ Faces Questions, Skepticism,” KFF Health News, July 21, 2025.

“Rural Hospital Closures,” Cecil G. Sheps Center for Health Services Research at the University of North Carolina-Chapel Hill, accessed Sept. 15, 2025.

“Senate GOP Mulls Shielding Rural Hospitals From Medicaid Cuts,” Roll Call, June 20, 2025.

“Key Takeaways From CMS’s Rural Health Funding Announcement,” KFF, Sept. 23, 2025.

“Estimated Budgetary Effects of Public Law 119-21, To Provide for Reconciliation Pursuant to Title II of H. Con. Res. 14, Relative to CBO’s January 2025 Baseline,” Congressional Budget Office, July 21, 2025.

“Medicaid’s Role in Small Towns and Rural Areas,” Georgetown University Center for Children and Families, Jan. 15, 2025.

“MEMORANDUM Re: The One Big Beautiful Bill is a Historic Investment in Rural Healthcare,” The White House, undated.

Notice of Funding Opportunity for the Rural Health Transformation Program, government document published on Sept. 15, 2025.

“The Federal Budget in Fiscal Year 2023: An Infographic,” Congressional Budget Office, March 5, 2024.

“The Federal Budget in Fiscal Year 2024: An Infographic,” Congressional Budget Office, March 20, 2025.

“Hill-Burton Facilities Compliance,” HRSA, accessed Sept. 16, 2025.

“Hospital Charity Care & The Hill-Burton Act,” working paper by Kelsey Moran updated on Sept. 15, 2025.

Phone interview with Matthew Fiedler, a senior fellow in economic studies at the Center on Health Policy at The Brookings Institution, Sept. 24, 2025.

Phone interview with Gbenga Ajilore, chief economist, and Allison Orris, director of Medicaid policy at the Center on Budget and Policy Priorities, Sept. 24, 2025.

Phone interview with Larry Levitt, executive vice president for health policy at KFF, Sept. 24, 2025.

Phone interview with Joseph Antos, a health policy expert and senior fellow emeritus at the American Enterprise Institute, Sept. 23, 2025.

Phone interview with Carrie Cochran-McClain, chief policy officer at the National Rural Health Association, Sept. 17, 2025.

Phone interview with Kelsey Moran, assistant professor in the Department of Health Management and Policy at the University of Miami, Sept. 15, 2025.

Phone interview with Alana Knudson, director of the NORC Walsh Center for Rural Health Analysis at the University of Chicago, Sept. 12, 2025.

Phone interview with Michael Meit, director of the Center for Rural Health and Research at East Tennessee State University, Sept. 11, 2025.

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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Federal funding ran out at midnight on Oct. 1, after Congress failed to pass even a stopgap budget while negotiations continued.

Now the question is how long the deadlock will last, with Democrats pitted against Republicans and a presidential administration that has broken with constitutional norms and regularly used political intimidation and primary threats to achieve its ends. Because Republicans hold only a slim majority in the Senate, any deal will need to attract at least a few Democratic votes.

Ramifications from a shutdown on public health systems and health programs will be felt far beyond Washington, D.C., halting almost all of the federal government’s nonessential functions, including many operations related to public health.

Even on Sept. 30, as the clock ticked toward midnight, President Donald Trump renewed threats about mass firings of federal workers if Democrats didn’t acquiesce to GOP demands. Some people worry that such workforce reductions would further enable the administration to undermine federal government operations and reduce the budget impasse to what’s been described as three-dimensional chess or a game of chicken.

Such threats to fire, rather than temporarily suspend, federal workers are “unprecedented,” said G. William Hoagland of the Bipartisan Policy Center. The lack of negotiations between Capitol Hill Republicans and Democrats in advance of the shutdown is also unprecedented in his experience, said Hoagland, a longtime GOP Senate Budget Committee aide.

The stalemate centers largely on health coverage, with Democrats and Republicans clashing over the Affordable Care Act and Medicaid cuts. For Americans with ACA marketplace plans, government subsidies cap the percentage of household income they must pay toward premiums. Lawmakers expanded the subsidies in 2021 and extended that additional help through the end of 2025, and the looming expiration of those expanded subsidies would increase costs and reduce eligibility for assistance for millions of enrollees.

Democrats want a further extension of the subsidies, but many GOP lawmakers are resistant to extending them as is and say that debate must wait until after a budget deal to keep the federal government afloat. Antagonism has grown, with the parties in a pitched battle to convince voters the other party is to blame for the government’s closure.

Said Senate Minority Leader Chuck Schumer on the Senate floor Sept. 30: “Republicans have chosen the losing side of the health care debate, because they’re trying to take away people’s health care; they’re going to let people’s premiums rise.”

But Senate Majority Leader John Thune accused Democrats of attempting to “take government funding hostage.”

The longer a shutdown lasts, the more impacts could be felt. For example, some community health centers would be at risk of closure as their federal funding dries up.

Long-term projects by the Federal Emergency Management Agency to reduce damage from future natural disasters will stop, for example. Rescue services at national parks that stay open will be limited. And at the National Institutes of Health, many new patients awaiting access to experimental treatments may not be admitted to its clinical center.

Entitlement programs such as Medicaid and Medicare will continue, as will operations at the Indian Health Service. But disease surveillance, support from the Centers for Disease Control and Prevention to local and state health departments, and funding for health programs will all be hampered, based on federal health agencies’ contingency plans.

The Department of Health and Human Services is expected to furlough about 40% of its workforce, which has already been downsized by about 20,000 positions under the Trump administration. Across the federal government, roughly 750,000 employees will be furloughed, according to an estimate released Sept. 30 by the Congressional Budget Office, a nonpartisan agency that calculates the cost of legislation. While furloughed employees won’t be working, eventually they will get back pay, totaling about $400 million daily, the CBO estimated.

At HHS, research is expected to pause on the links between drug prices and the Inflation Reduction Act, the major law enacted under former President Joe Biden to boost the economy. Despite reports that Food and Drug Administration Commissioner Marty Makary said the FDA would basically be untouched, the agency won’t accept new drug applications and food safety efforts will be reduced. Federal oversight of a program that helps hospitals save lives and evacuate individuals in environmental crises is expected to stop.

Fewer federal staff will be available to provide help to Medicaid and Medicare enrollees. CDC responses to inquiries about public health matters will be suspended. And the work of a federal vaccine injury program is also anticipated to stop.

Congressional Democrats insist the ACA subsidies must be renewed now because enrollment for the Obama-era health program opens on Nov. 1. Without the extended subsidies, health insurers are warning of double-digit premium hikes for millions of enrollees.

House Democratic Leader Hakeem Jeffries has argued that a “Republican-caused health care crisis” is hanging over Americans as a result of Trump’s new tax-and-spending bill, which adds restrictions to Medicaid that are expected to kick millions off the program. Republicans have also advanced mass layoffs and funding cuts at the nation’s health department and caused widespread confusion over access to some vaccines.

“We’re not going to simply go along to get along with a Republican bill that continues to gut the health care of everyday Americans,” Jeffries told reporters Sept. 29. “These people have been trying to repeal and displace people off the Affordable Care Act since 2010.”

Republicans, meanwhile, have blasted Democrats for holding up funding over the subsidies and say any deal will require concessions.

“If there were some extension of the existing policy, I think it would have to come with some reforms,” Thune, the Senate Republican leader, said Sept. 26.

Such a deal may involve changes to a policy that caps what consumers have to pay for ACA marketplace plans at 8.5% of their income, no matter how much they earn. It could also alter their ability to obtain plans with no premiums, an option that became more widely available because of the beefed-up subsidies.

Adding restrictions to the ACA subsidies is likely to decrease enrollment in the program, which saw declines during the first Trump administration and did not reach 20 million for the first time until last year, a milestone reached in large part due to the subsidies.

Several Republicans have expressed interest in extending the subsidies, including a group of GOP representatives who proposed legislation to do so last month.

Democrats may be betting that the timing of the shutdown will put pressure on their Republican colleagues to come to the negotiation table on the ACA subsidies.

Within days of the government’s closure, ACA enrollees are expected to get notices from their health insurers advising them of steeper premiums. Insurers have said the expiring subsidies have forced those large premium hikes because the healthiest and youngest people are more likely to opt out of coverage when prices go up.

The White House, meanwhile, ramped up its pressure campaign on Democrats. White House press secretary Karoline Leavitt insisted Sept. 29 that Trump wants to keep the government open.

“Our most vulnerable in our society and our country will be impacted by a government shutdown,” she said.

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A pesar de algunos avances este año, especialmente en estados con mayoría demócrata, los recientes reveses en las legislaturas más conservadoras dejan claro lo difícil que es proteger a los pacientes.

Este año fracasaron proyectos de ley para proteger a los consumidores de deudas médicas en Indiana, Montana, Nevada, Dakota del Sur y Wyoming, debido a la oposición de la industria. Y defensores advierten que los estados deben actuar, ya que se espera que millones de personas pierdan su seguro médico debido a la ley fiscal y de gasto del presidente Donald Trump.

“Este ya era un tema clave incluso antes del cambio de administración en Washington”, dijo Kate Ende, directora de políticas de la organización Consumers for Affordable Health Care, con sede en Maine. “La retirada a nivel federal hizo aún más urgente movilizarse”.

Este año, Maine se unió a una creciente lista de estados que han prohibido que la deuda médica aparezca en los reportes de crédito de sus residentes, una protección que puede facilitar el acceso a una vivienda, un auto o incluso un empleo. La medida fue aprobada por unanimidad y con apoyo bipartidista.

Se estima que 100 millones de personas en Estados Unidos tienen algún tipo de deuda relacionada con la atención médica.

El gobierno federal estaba a punto de prohibir que la deuda médica apareciera en los reportes de crédito, gracias a una normativa emitida en los últimos días del mandato del ex presidente Joe Biden. Esa medida habría beneficiado a unas 15 millones de personas en todo el país.

Pero la administración Trump no defendió la normativa ante las demandas legales de agencias de cobro y burós de crédito, que argumentaban que la Oficina para la Protección Financiera del Consumidor (CFPB, en inglés) se había excedido en su autoridad.

Un juez federal de Texas, designado por Trump, falló que la normativa debía anularse.

Ahora, solo los pacientes que viven en estados que han aprobado sus propias normas sobre reportes de crédito podrán beneficiarse de esta protección. Más de una docena de estados tienen estas restricciones, entre ellos California, Colorado, Connecticut, Minnesota, Nueva York y Vermont, que al igual que Maine, adoptaron una prohibición este año.

En los últimos años, más estados han aprobado otras protecciones contra la deuda médica, como límites a la tasa de interés que se puede cobrar y restricciones al uso del embargo de salarios o la incautación de bienes para cobrar facturas médicas impagas.

En muchos casos, estas medidas han recibido apoyo bipartidista, lo que refleja la popularidad de las protecciones al consumidor. En Virginia, el gobernador republicano firmó una ley este año que limita el embargo de salarios y establece un tope a los intereses.

Y varios legisladores republicanos en California se unieron a los demócratas para respaldar una medida que facilita el acceso a ayuda financiera de los hospitales para quienes enfrentan facturas elevadas.

“Este es el tipo de asunto de sentido común que afecta al bolsillo de las personas y que atrae tanto a republicanos como a demócratas”, señaló Eva Stahl, vicepresidenta de Undue Medical Debt, una organización sin fines de lucro que compra y perdona deudas médicas, y que ha trabajado para que se amplíen protecciones para pacientes.

Pero en varias legislaturas estatales, el impulso por nuevas protecciones se topó con barreras.

Proyectos de ley para prohibir que las deudas médicas aparecieran en los reportes de crédito fracasaron en Wyoming y Dakota del Sur, a pesar del apoyo de algunos legisladores republicanos. Y las medidas para limitar los cobros agresivos contra residentes con deuda médica fueron rechazadas en Indiana, Montana y Nevada.

En algunos estados, las propuestas enfrentaron una fuerte oposición de agencias de cobro, burós de crédito y bancos, que argumentaron ante los legisladores que sin información sobre deudas médicas podrían terminar otorgando a los consumidores préstamos de alto riesgo.

La representante estatal Lana Greenfield (republicana de Dakota del Sur), repitió las objeciones de la industria al pedir a sus colegas que votaran en contra de la prohibición. “Los bancos pequeños de comunidades pequeñas no podrían obtener información sobre una factura médica muy, muy grande. Y entonces, podrían otorgar un préstamo de buena fe a alguien sin saber realmente cuál era su crédito”, dijo Greenfield en el pleno de la Cámara.

Durante el gobierno de Biden, los investigadores de la CFPB encontraron que, a diferencia de otros tipos de deuda, la médica no era un buen indicador de la solvencia crediticia.

Pero el representante estatal Brian Mulder (republicano de Dakota del Sur), presidente del comité de salud que redactó la legislación, destacó el poder del sector bancario en el estado, donde regulaciones favorables lo han convertido en un imán para las instituciones financieras.

En Montana, una propuesta para proteger parte de los bienes de los deudores frente al embargo avanzó fácilmente en el comité. Sus defensores esperaban que fuera especialmente útil para pacientes nativos americanos, quienes enfrentan de forma desproporcionada la carga de la deuda médica.

Pero cuando el proyecto de ley llegó al pleno de la Cámara, los opositores “aparecieron en masa” y hablaron personalmente con los legisladores republicanos una hora antes de la votación, contó Ed Stafman, legislador demócrata y autor de la propuesta.

“Juntaron el número de votos suficientes para derrotar el proyecto por poco”, dijo.

Tanto defensores de los pacientes como legisladores que respaldaron estas medidas dijeron que son optimistas respecto a superar la oposición de la industria en el futuro.

Y hay señales de que algunas propuestas para ampliar las protecciones a los pacientes podrían avanzar en otros estados conservadores, como Ohio y Texas.

En Texas, una propuesta que obligaría a los hospitales sin fines de lucro a ampliar la ayuda financiera para quienes enfrentan facturas altas ha recibido el respaldo de organizaciones conservadoras influyentes.

“Estas cosas a veces toman tiempo”, dijo Lucy Culp, quien lidera el cabildeo estatal de Blood Cancer United (anteriormente conocida como Leukemia & Lymphoma Society). Esta organización ha impulsado leyes estatales de protección contra la deuda médica en años recientes, incluso en Montana y Dakota del Sur.

Lo más preocupante, dijo Culp, es la ola de pacientes sin seguro que se espera debido a los recortes en la cobertura médica derivados de la nueva ley fiscal aprobada por los republicanos. Esto agravará aún más el problema de la deuda médica en el país.

“Los estados no están preparados para eso”, advirtió Culp.

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Despite progress in some mostly blue states this year, however, recent setbacks in more conservative legislatures underscore the persistent challenges in strengthening patient protections.

Bills to shield patients from medical debt failed this year in Indiana, Montana, Nevada, South Dakota, and Wyoming in the face of industry opposition. And advocates warn that states need to step up as millions of Americans are expected to lose insurance coverage because of President Donald Trump’s tax and spending law.

“This is an issue that had been top of mind even before the change of administrations in Washington,” said Kate Ende, policy director of Maine-based Consumers for Affordable Health Care. “The pullback at the federal level made it that much more important that we do something.”

This year, Maine joined a growing list of states that have barred medical debt from residents’ credit reports, a key protection that can make it easier for consumers to get a home, a car, or sometimes a job. The measure passed unanimously with bipartisan support.

An estimated 100 million adults in the U.S. have some form of health care debt.

The federal government was poised to bar medical debt from credit reports under regulations issued in the waning days of former President Joe Biden’s administration. That would have helped an estimated 15 million people nationwide.

But the Trump administration did not defend the regulations from lawsuits brought by debt collectors and the credit bureaus, who argued that the Consumer Financial Protection Bureau exceeded its authority in issuing the rules. A federal judge in Texas appointed by Trump ruled that the regulation should be scrapped.

Now, only patients in states that have enacted their own credit reporting rules will benefit from such protections. More than a dozen have such limits, including California, Colorado, Connecticut, Minnesota, New York, and Vermont, which, like Maine, enacted a ban this year.

Still more states have passed other medical debt protections in recent years, including caps on how much interest can be charged on such debt and limits on the use of wage garnishments and property liens to collect unpaid medical bills.

In many cases, the medical debt rules won bipartisan support, reflecting the overwhelming popularity of these consumer protections. In Virginia, the state’s conservative Republican governor this year signed a measure restricting wage garnishment and capping interest rates.

And several GOP lawmakers in California joined Democrats in support of a measure to make it easier for patients to access financial assistance from hospitals for big bills.

“This is the kind of commonsense, pocketbook issue that appeals to Republicans and Democrats,” said Eva Stahl, a vice president at Undue Medical Debt, a nonprofit that buys up and retires patients’ debts and has pushed for expanded patient protections.

But in several statehouses, the drive for more safeguards hit walls.

Bills to ban medical debts from appearing on credit reports failed in Wyoming and South Dakota, despite support from some GOP lawmakers. And measures to limit aggressive collections against residents with medical debt were derailed in Indiana, Montana, and Nevada.

In some states, the measures faced stiff opposition from debt collectors, the credit reporting industry, and banks, who told legislators that without information about medical debts, they might end up offering consumers risky loans.

In Maine, the Consumer Data Industry Association, which represents credit bureaus, told lawmakers that regulating medical debt should be left to the federal government. “Only national, uniform standards can achieve the dual goals of protecting consumers and maintaining accurate credit reports,” warned Zachary Taylor, the group’s government relations director.

In South Dakota, state Rep. Lana Greenfield, a Republican, echoed industry objections in urging her colleagues to vote against a credit reporting ban. “Small-town banks could not receive information on a mega, mega medical bill. And so, they would in good faith perhaps loan money to somebody without knowing what their credit was,” Greenfield said on the House floor.

Under the Biden administration, CFPB researchers found that medical debt, unlike other debt, was not a good predictor of creditworthiness.

But South Dakota state Rep. Brian Mulder, a Republican who chairs the health committee and authored the legislation, noted the power of the banking industry in South Dakota, where favorable regulations have made the state a magnet for financial institutions.

In Montana, legislation to shield a portion of debtors’ assets from garnishment easily passed a committee. Supporters hoped the measure would be particularly helpful to Native American patients, who are disproportionately burdened by medical debt.

But when the bill reached the House floor, opponents “showed up en masse,” talking one-on-one with Republican lawmakers an hour before the vote, said Rep. Ed Stafman, a Democrat who authored the bill. “They lassoed just enough votes to narrowly defeat the bill,” he said.

Advocates for patients and legislators who backed some of these measures said they’re optimistic they’ll be able to overcome industry opposition in the future.

And there are signs that legislation to expand patient protections may make headway in other conservative states, including Ohio and Texas. A proposal in Texas to force nonprofit hospitals to expand aid to patients facing large bills picked up support from leading conservative organizations.

“These things can sometimes take time,” said Lucy Culp, who oversees state lobbying efforts by Blood Cancer United, formerly known as the Leukemia & Lymphoma Society. The patients’ group has been pushing for state medical debt protections in recent years, including in Montana and South Dakota.

More concerning, Culp said, is the wave of uninsured patients expected as millions of Americans lose health coverage due to cutbacks in the recently passed GOP tax law. That will almost certainly make the nation’s medical debt problem more dire.

“States are not ready for that,” Culp said.

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The networks, which have cropped up in several states in recent years, offer small-town hospitals an alternative to selling to large hospital systems and forfeiting local autonomy. 

“We found that we could both have the power of negotiation as a larger entity but also be able to negotiate lower costs for services and equipment,” said Dennis Goebel, CEO of Southwest Healthcare Services, a Bowman hospital that is part of the 22-member Rough Rider Network in North Dakota.

Since 2010, 153 rural hospitals in the U.S. have either shuttered completely or cut inpatient services, according to the Sheps Center for Health Services Research at the University of North Carolina. And 441 joined hospital chains between 2011 and 2021, according to a report commissioned by the Coalition to Strengthen America’s Healthcare, an advocacy group consisting of hospitals and health associations. 

Proponents of the networks hope more collaborations will be fueled by the recently approved federal $50 billion Rural Health Transformation Program, which became law as part of the sweeping tax-and-spend measure backed by the Trump administration. 

Many hospitals that join networks are motivated by the chance to combine their patient rolls for value-based care contracts, a reimbursement model in which insurers pay providers based on the quality of care they provide and the health outcomes of their patients. 

The hospitals can also pool staffers for health insurance plans, share specialists, and receive better rates on contracts for services ranging from prescription drug programs to mobile imaging. 

Retta Jacobi recently took advantage of the latter service when a semitruck with an MRI machine inside its trailer parked outside the Bowman hospital in southwestern North Dakota, a sparsely populated region dotted with ranchland and Badlands rock formations. She hoped the scan would pinpoint what was causing pain in her shoulders. 

The mobile MRI operation visits one or two hospitals in the Rough Rider Network each day. Without it, Bowman residents would have to drive 40 minutes for similar scans. 

Researchers haven’t yet examined whether the networks are working, according to a 2020 paper from the Rand Corp., a research nonprofit. 

But leaders from network members say their programs are saving money and improving patient outcomes by, for example, increasing rates of preventive care and decreasing hospital admissions. 

Jacobi, who provides speech therapy to children in the local school district, is doing physical therapy after a doctor examined her MRI results. She’s thankful she could get a diagnosis and treatment advice without having to travel far for the scan. 

“Anytime we can maintain more local control, it’s a good thing for our small towns,” Jacobi said.

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Hasta este año.

El plan de la administración Trump de retirar más de $550 millones en fondos federales para salud pública y pandemias en Texas hizo que se cancelara el evento, justo antes de su inicio programado para el 21 de julio.

“Hay personas que vienen todos los años y dependen de este evento”, dijo Dairen Sarmiento Rangel, directora del Departamento de Salud y Servicios Humanos del condado de Hidalgo. “Algunas personas incluso acampan afuera de Operación Salud Fronteriza para ser las primeras en recibir servicios. Este evento es muy importante para nuestra comunidad”.

Los gobiernos estatales y locales ya han tenido que hacer dolorosos recortes a sus programas, luego de importantes reducciones en la financiación federal para salud que ya han entrado en vigor. Ahora, se preparan para enfrentar los golpes financieros que están por venir —algunos no ocurrirán hasta finales del próximo año o incluso después— como resultado de la ley fiscal y de gasto aprobada por los republicanos en el Congreso en julio, conocida como la One Big Beautiful Bill, que pone en marcha gran parte de la agenda nacional del presidente Donald Trump.

Texas, por ejemplo, anticipa una reducción de hasta $39.000 millones en fondos federales para Medicaid durante los próximos 10 años debido a nuevas barreras para la inscripción, como revisiones de elegibilidad más frecuentes, según un análisis publicado en julio por KFF.

En conjunto, estas reducciones representan un cambio radical en la forma en que se financian y se ofrecen los programas estatales de salud. En la práctica, la administración está trasladando una parte importante de los costos de salud a los estados. Esto obligará a sus líderes a tomar decisiones difíciles, ya que muchos presupuestos estatales ya están presionados por la disminución en la recaudación de impuestos, la desaceleración del gasto federal por covid y la incertidumbre económica.

Más de una docena de estados han bajado sus proyecciones de ingresos para el año próximo, según un informe publicado en junio por Pew.

“Es casi inevitable que los estados recorten varios servicios de salud debido a la presión fiscal”, dijo Wesley Tharpe, asesor principal en política fiscal estatal del Centro para Prioridades Presupuestarias y Políticas (CBPP), una organización de tendencia progresista.

Algunos estados tratan de suavizar el impacto de forma proactiva.

En Hawaii, los legisladores se han propuesto ayudar a organizaciones sin fines de lucro que ya enfrentan disminución en fondos federales. Repartirán $50 millones en subvenciones a organizaciones de salud, servicios sociales y otras que hayan sufrido recortes. Para acceder a los fondos, deben demostrar que su financiación fue eliminada, reducida o afectada por los recortes.

“No es justo que organizaciones dedicadas a ayudar al pueblo de Hawaii se vean obligadas a reducir sus servicios por los recortes federales”, declaró el gobernador demócrata Josh Green en un comunicado.

Otros estados recortan proyectos para enfrentar la situación.

El gobernador de Delaware, Matt Meyer, demócrata, supo en marzo que la administración Trump retiraría $38 millones en fondos de salud pública al estado. Como consecuencia, un mes después, los líderes legislativos estatales frenaron un proyecto para renovar y ampliar el complejo del Capitolio estatal.

“Reconocimos que los recortes federales irresponsables a la red de protección social de miles de habitantes de Delaware nos obligaban a ahorrar recursos para proteger a los más vulnerables”, dijo David Sokola, presidente temporal del Senado estatal.

En Nuevo México, el estado con el mayor porcentaje de residentes inscritos en Medicaid, un grupo bipartidista de legisladores votó a favor de crear un fondo fiduciario para reforzar el financiamiento del programa. Según algunas estimaciones, aproximadamente el 10% de los más de 800.000 residentes que están cubiertos por Medicaid y el Programa de Seguro Médico para Niños (CHIP, en inglés) podrían perder su cobertura bajo esta nueva ley federal.

Algunos líderes estatales advierten a sus comunidades que lo peor está por venir.

En un evento realizado el 18 de agosto en un hospital del sur del Bronx, en la ciudad de Nueva York, la gobernadora demócrata Kathy Hochul subió al escenario junto a trabajadores de salud para criticar la nueva ley de Trump.

“Lo que los republicanos en Washington han hecho con la ‘Ley Más Horrible’ que he visto es, literalmente, perjudicar a los neoyorquinos”, dijo. El sistema de salud del estado se prepara para enfrentar recortes cercanos a los $13.000 millones al año.

En California, los legisladores analizaron el impacto de los recortes en una audiencia del comité de la Asamblea General el 20 de agosto, donde algunos legisladores demócratas señalaron que programas estatales como los de salud reproductiva estaban en peligro.

“Nos hemos preparado para esta realidad: la llamada ‘Big Beautiful Bill’ del presidente Trump ahora es ley”, dijo el legislador demócrata Gregg Hart durante la audiencia, calificándola como “un ataque directo a los programas fundamentales de California y a nuestros valores”.

“Lamentablemente, la realidad es que el estado no tiene la capacidad para compensar todos estos recortes federales draconianos con el presupuesto actual”, agregó. “No podemos simplemente firmar un cheque y hacer que esto desaparezca”.

La radical ley presupuestaria, que fue aprobada sin apoyo demócrata, reducirá el gasto federal en Medicaid en aproximadamen $1.000 millones durante la próxima década, según estimaciones de la Oficina de Presupuesto del Congreso (CBO). Las reducciones en el gasto vienen en gran medida de la imposición de un requisito laboral para las personas que obtuvieron Medicaid con la expansión promovida por la Ley de Cuidado de Salud a Bajo Precio (ACA), además de otras nuevas barreras para acceder a la cobertura.

Según la CBO, más de 7,5 millones de personas perderán la cobertura de Medicaid y quedarán sin seguro, mientras se extienden recortes fiscales para personas ricas que, según los demócratas, no los necesitan.

Por su parte, los republicanos y el presidente Trump afirman que el paquete fiscal y los recortes en los programas son necesarios para evitar el fraude y el despilfarro, y para garantizar la sostenibilidad de Medicaid, un programa federal-estatal que brinda cobertura a personas con discapacidades y de bajos ingresos.

“La One Big Beautiful Bill elimina a los inmigrantes ilegales, aplica requisitos laborales y protege a Medicaid para los verdaderamente vulnerables”, anunció la Casa Blanca en un comunicado del 29 de junio.

Los recortes a Medicaid no comenzarán hasta después de las elecciones legislativas de mitad de mandato en noviembre de 2026, pero ya se han aplicado otros recortes.

La administración Trump ha intentado recuperar $11.000 millones en fondos federales de salud pública destinados a los estados durante la pandemia, lo que provocó una batalla legal con una coalición de estados gobernados por demócratas. También recortó unos $1.000 millones en subvenciones federales para servicios de salud mental en las escuelas y detuvo los fondos de los Institutos Nacionales de Salud (NIH) que financiaban a más de 90 universidades públicas.

Un análisis de KFF Health News demuestra que las cancelaciones han afectado a todo el país, sin importar la afiliación política o la ubicación geográfica. De las organizaciones que sufrieron recortes en el primer mes, aproximadamente el 40% se encuentran en estados que Trump ganó en noviembre.

La secretaria de prensa del Departamento de Salud y Servicios Humanos (HHS), Emily Hilliard, dijo que la agencia prioriza las inversiones que respalden el mandato de Trump de enfrentar las enfermedades crónicas. Defendió algunos de los recortes y afirmó, erróneamente, que la nueva ley no reduce Medicaid.

“La pandemia de covid-19 ya terminó, y el HHS no seguirá desperdiciando miles de millones de dólares de los contribuyentes en una crisis que los estadounidenses superaron hace años”, dijo.

Líderes estatales señalan que los fondos federales por la pandemia, que la administración busca recuperar, se habían destinado a otras medidas de salud pública, como la vigilancia de enfermedades emergentes, la respuesta ante brotes y la contratación de personal. En mayo, fiscales estatales ganaron una orden de restricción temporal contra la administración.

“Lo que estamos viendo ahora es que los estados anticipan grandes recortes a Medicaid, pero también enfrentan una serie de recortes federales más pequeños, pero significativos, en programas de salud pública”, dijo Larry Levitt, vicepresidente ejecutivo de políticas de salud en KFF. (KFF Health News es uno de los programas de KFF)

Parte del desafío para los estados es simplemente entender los cambios.

“Creo que es justo decir que hay preocupación, confusión e incertidumbre”, afirmó Kathryn Costanza, experta en Medicaid en la Conferencia Nacional de Legislaturas Estatales.

Los estados intentan entenderlo todo, creando grupos asesores para seguir los cambios federales, presentando demandas para intentar bloquear los recortes y reasignando fondos.

En Colorado, los legisladores aprobaron una ley que permite que fondos estatales de Medicaid se usen para servicios de salud —excluyendo abortos— en clínicas de Planned Parenthood of America, después de que la nueva ley de Trump prohibiera la financiación federal para este tipo de atención. Aún está por verse si esa prohibición se mantiene en los tribunales.

La legislatura de Louisiana asignó $7,5 millones a universidades estatales para compensar los recortes en financiación federal para la investigación, gran parte de ella relacionada con temas de salud.

Y en Dakota del Sur, el banco de alimentos más grande del estado pidió a los legisladores que destinen $3 millones para compensar recortes en fondos del Departamento de Agricultura de Estados Unidos.

Los estados deben equilibrar sus presupuestos cada año, por lo que los recortes ponen en riesgo muchos servicios si los legisladores no están dispuestos a aumentar impuestos. El trabajo comenzará en serio en enero, cuando muchos estados inicien sus nuevas sesiones legislativas.

Y es probable que las decisiones difíciles continúen. Los republicanos en la Cámara de Representantes del Congreso consideran nuevas leyes que podrían traer más recortes, como la reducción al generoso financiamiento federal que actualmente reciben 20 millones de adultos inscritos en Medicaid gracias a la expansión de ACA.

Como resultado, algunos estados revertirán sus expansiones de Medicaid y recortarán aún más programas de salud.

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Until this year. The Trump administration’s plan to strip more than $550 million in federal public health and pandemic funds from Texas helped prompt cancellation of the event just before its scheduled July 21 start.

“Some people come every year and rely on it,” said Hidalgo County Health and Human Services Director Dairen Sarmiento Rangel. “Some people even camp out outside of Border Health so they can be the first in line to receive services. This event is very important to our community.”

States and local governments have made painful program cuts in the wake of major reductions in federal health funding that have already taken effect. Now, they’re sizing up the financial hits to come — some not until late next year or beyond — from the “One Big Beautiful Bill Act,” the tax and spending law congressional Republicans passed in July that enacts much of President Donald Trump’s domestic agenda.

Texas, for instance, expects to see its federal Medicaid funds reduced by as much as $39 billion over 10 years due to new barriers for enrollment, such as more frequent eligibility checks, according to a July analysis by KFF.

Taken together, the reductions amount to a seismic shift in how state health programs are provided and paid for. The administration is, in effect, pushing a significant amount of health costs to states. That will force their leaders to make difficult choices, as many state budgets are already strained by declining tax revenues, a slowdown in federal pandemic spending, and economic uncertainty.

Revenue forecasters in more than a dozen states have lowered expectations for the coming year, according to a June report by Pew.

“It’s almost inevitable that states will enact a number of cuts to health services because of the fiscal pressure,” said Wesley Tharpe, senior adviser for state tax policy at the left-leaning Center on Budget and Policy Priorities.

Some are proactively trying to stanch the impact.

Hawaii lawmakers are looking to aid nonprofits that are already contending with federal funding cuts. They’re doling out $50 million in grants to health, social service, and other nonprofits hit by federal funding cuts. To get the money, nonprofits must show a termination or drop in funding, or that they have otherwise been harmed by the cuts.

“It is not fair that organizations dedicated to supporting the people of Hawaii are being forced to scale back due to federal funding cuts,” Democratic Gov. Josh Green said in a statement.

Other states are scaling back projects to contend with cuts. Delaware Gov. Matt Meyer, a Democrat, received notice in March that the Trump administration was cutting $38 million in public health funding from the state. The next month, state legislative leaders halted a planned project to upgrade and expand the Capitol complex as a result.

“We recognized that the reckless federal cuts to the social safety nets of thousands of Delawareans called for us to hold back resources to protect our most vulnerable,” said David Sokola, president pro tempore of the Delaware Senate.

In New Mexico, the state with the highest percentage of residents enrolled in Medicaid, a bipartisan group of lawmakers voted to create a trust fund to boost funding for the program. About 10% of the more than 800,000 state residents covered by Medicaid and the related Children’s Health Insurance Program could lose their health coverage under the federal spending law, based on some estimates.

Some state leaders are warning constituents that the worst may be yet to come.

At an Aug. 18 event at a hospital in the South Bronx section of New York City, New York Gov. Kathy Hochul, a Democrat, stood on stage among health care workers in white coats to skewer Trump’s new law.

“What Republicans in Washington have done through the ‘Big Ugliest Bill’ I’ve ever seen is literally screwing New Yorkers,” she said. The state’s health system is bracing for nearly $13 billion in annual cuts.

And in California, lawmakers weighed the impact of the coming cuts from the federal law at a general assembly committee hearing on Aug. 20, where some Democratic legislators said state efforts to protect reproductive health services and other programs were in jeopardy.

“We’ve been bracing for this reality: President Trump’s so-called ‘Big, Beautiful Bill’ is now law,” Democratic lawmaker Gregg Hart said at the hearing, calling it a “direct assault on California’s core programs and our values.”

“Sadly, the reality is, the state does not have the capacity to backfill all of these draconian federal funding cuts in the current budget,” Hart said. “We cannot simply write a check and make this go away.”

The sweeping budget law, which passed without any Democratic support, will reduce federal spending on Medicaid by about $1 trillion over the next decade, based on estimates from the Congressional Budget Office. The spending reductions largely come from the imposition of a work requirement on people who’ve obtained Medicaid under the Affordable Care Act’s expansion, as well as other new barriers to coverage.

The law will mean more than 7.5 million people will lose Medicaid coverage and become uninsured, according to the Congressional Budget Office, while extending tax cuts for wealthy people who, Democrats say, don’t need them. Republicans and Trump have said the spending package and its accompanying program cuts were necessary to prevent fraud and waste, and to sustain Medicaid, a state-federal program for people with disabilities and lower incomes.

“The One Big Beautiful Bill removes illegal aliens, enforces work requirements, and protects Medicaid for the truly vulnerable,” the White House said in a June 29 statement.

The Medicaid cuts won’t begin until after the midterm elections in November 2026, but other cuts have already hit.

The Trump administration has sought to claw back $11 billion in federal public health funds earmarked to states because of the pandemic, spurring a legal fight with a coalition of Democratic-led states. It also cut about $1 billion in federal grants for mental health services in schools, and halted grants from the National Institutes of Health that provided money to more than 90 public universities.

HHS press secretary Emily Hilliard said the agency is prioritizing investments that advance Trump’s mandate to confront chronic disease. She defended some of the cuts and said, erroneously, that the spending law doesn’t cut Medicaid.

“The covid-19 pandemic is over, and HHS will no longer waste billions of taxpayer dollars responding to a crisis that Americans moved on from years ago,” she said.

State leaders say the pandemic funding the administration wants returned was earmarked for other public health measures, such as tracking emerging diseases, outbreak responses, and staffing. State attorneys general in May won a temporary restraining order against the administration.

“What we’re seeing now is states anticipating big cuts in Medicaid coming, but they’re also dealing with a whole variety of federal cutbacks in public health programs that are smaller but still quite meaningful,” said Larry Levitt, executive vice president for health policy at KFF, a health information nonprofit that includes KFF Health News.

Part of the challenge for states is simply understanding the changes.

“I think it’s fair to say there is concern, confusion, and uncertainty,” said Kathryn Costanza, a Medicaid expert at the National Conference of State Legislatures.

States are struggling to sort it all out, forming advisory groups that are tracking federal changes, suing to try to block the cuts, and reallocating funding.

In Colorado, lawmakers passed a bill to let state Medicaid dollars pay for non-abortion care at Planned Parenthood of America clinics after Trump’s law banned federal funding for such care. Whether the ban holds up in court remains to be seen.

The Louisiana Legislature sent $7.5 million to state universities to make up for cuts to federal research funding, much of which goes to health-related research.

And in South Dakota, the state’s largest food bank has asked lawmakers to spend $3 million to make up for funding cuts to the U.S. Department of Agriculture.

States must balance their budgets every year, so cuts put many services at risk if state lawmakers are unwilling to raise taxes. The work will begin in earnest in January, when many states begin new legislative sessions.

And the tough choices are likely to continue. Congressional House Republicans are considering legislation that could bring more cuts, including by slashing the generous cost sharing the federal government provides for 20 million adults who enrolled in Medicaid under the ACA’s Medicaid expansion.

Some states will roll back their Medicaid expansions and cut more health programs as a result.

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The mobile MRI unit visits Southwest Healthcare Services, the hospital in Bowman, North Dakota, each Wednesday. Without it, the community’s 1,400 residents would have to drive 40 minutes to get to an MRI machine, an expensive piece of medical equipment the hospital couldn’t afford on its own.

Southwest Healthcare Services and 21 other independent, rural North Dakota hospitals are part of the Rough Rider Network, which used its members’ combined patient rolls to negotiate better prices for the mobile imaging truck.

Independent rural hospitals are increasingly joining what are called clinically integrated networks, collaborative groups that allow them to avoid selling out to larger health systems while sharing resources to save money and improve patient care. Many are motivated by the chance to combine their patient rolls for value-based care contracts, a growing reimbursement model in which insurers pay providers based on the quality of care they provide and the health outcomes of their patients.

Supporters of the networks are exploring whether funding from the $50 billion Rural Health Transformation Program — part of President Donald Trump’s recent tax and spending bill — can be used to help start or expand such organizations.

For independent, rural hospitals, the networks are an alternative to shutting down or reducing services, or to giving up local autonomy and joining a large hospital system.

“Anything that can help our rural hospitals and add services is awesome,” said Jacobi, who provides speech therapy to children in the local school district.

Since 2010, 153 rural hospitals in the U.S. have shuttered completely or stopped offering inpatient services, according to the Sheps Center for Health Services Research at the University of North Carolina. A far larger number, 441, merged with or were acquired by hospital systems between 2011 and 2021. That’s according to a report commissioned by the Coalition to Strengthen America’s Healthcare, an advocacy group comprising hospitals and health associations.

The Rough Rider Network provides negotiating leverage to its members, which serve about two-thirds of rural North Dakotans, said Dennis Goebel, CEO of the Bowman hospital.

Health care vendors “probably wouldn’t be talking to us if we’re by ourselves,” he said. “They’re not looking for the little, tiny crumbs. They want a big contract, and they’ll give you better pricing.”

Some rural networks share specialists who aren’t needed full time at any one hospital, according to the Commonwealth Fund, a nonprofit focused on improving the health care system. Some networks also invest in broadband, housing, and other community development projects that can help people stay healthy and access care.

Hospitals can pool staffers for a network-wide employee health insurance plan, said Nathan White, CEO of Cibolo Health, a company that helps launch and manage networks in rural areas. He said they can also enter shared contracts for telehealth, prescription drug programs, and other services.

White said he started Cibolo Health after a leader from an independent, rural North Dakota hospital asked him about collaborating with similar facilities. The Rough Rider Network launched in late 2023 with assistance from the company and $3.5 million from the North Dakota Legislature.

Since then, Cibolo Health has helped start networks in Minnesota, Nebraska, Montana, and Ohio. Once a sixth one opens in September, Cibolo-affiliated networks will represent more than 120 hospitals, with service areas covering 4.7 million people, White said.

The networks, which are nonprofits owned by the hospitals, pay an annual fee to Cibolo Health, a for-profit company, for management services. White said leaders from 10 other states are considering joining this model.

Similar networks have been around for more than 30 years but became more popular after the passage of the 2010 Affordable Care Act, according to a report by the Rand Corp., a research nonprofit.

Rural health care providers are increasingly interested in forming such networks, said Marnell Bradfield, executive director of the Community Care Alliance, a network of hospitals and independent primary care offices that launched in 2015 in rural western Colorado. About once a month, she said, she gets a call from health care leaders exploring similar networks and asking about her experience.

The Rand Corp. wrote in its 2020 paper that it didn’t find any academic studies that examined whether these networks do what its supporters claim — save money and improve patient care.

“In theory, quality should improve with the alignment of health care organizations, but there is no evidence,” the report said. The paper also said such networks could end up increasing prices, something that can occur with traditional mergers and acquisitions.

Bradfield and White said they have the evidence, at least for their organizations.

Community Care Alliance members have reduced their insurance costs while improving patient outcomes, such as reducing their need for inpatient and emergency care, Bradfield said.

White said data from a pilot program between Caret Health, a care coordination company, and SMP Health-St. Kateri, one of Rough Rider’s hospitals, showed the program helped a significant number of patients catch up with preventive care.

Gabby Wilkie, finance director at the St. Kateri hospital, in Rolla near the Canadian border, said Caret Health staff called and texted patients who were behind on annual physicals, cancer screenings, vaccinations, and other visits. She said staffers explained to patients why this preventive care is important for their health before setting up a three-way call with St. Kateri staff to schedule an appointment. White said it took an average of 11 outreach attempts before patients came in for any visits.

“To be honest, we didn’t have the resources to reach out,” Wilkie said.

She said St. Kateri would have spent an estimated $300,000 to do that kind of outreach for 1,000 patients. Meanwhile, she said, the hospital estimates it will earn more than $100,000 when that many patients come in for their preventive care. Cibolo Health and the Rough Rider Network both contribute to the cost of the Caret Health service, which is now rolling out to other network hospitals.

Goebel said joining a network to remain independent is also beneficial for the economy of rural areas, where hospitals are often major employers. He said health systems sometimes cut services and staff at rural hospitals they acquire.

Jacobi is taking medication and doing physical therapy after a doctor examined her MRI results. If that doesn’t work, she may need to make a five-hour round trip to Bismarck to get an ultrasound-guided steroid shot. Jacobi was thankful she could get a diagnosis and treatment advice without having to travel far for the MRI.

“Anytime we can maintain more local control, it’s a good thing for our small towns,” she said.

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There never is.

Dahl Memorial’s three-bed emergency department — a two-hour drive from the closest hospital with more advanced services — instead depends on physician assistants and nurse practitioners.

Physician assistant Carla Dowdy realized the patient needed treatment beyond what the ER could provide, even if it had had a doctor. So, she made a call for a medical plane to fly the patient to treatment at Montana’s most advanced hospital. Dowdy also called out medications and doses needed to stabilize the patient as a paramedic and nurses administered the drugs, inserted IV lines, and measured vital signs.

Emergency medicine researchers and providers believe ERs, especially in rural areas, increasingly operate with few or no physicians amid a nationwide shortage of doctors.

A recent study found that in 2022, at least 7.4% of emergency departments across the U.S. did not have an attending physician on-site 24/7. Like Dahl Memorial, more than 90% were in low-volume or critical access hospitals — a federal designation for small, rural hospitals.

The results come from the 82% of hospitals that responded to a survey sent to all emergency departments in the country, except those operated by the federal government. The study is the first of its kind so there isn’t proof that such staffing arrangements are increasing, said Carlos Camargo, the lead author and a professor of emergency medicine at Harvard Medical School. But Camargo and other experts suspect ERs running without doctors present are becoming more common.

Placing ERs in the hands of nondoctors isn’t without controversy. Some doctors and their professional associations say physicians’ extensive training leads to better care, and that some hospitals are just trying to save money by not employing them.

The American Medical Association, open to all medical students and physicians, and the American College of Emergency Physicians both support state and federal laws or regulations that would require ERs to staff a doctor around the clock. Indiana, Virginia, and South Carolina recently passed such legislation.

Rural ERs may see fewer patients, but they still treat serious cases, said Alison Haddock, president of ACEP.

“It’s important that folks in those areas have equal access to high-quality emergency care to the greatest extent possible,” Haddock said.

Other health care providers and organizations say advanced-practice providers with the right experience and support are capable of overseeing ERs. And they say mandating that a physician be on-site could drive some rural hospitals to close because they can’t afford or recruit enough — or any — doctors.

“In an environment, especially a rural environment, if you have an experienced PA who knows what they know, and knows the boundaries of their knowledge and when to involve consultants, it works well,” said Paul Amiott, a board member of the Society of Emergency Medicine PAs.

“I’m not practicing independently” despite working 12-hour night shifts without physicians on-site at critical access hospitals in three states, he said.

Amiott said he calls specialists for consultation often and about once a month asks the physician covering the day shift at his hospital to come help him with more challenging cases such as emergency childbirth and complicated trauma. Amiott said this isn’t unique to PAs — ER doctors seek similar consultations and backup.

The proportion of ERs without an attending physician always on-site varies wildly by state. The 2022 survey found that 15 states — including substantially rural ones, such as New Mexico, Nevada, and West Virginia — had no such emergency departments.

But in the Dakotas, more than half of emergency departments were running without 24/7 attending physician staffing. In Montana it was 46%, the third-highest rate.

None of those three states have a program to train physicians as ER specialists. Neither does Wyoming or Idaho.

But Sanford Health, which bills itself as “the largest rural health system in the United States,” is launching an emergency medicine residency in the region. The Sioux Falls, South Dakota-based program is intended to boost the ranks of rural emergency doctors in those states, the residency director said in a news release.

Leon Adelman is an emergency medicine physician in Gillette, Wyoming, which, at around 33,800 residents, is the largest city in the state’s northeast. Working in such a rural area has given him nuanced views on whether states should require 24/7 on-site physician coverage in ERs.

Adelman said he supports such laws only where it’s feasible, like in Virginia. He said the state’s emergency physicians’ organization pushed for the law only after doing research that made it confident that the requirement wouldn’t shutter any rural hospitals.

Camargo said some doctors say that if lawmakers are going to require 24/7 on-site physician coverage in ERs, they need to pay to help hospitals implement it.

Adelman said when instituting staffing requirements isn’t possible, states should create other regulations. For example, he said, lawmakers should make sure hospitals not hiring physicians aren’t refraining just to save money.

He pointed to Vermont, where a report recommended that several of the state’s hospitals cut physicians from their ERs. The report was part of a mandated process to improve the state’s troubled health care system.

Adelman said states should also require PAs and NPs without on-site physician supervision to have extensive emergency experience and the ability to consult with remote physicians.

Some doctors have pointed to a case in which a 19-year-old woman died after being misdiagnosed by an NP who was certified in family medicine, not emergency care, and working alone at an Oklahoma ER. Few NPs have emergency certification, an analysis found.

The Society of Emergency Medicine PAs outlines training and experience PAs should have before practicing in rural areas or without on-site doctors.

Haddock said emergency physicians have seen cases of hospitals hiring inexperienced advanced-practice providers. She said ACEP is asking the federal government to require critical access and rural emergency hospitals to have physicians on-site or on call day and night.

Haddock said ACEP wouldn’t want such a requirement to close any hospital and noted that the organization has various efforts to keep rural hospitals staffed and funded.

Dahl Memorial Hospital has strict hiring requirements and robust oversight, said Dowdy, who previously worked for 14 years in high-volume, urban emergency rooms.

She said ER staffers can call physicians when they have questions and that a doctor who lives on the other side of Montana reviews all their patient treatment notes. The ER is working on getting virtual reality glasses that will let remote physicians help by seeing what the providers in Ekalaka see, Dowdy said.

She said patient numbers in the Ekalaka ER vary but average one or two a day, which isn’t enough for staff to maintain their knowledge and skills. To supplement those real-life cases, providers visit simulation labs, do monthly mock scenarios, and review advanced skills, such as using an ultrasound to help guide breathing tubes into patient airways.

Dowdy said Dahl Memorial hasn’t had a physician in at least 30 years, but CEO Darrell Messersmith said he would hire one if a doctor lived in the area. Messersmith said there’s a benefit to having advanced-practice providers with connections to the region and who stay at the hospital for several years. Other rural hospitals, he noted, may have physicians either as permanent staff who leave after a few years or contract workers who fly in for a few weeks at a time.

People eating at Ekalaka’s sole breakfast spot and attending appointments at the hospital’s clinic all told KFF Health News that they’ve been happy with the care they have received from Dowdy and her co-workers.

Ben Bruski had to visit the ER after a cow on his family ranch kicked a gate, smashing it against his hand. And he knows other people who’ve been treated for more serious problems.

“We’ve got to have this facility here because this facility saves a lot of lives,” Bruski said.

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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