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

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

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

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

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

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

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

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

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

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

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

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

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

An Influx of Money That’s Out of Reach

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

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

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

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

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

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

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

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

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

that helps primary care doctors in rural and other underserved areas prevent end-stage renal failure.

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

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

Exploring the Option of Home Dialysis

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

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

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

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

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

“It’s just unreal,” she said.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

A Lifeline of Care

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

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

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

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

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

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

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

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

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

A New Lease on Life?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Not all Montana health leaders are worried.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Lawmakers aren’t the only ones speaking out.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

“Everything has trade-offs,” Bennett said.

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

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But there are strings attached.

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

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

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

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

The money was divided according to a complicated formula.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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West River Health Services, en Hettinger —un pueblo de unos 1.000 habitantes en el suroeste del estado— tiene cuatro opciones, y ninguna es buena.

El hospital podría pagar los $100.000 que cuesta la nueva tarifa de la visa H-1B impuesta por la administración Trump y contratar a uno de los más de 30 postulantes de Filipinas o Nigeria.

Pero esa cifra equivale a lo que algunos hospitales rurales pagarían por dos técnicos de laboratorio durante un año, señaló Holzkamm, quien es la jefa del laboratorio en el centro de salud.

West River también puede optar por pedir al Departamento de Seguridad Nacional una exención del pago. Pero no está claro cuánto tiempo tomaría el proceso ni si el gobierno la otorgaría. Otra posibilidad sería seguir tratando de reclutar a alguien dentro de Estados Unidos. O dejar la vacante sin cubrir, dijo Holzkamm, pero eso aumentaría la carga de trabajo del actual “equipo que ya es mínimo”.

El sistema de salud en Estados Unidos depende del personal nacido en el extranjero para cubrir plazas como médicos, enfermeros, técnicos y otros profesionales, especialmente en centros que siempre enfrentan escasez de personal en zonas rurales.

Pero una nueva orden presidencial dirigida al uso de visas H-1B en la industria tecnológica está dificultando que hospitales como West River y otros proveedores rurales los contraten.

“La industria de la salud ni siquiera fue considerada. Van a ser víctimas colaterales, y en un grado tan extremo que está claro que no se pensó en eso en absoluto”, dijo Eram Alam, profesora asociada en Harvard cuyo último libro examina la historia de los médicos extranjeros en Estados Unidos.

Elissa Taub, una abogada de Memphis, Tennessee, que asesora a hospitales en el proceso de solicitud de visas H-1B, ha escuchado preocupaciones similares de sus clientes.

“No es que haya un excedente de médicos o enfermeros estadounidenses esperando para llenar esas plazas”, dijo.

Hasta hace poco, West River y otros empleadores pagaban hasta $5.000 cada vez que patrocinaban a un trabajador con visa H-1B, que está reservada a trabajadores extranjeros altamente calificados.

La nueva tarifa de $100.000  —parte de — se aplica a los trabajadores que viven fuera de Estados Unidos, pero no a quienes ya se encuentran en el país con una visa.

Kathrine Abelita, técnica de laboratorio en West River, es una de las nueve personas empleadas —seis técnicos y tres enfermeros— que actualmente tienen o han tenido visas H-1B. Abelita es originaria de Filipinas y trabaja en West River desde 2018. Ahora es residente permanente de Estados Unidos.

Respecto de la nueva tarifa, opinó: “Esto va a ser un gran problema para la atención médica rural”. Agregó que la mayoría de los trabajadores jóvenes estadounidenses prefieren vivir en áreas urbanas.

Según una encuesta del gobierno , el 16% de las enfermeras registradas, el 14% de los asistentes médicos y el 14% de las enfermeras practicantes y parteras que trabajan en hospitales del país son inmigrantes.

Además, casi una cuarta parte de los médicos se graduaron en escuelas de medicina fuera de Estados Unidos o Canadá, según .

La (AHA, por sus siglas en inglés), y más de han solicitado al gobierno que exima al sector salud de este nuevo arancel. Argumentan que el alto costo afectará de manera desproporcionada a las comunidades rurales que ya enfrentan dificultades para financiar y atraer personal médico.

“Una excepción general para los proveedores de salud es la solución más sencilla”, escribieron en una carta conjunta la Asociación Nacional de Salud Rural (NRHA, por sus siglas en inglés) y la Asociación Nacional de Clínicas Rurales de Salud.

La disposición contempla exenciones para personas, trabajadores de empresas específicas e incluso industrias completas, siempre que sea en función del “interés nacional”.

indican que la exención solo se otorgará en circunstancias “extraordinariamente raras”, esto implica demostrar que no hay trabajadores estadounidenses disponibles para el puesto y que obligar a la empresa a pagar los $100.000 “socavaría significativamente” los intereses nacionales.

Taub calificó esos requisitos como “extraordinariamente estrictos”.

Representantes de la NRHA y de la Asociación Médica Americana (AMA, por sus siglas en inglés), que organizó la carta firmada por las sociedades médicas, dijeron que no han recibido respuesta luego de enviar solicitudes a la secretaria de Seguridad Nacional, Kristi Noem, entre finales de septiembre y principios de octubre. La AHA no quiso decir si obtuvo alguna respuesta.

Funcionarios del Departamento de Seguridad Nacional remitieron las preguntas de �鶹Ů�� Health News a la Casa Blanca, que no respondió sobre los plazos para las exenciones individuales ni sobre la posibilidad de una excepción general para el sector salud.

En cambio, la vocera de la Casa Blanca, Taylor Rogers, envió una declaración en defensa del nuevo arancel, diciendo que busca “poner a los trabajadores estadounidenses en primer lugar”.

Sus comentarios reflejan el enfoque de la orden de Trump, que acusa a la industria tecnológica de abusar del programa H-1B al reemplazar a empleados estadounidenses por trabajadores extranjeros peor pagados. Pero la orden incluye a todos los sectores.

Alam, la profesora de Harvard, señaló que la dependencia que tiene el país de proveedores internacionales plantea preocupaciones legítimas, como el hecho de que se está atrayendo profesionales de países de bajos ingresos que enfrentan desafíos sanitarios y escasez de personal aún mayores que los de Estados Unidos.

Esta dependencia, que lleva décadas, se debe, explicó, al aumento poblacional, a que las facultades de medicina históricamente excluyeron a hombres no blancos, y al hecho de que resulta “mucho, mucho más barato” importar profesionales formados en el extranjero que invertir en ampliar la educación médica dentro del país.

Según un análisis de y , los médicos formados en el extranjero suelen trabajar en zonas rurales o urbanas empobrecidas y con servicios limitados.

Este año, cerca de un millar de trabajadores con visas H-1B han estado empleados en zonas rurales, según la carta enviada por las dos organizaciones de salud rural al gobierno de Trump.

Las visas J-1, que son las más comunes entre los médicos extranjeros que realizan su residencia y otra formación de posgrado en Estados Unidos, exigen que los aspirantes regresen a su país de origen durante dos años antes de solicitar una visa H-1B.

Sin embargo, un programa gubernamental conocido como Conrad 30 Waiver Program permite que, cada año, hasta 1.500 personas con visa J-1 permanezcan en Estados Unidos y soliciten una H-1B a cambio de trabajar durante tres años en áreas con escasez de proveedores, incluidas muchas comunidades rurales.

La disposición presidencial de Trump indica que los empleadores que patrocinan a trabajadores con H-1B que ya se encuentran en el país —como los médicos con estas exenciones— no tendrán que pagar la tarifa de seis cifras. Esa excepción fue aclarada en una guía publicada aproximadamente un mes después de la normativa.         

Pero los empleadores deberán pagar la nueva tasa si contratan médicos u otros trabajadores que solicitan la visa desde otros países.

Alyson Kornele, directora ejecutiva de West River Health Services, dijo que la mayoría de las enfermeras y técnicos de laboratorio extranjeros que emplea el hospital están fuera de Estados Unidos al momento de presentar la solicitud.

Ivan Mitchell, director ejecutivo de Great Plains Health en North Platte, Nebraska, dijo que la mayoría de los médicos de su hospital con visa H-1B ya estaban en el país con otro tipo de visa cuando se postularon. Pero mencionó que los fisioterapeutas, enfermeros y técnicos de laboratorio suelen solicitarla desde el extranjero.

Según Holzkamm, antes del nuevo arancel, contratar a solicitantes con visa H-1B para su laboratorio tomaba entre cinco y ocho meses.

Bobby Mukkamala, cirujano y presidente de la Asociación Médica Estadounidense, dijo que tanto los legisladores republicanos como los demócratas están preocupados por las consecuencias que esto tendrá en la atención médica rural.

Entre ellos se encuentra el líder de la mayoría en el Senado, John Thune, quien afirmó que planeaba comunicarse con el gobierno para plantear posibles exenciones.

“Queremos que el proceso sea más fácil, no más difícil; y menos costoso, no más caro, para quienes necesitan mano de obra”, dijo el republicano a �鶹Ů�� Health News en septiembre.

La oficina de Thune no respondió a las preguntas sobre si el senador ha tenido contacto con el gobierno respecto a posibles exenciones para personal médico.

El gobierno de Trump enfrenta al menos dos demandas judiciales que buscan bloquear la nueva tasa. Una de las demandas fue presentada por y un sindicato que representa a médicos recién graduados. , elevada por la Cámara de Comercio de Estados Unidos, menciona la preocupación por la escasez de médicos y la capacidad de los sistemas de salud para asumir este nuevo costo.

Kornele dijo que West River no podrá pagar una tarifa de $100.000, por lo que está redoblando esfuerzos de reclutamiento y retención local.

Pero Holzkamm afirmó que no ha tenido éxito al buscar técnicos de laboratorio en las universidades de North Dakota, ni siquiera entre quienes realizan prácticas en el hospital. Agregó que West River no puede competir con los sueldos que se ofrecen en las ciudades más grandes.

“Es un ciclo muy negativo en este momento. Estamos en serios problemas”, dijo.

Phillip Reese es especialista en análisis de datos y profesor asociado de Periodismo en la California State University, Sacramento.

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Because they aren’t U.S. citizens, they would each need a visa.

West River and other companies used to pay up to $5,000 in fees to sponsor each H-1B visa for such workers.

The nonprofit hospital now has to pay $100,000 if it wants to hire one of the new applicants, who are all from the Philippines or Nigeria. Or it could spend money on an attorney to petition the government for an exemption from the new fee.

H-1B visas are for highly skilled foreign workers in fields — such as the chronically understaffed rural health system — that struggle to find enough American employees.

In September, President Donald Trump increased the visa fee to $100,000 for workers living outside the U.S. It doesn’t apply to foreign workers or students who were already in the U.S. on a visa.

His proclamation rails against the tech world’s use of H-1B workers, but the new fee applies to all fields.

“The health care industry wasn’t even considered. They’re going to be collateral damage, and to such an extreme degree that it was clearly not thought about at all,” said Eram Alam, a Harvard associate professor whose examines the history of foreign doctors in the U.S.

H-1B applicants will receive a fee exemption only in an “extraordinarily rare circumstance.”

The , two , and asked Homeland Security Secretary Kristi Noem to grant categorical exemptions for the health care industry. The new cost will disproportionally harm rural communities that already struggle to afford and recruit enough providers, the groups argued.

DHS officials directed inquiries to the White House, which did not answer questions about individual waiver timelines or the possibility of an exemption for the health care industry.

Instead, White House spokesperson Taylor Rogers sent a statement defending the new fee, saying it will “put American workers first.”

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Not one U.S. citizen has applied.

West River Health Services in Hettinger, a town of about 1,000 residents in the southwestern part of the state, has four options, and none is good.

The hospital could fork over $100,000 for the Trump administration’s new H-1B visa fee and hire one of the more than 30 applicants from the Philippines or Nigeria. The fee is the equivalent of what some rural hospitals would pay two lab techs in a year, said Holzkamm, who is West River’s lab manager.

West River could ask the Department of Homeland Security to waive the fee. But it’s unclear how long the waiver process would take and if the government would grant one. The hospital could continue trying to recruit someone inside the U.S. for the job. Or, Holzkamm said, it could leave the position unfilled, adding to the workload of the current “skeleton crew.”

The U.S. health care system depends on foreign-born professionals to fill its ranks of doctors, nurses, technicians, and other health providers, particularly in chronically understaffed facilities in rural America.

But a new presidential proclamation aimed at the tech industry’s use of H-1B visas is making it harder for West River and other rural providers to hire those staffers.

“The health care industry wasn’t even considered. They’re going to be collateral damage, and to such an extreme degree that it was clearly not thought about at all,” said Eram Alam, a Harvard associate professor whose new book examines the history of foreign doctors in the U.S.

Elissa Taub, a Memphis, Tennessee-based attorney who assists hospitals with the H-1B application process, has been hearing concerns from her clients.

“It’s not like there’s a surplus of American physicians or nurses waiting in the wings to fill in those positions,” she said.

Until recently, West River and other employers paid up to $5,000 each time they applied to sponsor an H-1B worker. The visas are reserved for highly skilled foreign workers.

The new $100,000 fee — part of a by President Donald Trump — applies to workers living outside the U.S. but not those who were already in the U.S. on a visa.

West River lab tech Kathrine Abelita is one of nine employees — six technicians and three nurses — at the hospital who are current or former H-1B visa holders. Abelita is from the Philippines and has worked at West River since 2018. She’s now a permanent U.S. resident.

"It’s going to be a big problem for rural health care," she said of the new fee. She said most younger American workers want to live in urban areas.

Sixteen percent of registered nurses, 14% of physician assistants, and 14% of nurse practitioners and midwives who work in U.S. hospitals are immigrants, according to a . Nearly a quarter of physicians in the U.S. went to medical school outside the U.S. or Canada, according to .

The , two , and have asked the administration to give the health care industry exemptions from the new fee. The new cost will disproportionally harm rural communities that already struggle to afford and recruit enough providers, the groups argue.

“A blanket exception for healthcare providers is the simplest path forward,” the National Rural Health Association and National Association of Rural Health Clinics wrote in a joint letter.

The proclamation allows fee exemptions for individuals, workers at specific companies, and those in entire industries when “in the national interest.” says the fee will be waived only in an “extraordinarily rare circumstance.” That includes showing that there is “no American worker” available for the position and that requiring a company to spend $100,000 would “significantly undermine” U.S. interests.

Taub called those standards “exceptionally high.”

Representatives of the NRHA and the American Medical Association, which organized a letter from the medical societies, said they’ve received no response after sending requests to Homeland Security Secretary Kristi Noem in late September and early October. The AHA declined to say whether it had heard back.

Homeland Security officials directed �鶹Ů�� Health News’ inquiries to the White House, which did not answer questions about individual waiver timelines or the possibility of a categorical exemption for the health care industry.

Instead, White House spokesperson Taylor Rogers sent a statement defending the new fee, saying it will “put American workers first.” Her comments echo Trump’s proclamation, which focuses on accusations that the tech industry is abusing the H-1B program by replacing American workers with lower-paid foreign ones. But the order applies to all trades.

Alam, the Harvard professor, said the U.S.’ reliance on international providers does raise legitimate concerns, such as about how it takes professionals away from lower-income countries facing even greater health concerns and staffing shortages than the U.S.

This decades-long dependency, she said, stems from population booms, medical schools’ historical exclusion of nonwhite men, and the “much, much cheaper” cost of importing providers trained abroad than expanding health education in the U.S.

Internationally trained doctors tend to work in rural and urban areas that are poor and underserved, according to and .

Nearly 1,000 H-1B providers were employed in rural areas this year, the two rural health organizations wrote in their letter to the Trump administration.

J-1 visas, the most common type held by foreign doctors during their residencies and other postgraduate training in the U.S., require them to return to their home country for two years before applying for an H-1B.

But a government program called the Conrad 30 Waiver Program allows up to 1,500 J-1 holders a year to remain in the U.S. and apply for an H-1B in exchange for working for three years in a provider shortage area, which includes many rural communities.

Trump’s proclamation says employers that sponsor H-1B workers already inside the U.S., such as doctors with these waivers, won’t have to pay the six-figure fee, a nuance clarified in guidance released about a month later.

But employers will have to pay the new fee when hiring doctors and others who apply while living outside the U.S.

Alyson Kornele, CEO of West River Health Services, said most of the foreign nurses and lab techs it hires are outside the U.S. when they apply.

Ivan Mitchell, CEO of Great Plains Health in North Platte, Nebraska, said most of his hospital’s H-1B physicians were inside the U.S. on other visas when they applied. But he said physical therapists, nurses, and lab techs typically apply from abroad.

Holzkamm said it took five to eight months to hire H-1B applicants at her lab before the new fee was introduced.

Bobby Mukkamala, a surgeon and the president of the American Medical Association, said Republican and Democratic lawmakers are concerned about the ramifications for rural health care.

They include Senate Majority Leader John Thune, who said he planned to reach out about possible exemptions.

“We want to make it easier, not harder, and less expensive, not more expensive, for people who need the workforce,” the Republican told �鶹Ů�� Health News in September.

Thune’s office did not respond to questions about whether the senator has heard from the administration regarding potential waivers for health workers.

The Trump administration is facing at least two lawsuits attempting to block the new fee. includes a company that recruits foreign nurses and a union that represents medical graduates. , by the U.S. Chamber of Commerce, mentions concerns about the physician shortage and health systems’ ability to afford the new fee.

Kornele said West River won’t be able to afford a $100,000 fee so it’s doubling down on local recruiting and retention.

But Holzkamm said she hasn’t been successful in finding lab techs from North Dakota colleges, even those who intern at the hospital. She said West River can’t compete with the salaries offered in bigger cities.

“It’s a bad cycle right now. We’re in a lot of trouble,” she said.

Phillip Reese is a data reporting specialist and an associate professor of journalism at California State University-Sacramento.

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

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El gobierno de Trump, que ha prometido “transparencia radical”, afirmó en un documento de que planea publicar el “resumen de proyectos” de los estados que obtengan fondos. Siguiendo el ejemplo de los reguladores federales, muchos estados ocultan sus solicitudes completas, y algunos se han negado a revelar cualquier detalle.

“Seamos claros”, dijo Alan Morgan, director ejecutivo de la Asociación Nacional de Salud Rural (NRHA, por sus siglas en inglés). “Los directores de hospitales, los administradores de clínicas, los líderes comunitarios: todos van a querer saber qué están haciendo sus estados”.

Entre los miembros de la NRHA se incluyen hospitales y clínicas rurales con dificultades económicas, a los que prometieron beneficiar con el Programa de Transformación de la Salud Rural del gobierno de Trump.

Morgan señaló que sus miembros están interesados en saber qué proponen los estados, qué ideas son aprobadas o rechazadas y cuáles son sus justificaciones presupuestarias, que explican cómo podría gastarse el dinero.

Mejorar la atención médica rural es una “tarea increíblemente complicada y difícil”, afirmó Morgan.

El Programa de Transformación de la Salud Rural, con una duración de cinco años, fue aprobado por el Congreso en una ley —la llamada One Big Beautiful Bill Act— que también reduce drásticamente el gasto de Medicaid, del cual dependen en gran medida los proveedores de salud en zonas rurales. Este programa está siendo observado con atención porque representa una inyección muy necesaria de fondos, aunque con la condición impuesta por el gobierno de Trump de que el dinero se utilice en ideas transformadoras y no simplemente para mantener a flote a hospitales rurales en crisis.

La ley indica que la mitad de los $50.000 millones se dividirá en partes iguales entre todos los estados con una solicitud aprobada. El resto se distribuirá en base a un sistema de puntos. , $12.500 millones se asignarán en función del nivel de “ruralidad” de cada estado. Los otros $12.500 millones se otorgarán a estados que obtengan en iniciativas y políticas alineadas, en parte, con los objetivos del gobierno de Trump bajo el lema “Hacer a Estados Unidos Saludable de Nuevo” ().

El secretario de Salud y Servicios Humanos, Robert F. Kennedy Jr., ha prometido en repetidas ocasiones abrir el gobierno al pueblo estadounidense. Su agencia tiene una dedicada a la “transparencia radical”.

“Estamos trabajando para que este sea el Departamento de Salud y Servicios Humanos (HHS, por sus siglas en inglés) más transparente en sus 70 años de historia”, en un testimonio escrito al Congreso en septiembre.

Lawrence Gostin, profesor de derecho en salud pública en la Universidad Georgetown, dijo que el HHS está actuando “de manera totalmente opaca” y que el público tiene derecho a exigir “mayor apertura y claridad”. Sin transparencia, agregó, la población no puede evaluar las responsabilidades de esa agencia.

Catherine Howden, vocera de los Centros de Servicios de Medicare y Medicaid (CMS, por sus siglas en inglés), dijo que la agencia seguirá las regulaciones federales que rigen los al publicar información sobre el programa de salud rural.

Las solicitudes de subvención “no se hacen públicas durante el proceso de evaluación por méritos”, dijo Howden, y agregó: “El propósito de esta política es proteger la integridad de las evaluaciones, la confidencialidad de los solicitantes y la naturaleza competitiva del proceso”.

Demócratas y algunos defensores de la atención de salud temen que las decisiones sobre la distribución del dinero tengan motivaciones políticas.

“Me preocupan las represalias políticas”, dijo la representante Nikki Budzinski, demócrata de Illinois. Como los demócratas controlan la política de nuestro estado, “nuestra solicitud podría no ser tomada tan en serio como la de otros estados liderados por republicanos”, agregó.

En noviembre, los legisladores demócratas de Illinois en la Cámara de Representantes enviaron al administrador de los CMS, Mehmet Oz, solicitando una “evaluación justa e integral” de la solicitud estatal. Las autoridades de Illinois aún no han comunicado su propuesta a �鶹Ů�� Health News, que presentó una solicitud de registros públicos.

Heather Howard, profesora en la Universidad de Princeton, dijo que le “sorprende gratamente la transparencia de muchos estados”.

Howard dirige el programa State Health and Value Strategies de la universidad, que el fondo de salud rural, y elogió a la mayoría de los estados por publicar sus resúmenes del proyecto.

“Esto demuestra el enorme interés que despierta el programa”, dijo Howard.

Su equipo, que revisó cerca de dos docenas de resúmenes estatales, identificó temas comunes como la expansión de servicios móviles y a domicilio, mayor uso de tecnología, y desarrollo de la fuerza laboral con becas, bonos por contratación y ayuda para cuidado infantil en puestos de alta demanda.

“Creo que es emocionante”, dijo Howard. “Considero muy valioso lo que podemos aprender de estas propuestas”.

Howard señaló que las solicitudes de Georgia y Alabama incluían el uso de telerrobótica: una propuesta para utilizar robots para realizar ecografías remotas.

Otro tema que “me entusiasma”, dijo, es el esfuerzo de los estados por crear grupos o comités asesores, como en Idaho, donde se espera que los grupos de trabajo se enfoquen en tecnología, desarrollo de fuerza laboral, colaboración con comunidades indígenas, y salud mental y conductual.

Los 50 estados presentaron sus solicitudes a los reguladores federales antes de la fecha límite del 5 de noviembre, y las resoluciones se anunciarán antes de que termine el año, según los CMS.

Hasta finales de noviembre, casi 40 estados habían hecho público su resumen del proyecto, que es la parte principal de la solicitud donde se describen las iniciativas propuestas, según un seguimiento de �鶹Ů�� Health News. Más de una docena de estados también publicaron sus presupuestos.

Un pequeño grupo de estados —Idaho, Iowa, Kansas, Minnesota, Nuevo México, Dakota del Norte, Carolina del Sur y Wyoming— publicó todos los componentes de la solicitud.

�鶹Ů�� Health News presentó solicitudes de registros públicos para obtener las peticiones completas de los estados. Algunos se negaron a entregar cualquier parte de sus materiales.

Nebraska, por ejemplo, rechazó la solicitud argumentando que su contenido es “información comercial o propietaria” que “podría beneficiar a competidores comerciales”.

Kentucky compartió el resumen de su solicitud, pero indicó que el resto es un “borrador preliminar” no sujeto a divulgación bajo las leyes estatales.

Erika Engle, vocera del gobernador de Hawaii, Josh Green, dijo que el gobernador “está comprometido con la transparencia”, pero se negó a compartir la propuesta del estado.

Hawaii y otros estados aún están procesando solicitudes formales de registros públicos.

Este programa de salud rural forma parte de la ley aprobada en julio que se prevé que reducirá el gasto federal de Medicaid en zonas rurales en durante los próximos 10 años.

Se espera que estos recortes afecten las finanzas de centros rurales, poniendo en riesgo su capacidad para seguir operando. Un informe reciente de Commonwealth Fund reveló que muchas áreas rurales siguen a atención primaria. Pero las normas del programa de salud rural indican que solo el 15% de los nuevos fondos puede utilizarse para pagar atención directa a los pacientes.

Entre los recortes a Medicaid y la nueva inversión del programa, “hay una verdadera oportunidad para que las políticas nacionales tengan un impacto en las zonas rurales, tanto de forma negativa como positiva”, señaló Celli Horstman, investigadora principal de la fundación en Nueva York y coautora del informe.

Entre las propuestas disponibles al público, los estados con gobiernos demócratas muestran disposición para apoyar algunos de los objetivos del gobierno, aunque también rechazan otros, lo cual podría restarles puntos.

Por ejemplo, Nuevo México indicó que presentará una ley para que los estudiantes tomen la Prueba Presidencial de Aptitud Física (Presidential Fitness Test) y que los médicos realicen cursos de educación continua sobre nutrición. Pero no impedirá que las personas usen sus beneficios del Programa de Asistencia Nutricional Suplementaria (SNAP, por sus siglas en inglés) para comprar productos “no nutritivos” como sodas o dulces.

Muchos estados planean invertir en tecnología, como telesalud, ciberseguridad y equipos para monitoreo remoto de pacientes. Otros temas incluyen mejorar el acceso a alimentos saludables, fortalecer los servicios de emergencia, prevenir y tratar enfermedades crónicas, y recurrir a trabajadores comunitarios de salud y paramédicos para visitas domiciliarias.

Algunas propuestas específicas incluyen:

• Arkansas quiere gastar $5 millones en su programa “FAITH” —Acceso, Transporte y Salud Basados en la Fe— para que instituciones religiosas rurales organicen eventos de educación y pruebas preventivas. También se instalarían circuitos para caminar y equipos de ejercicio en las congregaciones.
• Alaska, que históricamente ha usado trineos de perros para entregar medicamentos en zonas remotas, quiere probar el uso de “sistemas aéreos no tripulados” para agilizar la entrega de medicinas.
• Tennessee quiere aumentar el acceso a actividades saludables con inversiones en parques, senderos y mercados agrícolas.
• Maryland propone abrir mercados móviles e instalar refrigeradores y congeladores para facilitar el acceso a alimentos frescos y saludables que suelen dañarse en zonas rurales con pocos supermercados.

El senador estatal Stephen Meredith, un republicano que representa una parte del oeste de Kentucky, dijo que espera que los hospitales rurales sigan cerrando, pese al programa estatal.

“Creo que estamos tratando los síntomas sin curar la enfermedad”, señaló después de escuchar una .

Morgan, cuya organización representa a hospitales rurales que probablemente cerrarán, dijo que las ideas del estado pueden sonar bien.

“Uno puede escribir una narrativa que suene maravillosa”, afirmó. “Pero traducir esas metas aspiracionales en un programa funcional, eso es más difícil”.

Los reporteros de �鶹Ů�� Health News, Phil Galewitz, Katheryn Houghton, Tony Leys, Jazmin Orozco Rodriguez, Maia Rosenfeld, Bram Sable-Smith y Lauren Sausser contribuyeron con este artículo.

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The Trump administration, which has promised “radical transparency,” that it plans to publish the “project summary” for states that win awards. Following the lead of federal regulators, many states are withholding their complete applications, and some have refused to release any details.

“Let’s be clear,” said Alan Morgan, chief executive of the National Rural Health Association. “The hospital CEOs, the clinic administrators, the community leaders: They’re going to want to know what their states are doing.” The NRHA’s members include struggling rural hospitals and clinics, which would benefit from the Trump administration’s Rural Health Transformation Program.

Morgan said his members are interested in what states propose, which of their ideas are approved or rejected, and their budget narratives, which detail how the money could be spent.

Improving rural health care is an “insanely complicated and difficult task,” Morgan said.

The five-year Rural Health Transformation Program was approved by Congress in a law — the One Big Beautiful Bill Act — that also drastically cuts Medicaid spending, on which rural providers heavily depend. It’s being watched closely because it’s a much-needed influx of funds — with a caveat from the Trump administration that the money be spent on transformational ideas, not just to prop up ailing rural hospitals.

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

Health and Human Services Secretary Robert F. Kennedy Jr. has repeatedly promised to open the government to the American people. His agency has devoted to “radical transparency.”

“We’re working to make this the most transparent HHS in its 70-year history,” in written testimony to lawmakers in September when releasing information about the rural health program.

Grant applications are “not released to the public during the merit review process,” Howden said, adding, “The purpose of this policy is to protect the integrity of evaluations, applicant confidentiality, and the competitive nature of the process.”

Democrats and many health care advocates are concerned politics will affect how much money states get.

“I am very concerned about retaliation,” said Rep. Nikki Budzinski (D-Ill.). Because Democrats control her state’s politics, “our application might not be as seriously considered as other states that have Republican leadership,” she added.

Illinois’ Democratic members of the U.S. House to CMS Administrator Mehmet Oz in November asking for “full and fair consideration” of their state application. Illinois officials have not yet released their state’s proposal to �鶹Ů�� Health News, which has a pending public records request.

Heather Howard, a professor of the practice at Princeton University, said she is “pleasantly surprised at how transparent the states have been.”

Howard directs the university’s State Health and Value Strategies program, which the rural health fund, and praised most states for publicly posting their project summaries.

“To me, it speaks to the intense interest in this program,” Howard said. Her team, reviewing about two dozen state summaries, found themes including expansion of home-based and mobile services, increased use of technology, and workforce development initiatives like scholarships, signing bonuses, and child care assistance for high-demand positions.

“I think it’s exciting,” Howard said. “What’s great here is the experimentation we’re going to learn from.”

Telerobotics appeared in Georgia’s and Alabama’s applications, she said, including a proposal to use robotic equipment for remote ultrasounds.

Another theme that “warms my heart,” Howard said, was the effort among states to create advisory groups or committees, including in Idaho, where work groups are expected to focus on technology, workforce development, tribal collaboration, and behavioral health.

All 50 states submitted applications to federal regulators by the Nov. 5 deadline and awards will be announced by the end of the year, according to CMS.

As of late November, nearly 40 states had released their project narrative, the main part of the application, which describes proposed initiatives, according to �鶹Ů�� Health News tracking. More than a dozen states have also released their budget narratives.

Also as of late November, only a handful of states — Idaho, Iowa, Kansas, Minnesota, New Mexico, North Dakota, South Carolina, and Wyoming — had released all parts of the application.

�鶹Ů�� Health News filed public records requests for states’ complete applications. Some states have refused to release any of their application materials.

Nebraska, for example, rejected a public records request, saying its application materials are “proprietary or commercial information” that “would give advantage to business competitors.”

Kentucky shared its application summary but said the remainder of the application is a “preliminary draft” not subject to release under state laws.

Erika Engle, a spokesperson for Hawaii Gov. Josh Green, said the governor “is committed to transparency” but declined to share any of the state’s proposal.

Hawaii and other states are still processing formal public records requests.

The rural health program is part of the July law projected to reduce federal Medicaid spending in rural areas by 10 years.

Those cuts are expected to affect rural health facilities’ bottom lines, threatening their ability to stay open. A recent Commonwealth Fund report found that rural areas continue to to primary care. But the guidelines for the rural health program say states can use only 15% of their new funding to pay providers for patient care.

Between the Medicaid cuts and funding boost from the new program, “there’s real opportunity for national policy to impact rural, both in the negative and the positive potentially,” said Celli Horstman, a senior research associate at the New York-based policy think tank who co-authored the report.

Among the publicly available rural health transformation proposals, Democratic-leaning states show support, or are willing to adopt, some of the administration’s goals but will lose out on points from eschewing others.

For example, New Mexico said it would introduce legislation requiring students to take the Presidential Fitness Test and physicians to complete continuing education courses on nutrition. But it won’t prevent people from using their Supplemental Nutrition Assistance Program benefits to buy “non-nutritious” foods such as soda and candy.

Many states want to invest in technology, including telehealth, cybersecurity, and remote patient monitoring equipment. Other themes include increasing access to healthy food, improving emergency services, preventing and managing chronic illnesses, and enlisting community health workers and paramedics for home visits.

Specific proposals include:

• Arkansas wants to spend $5 million through its “FAITH” program — Faith-based Access, Interventions, Transportation, & Health — to enlist rural religious institutions to host education and preventive screening events. Congregations could also install walking circuits and fitness equipment.
• Alaska, which historically relied on dogsled teams to bring medication to remote areas, is looking to test the use of "unmanned aerial systems" to speed up pharmacy deliveries to such communities.
• Tennessee wants to increase access to healthy activities by spending money on parks, trails, and farmers markets.
• Maryland wants to start mobile markets and install refrigerators and freezers to improve access to fresh, healthy food that often spoils in rural areas with few grocery stores.

State Sen. Stephen Meredith, a Republican who represents part of western Kentucky, said he still expects rural hospitals to close despite his state’s rural health transformation program.

“I think we’re treating symptoms without curing the disease,” he said after listening to a presentation on Kentucky’s proposal at .

Morgan, whose organization represents rural hospitals likely to close, said the state’s ideas may sound good.

“You can craft a narrative that sounds wonderful,” he said. “But then translating the aspirational goals to a functioning program? That’s difficult.”

�鶹Ů�� Health News staffers Phil Galewitz, Katheryn Houghton, Tony Leys, Jazmin Orozco Rodriguez, Maia Rosenfeld, Bram Sable-Smith, and Lauren Sausser contributed to this report.

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

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This story can be republished for free (details).