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 Â鶹ŮÓÅ 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 Â鶹ŮÓÅ 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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During a January White House roundtable touting the first grants to states under a new $50 billion rural health fund, Centers for Medicare & Medicaid Services Administrator Mehmet Oz called the idea “pretty cool.” Later that day, Sen. Bernie Sanders, the independent from Vermont, said it is decidedly . And obstetricians and others chimed in on social media to express alarm, with one political activist calling it a “.”

The disparate responses highlight how excitement over the tech-heavy ideas states pitched in their applications for the federal Rural Health Transformation Program conflicts with the reality that there simply aren’t enough health workers to serve patients in many rural communities. Now, as states prepare to spend their first-year awards, tension is mounting, and nowhere is that strain more visible than in Alabama.

Oz has lauded the state’s proposal to invest in the relatively new technology of robotic ultrasounds.

“Alabama has no OB-GYNs in many of their counties,” Oz said, sitting with President Donald Trump and Cabinet members. The dearth of care, , prompted the proposal to use robots for ultrasounds on pregnant women.

Britta Cedergren directs the and has a firm grip on reality: “No one is using autonomous robots.”

While robotic ultrasounds are a “really neat technology,” she said, they are not yet being used in the state. Instead, clinicians providing obstetric care lean on phone consultations and — when equipment and internet are available — telehealth.

The goal, she said, is to “support places where there is no care.”

Cedergren is part of multiple state maternal and fetal health groups and works daily with doctors, hospitals, and first responders. While enhanced technology is vital for patient care, it’s not a replacement for a well-trained workforce and a coordinated care and data system, she said.

In 2024, the most recent year for which data is available, Alabama’s infant mortality rate was per 1,000 live births. The nationwide rate was 5.5 per 1,000 live births, according to released by the Centers for Disease Control and Prevention.

Hospital-based obstetric unit closures, which often lead to a loss of health care providers who can care for expectant mothers and their babies, are a long-standing, ongoing trend in rural America. But Alabama’s loss of services has been particularly profound.

In 1980, 45 of the state’s 55 rural counties had hospital-based obstetric services. By 2025, , according to state data. And the losses aren’t slowing. Five hospital obstetric units closed in 2023 and 2024, including in three rural counties: Monroe, Marengo, and Clarke.

, a professor at the University of Minnesota School of Public Health, found that closures in remote areas in preterm births, a leading cause of infant mortality.

“People will be pregnant and give birth in communities all over the place,” she said. “You have to be able to get to a place where you can be cared for.”

Nearly all 50 states’ applications for the Rural Health Transformation Program declared workforce shortages and maternal health needs as priorities, but only Alabama proposed using robots to fill the gap. The rural fund, which Congress created as a last-minute sweetener in Trump’s One Big Beautiful Bill Act last summer, encouraged states to be creative, be innovative, and pitch tech solutions.

Alabama was awarded $203 million for the first of the program’s five years. Among nearly a dozen , the state’s application included bolstering its rural workforce as well as improving maternal and fetal health.

Mike Presley, a spokesperson for the , which is overseeing the plan, said no one was available for an interview about telerobotic ultrasounds.

LoRissia Autery, an obstetrics and gynecology specialist in rural Alabama northwest of Birmingham, said the robots won’t decrease maternal and infant mortality. There are nuances, she said, to doing ultrasounds.

Many of her patients have high-risk pregnancies with diabetes, high blood pressure, and hepatitis C, she said. She said she worries about the kind of care that will be given to her patients, many of whom drive an hour or more to get to her, if robots are used instead of a trained specialist.

“It takes away just the care that we need to have for women,” said Autery, who co-founded . The clinic includes three doctors, draws patients from five counties, and could use an additional physician to meet the demand, Autery said.

“Probably for the past six or seven years, we’ve been putting out feelers trying to find a fourth partner,” Autery said. “It’s difficult for a variety of reasons.”

In his social media remarks to Oz, Vermont’s Sanders called the lack of rural health care providers in the U.S. an “international embarrassment.”

“In the richest country on earth, we need more doctors, nurses, dentists and mental health counselors, not more robots,” Sanders wrote on the social platform X.

At least one country is using robots paired with trained workers to decrease deaths.

In the remote Canadian village of La Loche, Julie Fontaine operates an ultrasound robot at a clinic with two on-site nurse practitioners and rotating doctors. She said patients like the robot because it saves them the time and expense of traveling to a bigger regional health care facility six to seven hours away.

“When people come in, they’re like, ‘Wow, like, technology these days,’” said Fontaine, a member of the in northern Saskatchewan. “It’s something they’ve never seen before or even used.”

When working with patients, Fontaine connects the robotic ultrasound machine to a tele-sonographer at a control station in Saskatoon. The sonographer then remotely operates a robotic arm on the machine. A radiologist, who can be anywhere, reads the scan’s report and sends it back to the family doctor in La Loche, said Ivar Mendez, a neurosurgeon and the director of Canada’s . Most babies in Canada, he said, are delivered by family doctors or midwives, not specialists.

“The most important thing is the identification of a high-risk pregnancy early enough so you can intervene,” said Mendez, who added that the robotic ultrasound is “as good as the in-person ultrasound” but can’t be used when a patient needs a more invasive vaginal ultrasound. The mortality rate for mothers and newborns in the north, site of the La Loche clinic, is 20 to 25 times greater than in the rest of the nation, he said.

“One of the reasons is that there’s no availability of prenatal ultrasonography in those communities, so pregnant women have to travel to cities and they’re put up at hotels,” he said.

In a , Mendez and his team at the University of Saskatchewan examined 87 telerobotic ultrasounds and found that 70% of the time, the robotic ultrasound made travel for care unnecessary. Nearly all the patients said they would use the robot again.

The same robotic ultrasound technology was in the U.S.

Nicolas Lefebvre, chairman and chief executive of the robot’s creator and manufacturer, AdEchoTech, said the company has “U.S. maternity-specific projects that are currently under preparation.” The average price of a robot will be $250,000 to $350,000, according to AdEchoTech’s U.S.-based business development consultant.

Using robotic ultrasounds is one part of Alabama’s proposed maternal and fetal health initiative, according to the . Acknowledging loss of hospital obstetric units, officials said they planned to connect smaller rural providers and health care facilities that lack “high-quality maternal and fetal health services” to regional care hubs that can provide the services digitally, including through telerobotic ultrasound.

For their workforce initiative, state officials proposed training programs for doctors, emergency services, and nurse-midwives.

The estimated required funding for the maternal and fetal health initiative is . Alabama officials proposed for their workforce initiative over five years.

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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 Â鶹ŮÓÅ 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 Â鶹ŮÓÅ 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 Â鶹ŮÓÅ 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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Â鶹ŮÓÅ Health News is working to collect and post complete application materials, by state, here and will update this repository as new materials, released in response to public records requests, arrive.

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Federally recognized tribes can’t directly apply for a share of the rural health fund — only states can. And states aren’t required to consider tribes’ needs. But state applications for the five-year payout show some states with significant Native American populations did so anyway.

Workforce development, technology upgrades, and traditional healing are a few of the initiatives specifically aimed at Native American communities that some states included in their applications, which were due to the Centers for Medicare & Medicaid Services on Nov. 5. The fund was a late addition to the One Big Beautiful Bill Act in response to worries about the harm the spending reductions in Republicans’ bill would have on rural hospitals’ finances.

Some states, , Nevada, , are also considering setting aside 3% to 10% of their federal payouts to distribute among tribes. Washington proposed setting aside $20 million per year.

Federally recognized tribes have direct relationships with the U.S. government, but state governments also allocate resources to tribes and can create policies that support tribal priorities. States and tribes share concerns about the effect that the massive GOP budget bill, which President Donald Trump signed into law in July, will have on the U.S. health system. The law is expected to reduce federal Medicaid spending by nearly $1 trillion and increase the number of uninsured by , according to Â鶹ŮÓÅ, a health information nonprofit that includes Â鶹ŮÓÅ Health News.

Catherine Howden, a CMS spokesperson, said that states are required to develop their applications in collaboration with key stakeholders, including the state governments’ tribal affairs offices or tribal liaisons, as well as “Indian health care providers, as applicable.” But these entities do not include tribal governments or official tribal representatives.

Tribes can apply for Rural Health Transformation Fund subgrants through their states. But during a recent call with federal health officials, tribal leaders expressed frustration about being regarded as just another stakeholder in the issue rather than sovereign nations. Tribal sovereignty guides most government-to-government consultations over proposed federal actions that would have a substantial effect on tribes.

“Even in a scenario where tribal consultation is required, the quality and quantity of that tribal consultation on a state-by-state basis is all over the place,” said Liz Malerba, director of policy and legislative affairs for the United South and Eastern Tribes Sovereignty Protection Fund, which advocates for tribal nations from Texas to Maine. Malerba is a citizen of the Mohegan Tribe.

Federal policy works better when tribal nations are directly eligible for funding that supports essential services in their communities, Malerba said, adding that tribal leaders are concerned that the reach of the program into their communities will vary considerably.

There are and Native American and Alaska Native people in the U.S. The population faces a lower life expectancy and when compared with other demographics. The Indian Health Service, the federal agency responsible for providing health care to Native Americans and Alaska Natives, has been by Congress.

Â鶹ŮÓÅ Health News analyzed how 12 states with significant Native American populations took tribes into account as they developed plans for the pot of federal money.

, , , and were among the states that held tribal consultations or listening sessions ahead of the Nov. 5 application deadline.

In states that did not initiate input from tribes, some Native American leaders made sure their voices were heard in other public hearings. Jerilyn Church, CEO of the Great Plains Tribal Leaders’ Health Board, said she attended an October public meeting in South Dakota because she felt it was important for state leaders to consider how they could use the program’s resources on reservations. There are nine federally recognized tribes in the state, and Native American people make up 9% of the population.

“I felt like we needed to help be that advocate,” said Church, a citizen of the Cheyenne River Sioux Tribe.

In the proposed initiatives included in its rural fund application, South Dakota such as improved telehealth and funding for doula programs. It also said the state will continue meeting with the Great Plains tribal health board throughout the five-year funding cycle.

In Oklahoma — where more than 14% of the population is Native American, a higher share than in most other states — tribal representatives were invited to weigh in with the rest of the public when the state was gathering information for its application, the details of which have not been publicly released.

“We’ve welcomed input from any Oklahoman,” said state health department spokesperson Erica Rankin-Riley.

North Dakota in the Rural Health Transformation Program and included initiatives such as expanding physician residency slots with tribal-specific rotations and opportunities for farm-to-table food distributions. But that would have pledged 5% of its federal allotment to tribes. There are five federally recognized tribes in the state, and Native Americans make up nearly 5% of the population.

Some states did include proposals to fund high-priority initiatives for tribes.

for the rural fund included an initiative focused on improving health among Native American communities. Its goals include investing in workforce development for tribes, better care coordination between tribes and rural hospitals, and $2.4 million annually to support Washington State University’s rural health education programs, including its Indigenous health program.

included integrating Indigenous traditional healing in Alaska Native village clinics. It would include offering traditional-healing house calls, hands-on training for healers, and traditional-medicine training for health care providers and staff, according to the application.

One of would support the state’s nine federally recognized tribes in improving health outcomes. The state estimates the initiative would require $20 million per year, or 10% of the Rural Health Transformation Program award.

Whether or not states identified funding for tribes or included tribal priorities in their proposals, tribes will be eligible to apply to their states for subgrants of the Rural Health Transformation Program money. While larger tribes that have more resources, such as grant writers and staff to implement programs, could benefit, smaller tribes may struggle to produce competitive applications.

Church said that the Great Plains Tribal Leaders’ Health Board will know the fruits of its labor when states are notified of their rural health fund allotments by the end of the year.

“Hopefully the work that we did, the advocacy that we did, and the outreach,” Church said, “will result in resources getting to our tribes.”

Â鶹ŮÓÅ Health News South Dakota correspondent Arielle Zionts contributed to this report.

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

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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 Â鶹ŮÓÅ 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 Â鶹ŮÓÅ 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.

Â鶹ŮÓÅ 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.”

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

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

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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 Â鶹ŮÓÅ 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 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 , $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.

Top Senate Democrats have raised alarms about the rural health program. They include Ron Wyden of Oregon and Tina Smith of Minnesota, who 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 .

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 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 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. and 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 .

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.”

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

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WASHINGTON — Nationwide, states are racing, is quickly becoming a quaint idea.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Â鶹ŮÓÅ Health News Montana correspondent Katheryn Houghton contributed to this report.

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

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