How is the federal funding landscape affecting rural health?

UC Berkeley School of Public Health: Broadly, what’s the current state of rural health in the United States? What are the biggest hurdles to receiving quality medical care if you are in a rural area?

Kimberly MacPherson: Roughly one in five Americans live in rural communities burdened by limited health care access, socioeconomic disadvantages, and disproportionate social and environmental impacts. They face barriers that include geographic isolation, transportation challenges, limited access to broadband, and clinical workforce shortages. One third of rural hospitals are at risk of closing and many no longer can offer critical services such as maternity or mental health.

The One Big Beautiful Bill Act, passed this summer, includes cuts to Medicaid of almost $1 trillion over the next 10 years. The Congressional Budget Office estimates that this means that 11.8 million Americans may lose their health insurance. (The current government shutdown is partially due to the battle over whether or not to reverse these cuts.) How do you think this change will play out in rural America?

Rural parts of the country have higher rates of people on Medicaid, so they are likely to experience a disproportionate impact of any cuts to funding or enhanced barriers to maintaining eligibility. They also already have more systemic challenges stemming from healthcare workforce shortages, financial strain on local hospitals, higher rates of disabilities and slower adoption of behaviors that minimize health risks. The cuts to Medicaid could worsen all of these challenges and have a negative impact on the physical and mental health of rural Americans.

The federal government has recognized some of the risks to rural health from this budget bill and created the Rural Health Transformation Fund to support those communities. This fund has $50 billion to distribute. The statute says that half will go equally to all states that have an application approved (regardless of size, need, etc). States have until early November to apply and can use the funds in different ways that are specific to their needs. Our alum Lynn Barr has been doing podcasts and webinars to help support those who are applying. (You can hear her on Becker’s Healthcare Podcast.) Fifty billion collars may sound like a lot of money but it is insufficient to close the gap created by the cuts. A KFF analysis of the CBO scoring determined that the funds could only offset about a third of the cuts (37%) to rural Medicaid spending over the 10 years.

Is there a particular area or region of the U.S. that will be most affected by the proposed changes to Medicaid? I’ve seen some headlines saying that red states will be hit hardest.

Some states have more robust healthcare and social programs targeted at Medicaid beneficiaries; cover a wider set of the population, and spend more per Medicaid beneficiary than others, so they could face a bigger gap and face harder choices as federal funding goes away.

Large states with high rates of low-income residents might also be heavily affected as many of those people could end up uninsured, which places a huge burden on the delivery system. That group includes blue states such as California and New York but also red states like Texas and Florida. States generally cannot run deficits like the federal government, so will need to come up with combinations of cuts and innovative strategies to try and preserve access to quality healthcare.

Recently, Trump proposed a $100,000 fee for new H-1B visas. How will this affect the ability of rural health centers and hospitals to recruit and keep staff?

This new supplemental fee could make it harder for clinical settings to recruit healthcare providers ; and that would be even more challenging in rural areas. They already have more pronounced shortages and fewer financial resources as compared to urban settings.

The American Hospital Association and others have been pressing for an exemption for healthcare professionals. There is a National Interest Exemption process which is not yet well defined and rural facilities would likely have a harder time with the administrative burden associated with trying to seek it. Senators from red states including Iowa and West Virginia have said that hospitals in those states are asking them to seek a rural carveout from the new fee. Those two states, along with North Dakota, have the highest percentage of foreign-trained doctors in the U.S.

And what about deportations? Is that potential reduction in workforce affecting rural health?

The fear and anxiety caused by the escalation of federal deportation activity has had a chilling effect in many places across the country. In rural areas, given the pre-existing workforce shortages, anything that further disrupts people feeling able to show up to work can negatively impact the healthcare delivery options in that community.

Also, when residents fear being deported they are less likely to seek healthcare and social services for themselves or their family.

What about Trump’s tariffs? Are they affecting healthcare systems in rural America?

Again, given the smaller scale and financial strain that many rural health facilities face, anything that increases the cost of needed medical or administrative supplies adds a meaningful burden.

As they are often smaller in size and not part of a health system, rural hospitals and clinics do not get to access economies of scale and purchasing leverage that is more typical with urban facilities. They also have less capacity to absorb higher prices or go longer with the inventories they currently have on hand.

The rural residents also face challenges from tariffs and non-healthcare goods are also more expensive and that might force them to make difficult choices on whether or not to seek care that would have an out-of-pocket expense. Delayed care can lead to worsening conditions and the need for more expensive care later.

UC Berkeley School of Public Health has an online MPH program that focuses on rural health. Why do you think this is so important for an urban school like Berkeley to offer?

Berkeley Public Health is committed to bringing innovative and equity-focused training to public health leaders serving rural communities across the U.S., to prepare this critical workforce for the challenges they face.

When we launched our online MPH program specifically designed for working professionals in 2012, we immediately saw the contributions of student voices from rural communities in class discussions and course projects. We believe that educating and empowering passionate, talented, mid-career public health professionals where they live and work, combined with Berkeley faculty’s innovative thinking, can build health systems’ capacity toward improved public health in rural communities.

Rural health care professionals have a deep understanding of the health challenges facing their own communities, including problems with health care systems and policies — yet their voices are too often absent in discussions of health care policy at the state and federal levels.

Involvement in Berkeley’s world class education and research equips rural health leaders with the skills and knowledge to shift those discussions.