Episode 66. HRSA's Dwindling Rural Health Commitments with Alexa McKinley Abel, Carole Johnson and Toniann Richard
Michelle Rathman: Hello, one and all and welcome back to a brand-new episode of The Real Impact. I'm Michelle Rathman and I am grateful that you have joined us once again for another conversation that works hard to connect the dots between policy and rural everything. Now we have got another power packed guest panel today, but before we get into that, I do wanna say a very quick thank you to our partners at the National Association of Rural Health Clinics.
We are really appreciative not only for their partnership, but really for the work that they do to advocate for policies that help to enhance the ability of 5,000 plus rural health clinics to deliver cost-effective, quality healthcare to patients in rural and underserved communities. Now, a little bit later in this show, you're gonna hear some news about an event that they're hosting, so stay tuned for that. It sounds like a magnificent time.
Okay. Now also before we move on, you may recall that earlier this summer. I had the opportunity to record an episode with Mr. Anthony Flaccavento from the Rural Urban Bridge Initiative. Well, last week I was on a call with Anthony and a few hundred others as they prepared to kick off their Beyond Resistance campaign, which officially launched on September 10th.
And from that event you should know that Anthony and guests, including, Ro Khanna, Sarah James of the Rural Democracy Initiative and others shared that beyond resistance it's the first major national campaign to put working class and rural people front and center in the fight for politics and economies that work for rural and working-class people.
Now they have got events lined up, several other events lined up for the rest of this year and I believe into next. And to help you navigate your way through that, we are gonna put those links on our website. Very easy to find. Here it goes, theruralimpact.com. Just simply head to our resource page and we'll make sure that we give you all those connections so that you can easily click through and find your way to the information that you're gonna hear on this entire episode, including what I just shared.
Now, also, really quick, if you are a rural serving organization from sectors A to Z, get in contact with us. All you have to do is email partnerships, that's plural. [email protected], and we'll be happy to explore with you ways to help you also expand your rural reach and get connected with those who you feel are important to connect with, with your message and the services and all the work that you're doing to advocate for rural policy and help make rural communities thrive.
Okay. On today's dose of rurality, as I'm calling it, we're circling back to a topic that cannot afford to be on the back burner, because while things are still at a raging boil with the passing of the OBBB or H.R.1, because that makes perfect sense, we are also just days away from what could be a shutdown of the federal, federal government, or a CR that has this kind of hobbling along on a budget that does not simply put, get the job done.
Okay, so first up for this particular episode, I opted to start with a phone a friend. I know we didn't make that up. We stole it from a show a long time ago, but because the House Appropriations Committee just released this morning, their report language for FY 2026 Labor HHS Appropriations Bill, and while things may have changed by the time you hear this, it's important to note it's good to know what the house was planning for FY 2026 budget, considering the funding continues to be on this date at the FY 2024 levels, you might say they're a little behind.
So here now is my quick phone a friend conversation with Alexa McKinley Abel, and then I'll preview the main events. So here we go.
Michelle Rathman: Hey Alexa, you are now officially on the Rural Impact Phone a Friend List today September 8th. I called you because the House Appropriations Committee just this morning that I learned from you in your great morning email update released its report language for FY 2026 Labor HHS Appropriations Bill, which is you note, and you did when you were with us last time, includes significant investments and increase in rural health programs.
Which is very welcome news to a lot of folks who've been doing a lot of nail biting, dare I say, and hair pulling. Speaking of present company, myself included, so a lot has been happening. Why don't you break it down for us? First, let's talk about what's on the top of the list, which I think maybe there's a reason for it is the New Rural Hospital Provider Assistance Program, not to be confused with the Rural Health Transformation Fund or anything like that.
This is very specific, different why.
Alexa McKinley Abel: Yeah, great question. So, this is, like you said, a brand-new proposal called the Rural Hospital Provider Assistance Program. It would be a hundred million dollars, administered by the Health Resources and Services Administration in a formula grant. And it's really targeted to hospitals with, low wage, a low wage index, of 0.9 or less, 50 beds or less. And then these hospitals also have to be located in the top quintile of states, with the highest poverty levels. So that means, the top 10 states with the biggest population living under the federal poverty line. So, this is not an opportunity that's going to be available to hospitals in every state.
It's going to be those top 10 states as calculated, you know, by the looking at the federal poverty level.
Michelle Rathman: And we'll make sure that we put links to that resource 'cause I think it's important for people to be able to look on a map and understand. Now the next one is a financial and community sustainability for at-risk hospitals and people on this podcast. You've been hearing for a long time, there's plenty of hospitals at risk.
Talk about that funding level and what, what specifically it's earmarked for.
Alexa McKinley Abel: Yeah, so this does get confusing as so many of these have really similar names. This would be a $10 million for really targeted technical assistance for hospitals that are at imminent risk of closure. So, there's other TA programs throughout the federal go government. This is really for those hospitals that are about to close their doors in order to keep them open and maintain that access to care in their communities.
And this is something that's been proposed in past appropriations bills, but never actually passed and funded. So, another go at this one.
Michelle Rathman: Another go at this one, which is great to hear. So, the next one is Medicare Rural Hospital Flexibility Program. This is, I think, a pretty significant win as well.
Alexa McKinley Abel: Yes, definitely. So, you may recall that this was proposed to be eliminated in the president's fiscal year 2026 budget, and instead the house is funding it at a higher level than the last couple of years. And the same with the Senate as we saw back in July. So, all indications are kind of showing that the flex program and also the small hospital improvement program, which is part of the flex portfolio seem to be safe and Congress really recognizes their importance in the rural healthcare delivery system.
Michelle Rathman: And I think it's important to remind people this is a one-year budget. We're talking about here. So, I mean, this stuff has to get done. I know there's a deadline, but first before we go on, we also see funding an increase in funding for State Offices of rural health, which is very near and dear to my heart for many reasons.
That's a win, 13 million over from over 12 million. So, another million thrown into a pot. The Rural Hospital Stabilization Program, that's at 20 million. What. Tell us about that.
Alexa McKinley Abel: That is a huge increase over what we've seen that's been funded at, I believe, 4 million. And then the Senate proposed around 10 million this year. Um, and the house bumped that would bump it up to 20 million. And this is a program that's already kicked off. I believe the first cohort of hospitals that were chosen to receive technical assistance under this program have been announced within the last couple of months and applications are either closed or just closed, for the next cohort.
So, this is really, again, a technical assistance program. We're really seeing the house at least try to funnel a lot of resources into rural hospitals in their appropriations bill.
Michelle Rathman: Yes. And to which I say it's that about time it's necessary and, and hope, hopefully sustainable. So, the next one I think is really I, because it's, again, the, the title of it could mean so many things, the Rural Healthcare Services Outreach Programs at 110 billion plus what's
Alexa McKinley Abel: Yeah.
Michelle Rathman: included in that?
Alexa McKinley Abel: This is 110 million. That's a $10 Million. increase from, yeah, a $10 million increase from the last couple of years. And this is a suite of programs that, provide grants to, community-based organizations, different partnerships that then have to increase access to care. And they're really afforded a lot of flexibility in how to do so, so it's to meet the community's needs. There's been really incredible outcomes coming out of this suite of programs. Something like over 90%, uh, of rural residents served, showed improvements on at least one clinical outcome. So, something like, um, A1C levels. And these programs. I also will note this is outside of the appropriations context, but these programs authorities expire at the end of this year. So, we're also working really hard on getting, the outreach programs reauthorized by the end of 2025 as well.
Michelle Rathman: That's, I mean, I would imagine that that has to happen for this money to be appropriated. So, the two go hand in hand.
Alexa McKinley Abel: They can continue to appropriate the program. The thing is we really just like to have authorization and statute just to provide a little bit more security because if it's not appropriated one year. Then the program kind of just ceases to exist. And, I mean, it hasn't happened with outreach. It's such a big program just looking at that funding level.
But it is just that added security, to have the authorization current in, in statut.e
Michelle Rathman: Frankly in this environment, I think it's very smart. Like check that box.
Okay, so there's some other things in here. Rural health research and policy developments, rural residency planning, Rural Communities Opioid Response Program, which I know your organization and so many others applaud. It's, it's just so necessary.
Some other things in here. Let's talk a little bit about the, uh, nursing workforce development, which I was really pleased to see as well.
Alexa McKinley Abel: Yeah, there was significant money, set aside for the nursing workforce development program. So that's really a suite again, of different programs that try to boost the nursing workforce, which as we know in rural areas, so, so important and needed. I think it's a slight decrease from past levels, but still around $258 million towards nursing workforce development.
Michelle Rathman: Absolutely. Well, we, we are gonna make sure that we put the link of all this great information on our website so people can access it.
So again, reminding people the date, we're recording this on Monday, the 8th of September, tomorrow the ninth, the whole gang gets together and does their markup, if you will, on the bill. And then what do you, what is the National Rural Health Association hope to or wish to have be the next iteration? What's the next phase until, you know, we got till the end of September, so the clock is ticking as they say.
Alexa McKinley Abel: Yeah, what we would love to see is this, funding level, these funding levels passed, right? We would love to see Congress a comprehensive fiscal year 2026 budget, and they haven't passed anything but a CR in the last couple of years, which leaves funding levels, the same from the prior year. And we're still at 24 levels right now. So our wish at NRHA is to see either the house or the Senate's numbers, passed through Congress and seeing those increases for our programs at the Federal Office of Rural Health Policy and at HRSA more broadly.
Michelle Rathman: Yeah. When before I let you go, I mean, I can't miss the opportunity. There are ways for people who are not in the so-called healthcare space to do themselves a favor and advocate because at the end of the day, like. Said at 24 levels, we are now facing a whole nother area of headwinds where rural health is concerned.
So, this money is critically important, and I hate to maybe sound like I'm overusing the term. What can people of any profession, any place of point in time in their life, what can they do to convince their member of Congress that this budget is a thumbs up for rural?
Alexa McKinley Abel: Yeah, it's really as simple as getting in touch with your member of Congress, which if you haven't done that, it sounds kind of daunting, but organizations like the National Rural Health Association really try to make it as simple as possible. We have template letters that you can just fill in and email. We have advocacy campaigns on our website where you just put in your, zip code and it automatically populates with who your representative and senators are, and sends a pre-written email about how important it is that Congress passes an FY 26 budget.You really don't need to do anything. You can add some other language in there if you want, but contacting your members of Congress, like you said, Michelle, it's the most important thing you can do right now to drive home the fact that we need more funding for rural health.
Michelle Rathman: Yes. And on top of that I'll add, if you have a story to tell and we all do tell your story. Why is your community health center so important to you? Why is your critical access hospital so important to you, your primary care provider? I mean, all of these things are connected, so, stories also have an opportunity, as dare I say, to make an impact.
Alexa, thank you so much for joining us. I know we're gonna call you back because there's always something happening in your space.
Alexa McKinley Abel: Yep. Thanks for having me.
Michelle Rathman: Thank you.
Many thanks to Alexa. Once again, I'm always so appreciative for the updates that she's able to provide us. And here's a quick invitation from me to you. If you are not following rural health policy and all of the moving parts, well, that's what we're here for. So, make sure again that you subscribe to us, get our updates, we'll make sure that we put as much new information in there as we possibly can. And be sure to check our resource page for those advocacy campaigns that Alexa talked to us about here just a moment ago.
Up next, I am so pleased to have you join me for a really candid conversation with a person whom I had the opportunity to sit down with while on location in Washington DC back in February of 2024, which feels like a million years ago. And this is while I was attending a policy conference. If you guessed, my next guest is the Former Administrator of the Health Resources and Services Administration. That's HRSA. Now Senior Fellow at the Century Foundation, Carol Johnson.
Well, you'd be right, ding, ding, you win a prize. And after I have that conversation with Carol, and a quick break to hear from our new partners, you are going to hear a really intriguing conversation with a powerful voice for community health centers, a leader who really is working on the ground with hard evidence on how difficult and challenging it can be today to deliver quality healthcare in the rural space under conditions that we find ourselves in.
And that is none other than Toniann Richard, CEO of HCC Network out of the Show Me state. And that would be Missouri. Kind of doing the quizzes today on the rural impact. Okay, old friends and my new ones, it is that time when I invite you to sit back and tune out that background noise. We know there's plenty of it. Get yourself on a podcast conversation frame of mind and hear my conversations with Carole Johnson and Toniann Richard. Are you ready? I know I am. So let's go.
Michelle Rathman: Carole Johnson, Senior Fellow at the Century Foundation, and Former Administrator of the Health Resources and Services Administration known as HRSA. Welcome back to the Rural Impact. I mean it when I say I cannot tell you how much we appreciate having you join us again in your new role.
Carole Johnson: Well, thank you so much, Michelle. It's really, I'm really grateful to be here with you and to have the chance to talk with you and your listeners about what's happening in rural health and the challenges on the horizon.
Michelle Rathman: And challenges is a really great place to start. You make my job easy because Carole, during your tenure at HRSA, and I did have the privilege of sitting next to you in DC at the NRHA Policy Conference when we were talking about things that you were doing. You led the agency's expansion of healthcare services historically, of course, and underserved in rural communities.
You, you do this with purpose. This is on purpose work that you do. You include an focused on improvements that directly respond to families needs. Just a few examples that I wanna make sure that folks know if they don't already, adding night and weekend hours at HRSA funded health centers, recognizing that not everybody's schedule is the same, integrating mental health and substance use disorder treatment into primary care, which has been a game changer, really growing school-based health services, investing in scholarships, loan repayment, stipends to recruit and train our next generation of physicians and nurses and other healthcare providers. This is a growing concern, the workforce. And the last few things I wanna mention is the National Maternal Mental Health Hotline. And this weekend we are recording this on August 25th. I did go to those pages of the website and it's like a ghost town the last time they were reviewed. And I think it's important for me to state that.
So, the question in all this is now nine months into the Trump Administration, we've seen many of the programs that I just talked about defunded, and in an August 21st report from ProPublica, I read that in total more than 20,500 workers or about 18% of the Department of Health and Human Services workforce has either left or been pushed out.
So, I venture to say, Carole, that nobody better than you understands what this really means. 'cause the numbers can be like, uh, but what does that mean for rural health? So can you please give us, only as you can, an insider's perspective of, of what the impact will be realistically? What can we can expect coming down the road?
Carole Johnson: Yeah. Thank you so much, Michelle. I'm so proud of the work that we did at HRSA in partnership with communities all over the country. Rural health leaders really told us what was needed, and we invested, as you said, in building the workforce, in expanding access to mental health and substance use disorder services, in addressing the maternal mortality crisis. I mean, we, in partnership with rural communities, we're on the front line doing this work.
We, we secured significant new resources from the Congress to be able to do this. And so, it is heartbreaking to see what is happening now, not only to the, you know, close to 30% of HRSA staff that is gone. And you know, that's a combination of people who were laid off, people who were sort of encouraged to retire early, the whole combination.
And so, program staff, contracting staff, grant staff, if you're calling now about your grant and the phone's ringing and ringing, that's because those people would love to answer the phone, but they're not working there anymore. And it isn't just the people, you know the people are so important to me because I saw how critical they were to delivering on the services, but it's the services, it's what people are able to deliver for rural communities.
And what I'm concerned about are a couple of things. One, the dramatic cuts to Medicaid and what that's gonna mean for rural communities across the country. Two, the fact that all of the underlying funding for community health centers, for FQHCs, the National Health Service Corps, are teaching health centers. It all expires at the end of September, and you know, what's the plan to be able to continue that work?
Three, all of the critical programs that you talked about that are in the President's Fiscal Year 2026 Budget to be zeroed out. Everything from our State Offices of Rural Health, the Rural Health Hospital flexibility grants, the Healthy Start Program, our geriatric training programs, you know rural communities face older populations more than many other places in the country.
Our nurse education and retention programs obviously have so many nurses who are reaching retirement age. We wanna bring the next generation in while helping current nurses stay in practice so that they can train the next generation, all of our scholarships for disadvantaged students, which is the way in which we help students who are from economically disadvantaged communities, oftentimes rural communities.
And so, we're training a lot of nurses in South Dakota and Montana and rural Texas and other places like that through our scholarships for disadvantaged students programs. All of these programs are slated to be eliminated next year.
Then the final thing I'll say is in addition to all of that, there is what's happening this year with HRSA's Fiscal 2025 Awards. You know, not all of those awards have been made yet, and we know at least some of them they're just not gonna make. And that is devastating for rural communities who are banking on that money to continue to be able to provide services in their community to support the trainees who they hope will continue to practice in their communities.
And so you roll that all together and it's, it paints a very challenging picture for rural communities in terms of what healthcare services will look like and the fact that this critical partner, which is HRSA, that has been hand in glove and delivering services in rural communities for decades, is just slated for elimination, and some pieces of it will, may survive in what they plan to put going forward, but on the books, their plan is to just zero out HRSA and get rid of it.
Michelle Rathman: Carole, I mean, listen, you like I am, I feel myself almost breathless because I just, when you put it all in that big context, I mean that connected, pardon me, a lot of dots of what the big picture is going to look like. And I think one of the things that has been, and I've been vocal about this here on this podcast and others that I have been doing is saying, what I'm hearing is we have to find ways to adapt, and I'm struggling to understand how we adapt. I mean, it's like you, how do you adapt going over the track, a train track down a, down a cliff is what it feels like? And so, you know, I even take a look at, as you said, I want people to understand when you talk about grants that have already been allocated, it's like your paycheck being completely cut off.
And having no, no reserves to, to manage that. So how, how do we manage that? How, how do we manage? Because we know that even though you said in the president's budget, it's zeroed out, but there's work being done right now, you know, to advocate to members of the Senate and the House to, you know, put those things back in. You are now in a different position than you were before. What do you have to say to our listeners as a person now working and we talk about your work there as well before we close out, what do we do to help implore people to understand how important this is and the devastation that it will actually cause in rural areas in very real ways.
Carole Johnson: Well, Michelle, thank you 'cause the conversations like this and echoing the stories and telling the impact is really important. We are seeing, not universally, but in some instances HHS is reversing course and funding things that they weren't gonna fund this year 'cause they got some noise about it or because a number of constituents came to them and showed them the impact.
And, and it's sort of, there's no real rhyme or reason for me to say, to tell your listeners about what it is, that's the magic bullet that's gonna make that happen. But it has happened in a couple of examples, in a couple of CDC programs, one or two other programs where there was a groundswell that caused them to restore some funding that otherwise would've gone away.
I will say. It's very hard for rural communities to do. Rural communities are spending people in rural communities who work in these programs are spending all of their time and all of their energy actually doing what needs to be done to deliver services on the ground. Our job was to wrap around them and provide the support so that they could get the resources to do that.
To have to like take time away from that and figure out how to organize and lift up your voices to be able to fight for the money. It's not something we want to divert people from healthcare services to have to do, but unfortunately it's sort of the circumstances that we're seeing right now.
Michelle Rathman: I wonder if you could talk just a little bit, I mean, you've been doing a lot of writing and I really do appreciate that you are, you continue to be on our radar screen. There's a lot of talk and I talked to our guest from last week about this Rural Health Transformation Fund. Someone again, who was in that position, I mean, your head must have been spinning just a little bit to even think about what that looks like.
Kind of look over here, we've got this money. You recognizing the reality that the deficit is going to far exceed the benefit of what this can do. And I might sound pessimistic 'cause I am.
Carole Johnson: Yeah, so lemme start with sort of the, the less good news and maybe I'll try to pull out a silver lining here.
The there is close to a trillion dollars worth of cuts in Medicaid in the package that Congress passed and the president signed, and those go on in perpetuity. They don't end at some point.
They go on in perpetuity. To essentially try to address some of the political problems they had in passing the bill. Congress passed this $50 billion Rural Transformation Fund that is only available for five years, and if money isn't spent quickly enough, HHS can come in and start taking it back.
So, there is some, there is some effort to put some dollars on the table in the very short term, they will not make up for the coverage losses that rural communities are going to see. They will not make up for the gaps that rural hospitals are going to see in the long term when it comes to these resources.
Look, I ran the Provider Relief Fund, which was the resources that Congress made available to hospitals and other healthcare providers in response to COVID. It was short term money, but the goal of that short term money was to say, we're gonna bridge this short-term challenge. And then when utilization in hospitals, when people start coming back to care, the money will come back, and then it'll be able to level off and people will be able to be whole.
That has happened basically in the health, in in response in the COVID situation. The plan here is we're gonna put this short-term money on the table and then everyone's gonna hit the cliff and the hole will be there after five years. And so it, while there is a big looming cliff coming, and with respect to that, I would tell your listeners, don't miss this opportunity that there is $50 billion on the table.
There is a lot of uncertainty about exactly how it's gonna happen, where these dollars are gonna go. But I would say get in front of your state as fast as you can, figure out who is writing your plan for your state, tell your story, have your data. Make sure they understand like how challenging it is for you to recruit a workforce, what it's gonna mean when Medicaid dollars go away for you and how you're not gonna be able to keep operations. You might have to shut down service lines. You might have to shut down altogether. Tell your story to your state now, so that as much of those resources as you can secure in the short term you do, and then think strategically about how you use them because they are going to go away.
And so, you know, we have seen in other situations where when short term emergency money happens, not the provider relief fund, but in some other instances I've seen this where short term money becomes available, people then sort of invested into increasing salaries and things that will help them with retention, and then it's, then it disappears.
And then they struggle to be able to maintain that going forward. And they end up, you know, where they would've been without it, maybe even worse, um, because your workforce is frustrated by that outcome. So, um, all of that is to say. It is not a, it is not a solution. It is a bandaid. But don't miss the opportunity while it's on the table 'cause you gotta take advantage of everything right now.
Michelle Rathman: Exactly, and I don't call it a growth strategy. I call it a shrink strategy. And, and with that, I do encourage listeners, and this is a kind of a broken record here, is do not go through this alone. If you are a rural health leader, really making sure that you stay in close contact with your other civic leaders and let them know, give them, give them the what's up. And what this means, because again, healthy workforce, we’re reliant upon that and so forth, so many dots to connect. Okay. Before I let you go, you are now,
Carole Johnson: I do just wanna say community leaders care so much about this at the local level. I saw this when I was a state leader because not only are healthcare services essential to the wellbeing of your community, there also are really good jobs. And so, your community leaders can be big advocates for you as well.
And so, make sure their voices get heard. 'cause some of these Medicaid cuts don't happen right away. And so there may be an opportunity to continue if we continue to lift up voices to try you know, minimize some of this incredible damage that's coming.
Michelle Rathman: Listen, if it can happen this way, it can go back this way. I mean, with, with the stroke of a policy pen, things do happen. We just, we have to get there. Because again, the implications for the insured, the, the commercial payers. I mean, all of it's going to have an impact. There's no escaping that. Oh my gosh, I could talk to you forever, 'cause I'm thinking about getting my weekly, updates on my, all the listservs that I'm on, and then like it says, rural health policy and it's like, contact us. There's no longer this long list of policy things.
Okay, before we go, you are now a Senior Fellow at the Century Foundation. And in response to the massive cuts to HRSA, you wrote, and this is a quote from a piece that you wrote, 'as we work to help underserved communities navigate a future without HRSA, a huge thank you to team HRSA for your tireless work and dedication to the people in this country who need it most.'
With that, what are your plans to address rural health disparities now that the policy, this, these policies of the HRSA do kind of reverse the building blocks that you put into place? And what can we all do to better prepare for the losses of the supports that we've become quite, and rightfully so dependent on, because these are investments. These aren't, it's, they look at spending it, but these were investments in rural health infrastructure.
Carole Johnson: Yeah. Well, thank you for sharing that quote. I really do, from the bottom of my heart, I'm so grateful for the team at HRSA, those who were laid off and the people who were still there trying to make it work with less people and keep the lights on and keep as much money as they can, moving out to communities as quickly as they can, given the challenging circumstances that they're in.
I would say this is a moment to really engage in community as broadly as we can. Foundation funders, private funders, you know, thinking about how we might be able, I've seen some foundation step up and say they're gonna try to close, to try to help close some gap. No one can make up the difference here.
But if you've got the thing, one of the things that really worries me is if we've recruited someone into a health professions training program and you run out of money because the obligations are not being met and then that student is in a very difficult spot. That's a place where I think you gotta sort of triage, prioritize what the, what it is, get to your, get in conversation with your state, make sure your voices are heard.
You and I talk you, I know you have raised the, you know, the more and more politicization of the grant process at the federal level means that you know, the level playing field's gonna change. That's not fair to rural communities but we gotta do everything we can to get every voice we can lifting up rural needs here and holding people accountable for the fact that these are commitments that have been made to rural communities, and it matters to the health and wellbeing of everyone in this country.
Michelle Rathman: Yeah. And connect the dots because, you know, to deliver a healthcare. The notion that AI is somehow gonna be the answer to all of this is just absolutely absurd in a word, is what I think. So.
Carole Johnson: Right, and look, no one's saying that technology can't be part of the solution. It can, but technology, it also depends on good, well-trained clinicians on each end of that conversation who are helping to support that care in rural communities. And so, we wanna be part of what modern healthcare looks like going forward, but we can only do that if the resources and supports are there to be able to help ensure that your listeners and the communities that they serve get the care they need.
Michelle Rathman: Yes, it's equitable across the board. I mean, we come one, come all. It is really a good way to look at it. Oh my gosh, Carole, if there's any rural news that you have for us, I'll be following you. Where can folks follow you? Because I think they should. Where can they find you on social?
Carole Johnson: Well, I really, I really appreciate that I, you know, any and all of your listeners who want to connect, I'm on LinkedIn and I always share our papers there, but I also, on the Century Foundation website, all of our, papers get shared there as well.
Michelle Rathman: Excellent. Well, we'll make sure that we put all those links on our resource page. So, thank you again, Carole, even though we have to say goodbye to you,
I am inviting all of you to stay with us because first, you are gonna hear about an event designed specifically to help strengthen America's rural health clinics from our partners at the National Association of Rural Health Clinics. And then I am really eager to have you hear my conversation with my next guest whose organization cares for, 7,900 unique patients in west central, rural Missouri through a network of six clinics. This is somebody also in the know, so stay with us because we're gonna continue this dot connecting conversation.
Michelle Rathman: Hey, we are back and thanks again to our partners at the National Association of Rural Health Clinics. It looks like they have an outstanding event planned in Reno, so be sure to check that out. And as I promised, I am now joined by someone who is uniquely, and I mean that uniquely qualified to discuss the impact and the importance strengthening America's rural serving health organizations, including community health centers. And that is Toniann Richard, Chief Executive Officer of HCC Network, uh, home base in Lexington, Missouri, but covering a whole lot of territory. So welcome Toniann to The Rural Impact. We're happy to have you here.
Toniann Richard: Hi. Thanks for having me.
Michelle Rathman: Okay. You know, you've, you've been getting around as they say, Toniann, and you've been an outstanding voice for rural health over these last few months, I mean, for the whole span of your career, but it's been with good reason because we need to start off this conversation as we had the first part of this episode by, first of all, having you share with our listeners what HCC Network is.
It might not be a household name in other parts of the country but really talk about the importance of your work and the impact that you're making in rural Missouri.
Toniann Richard: Sure. Thanks. So, HCC network, started out as a rural health network in 2004. Uh, really out of the, a public health initiative through the state of Missouri in our local public health department. We formed as a vertically integrated network working with hospitals, schools, public health organizations, municipalities, all to really strengthen the system, the ecosystem of rural healthcare. Interestingly enough, we were originally formed to try to focus on workforce issues, specifically around dental access, for kids on Medicaid. And so here we are getting ready to talk about the changes to Medicaid and how that will impact rural communities. But, fast forward we opened our first clinic in 2013, as a result of a really innovative board, and community partners where a rural health clinic, was struggling, with some overhead allocation.
Their volumes were declining, in that space. And the, CEO came to us. He was also a member of our board and said, “Hey, under the FQHC model, this is a thriving clinic. What can we do to, retain those services, sustain them into the future, keep the workforce, et cetera.” And so, we got creative and, applied for and received FQHC status in 2013. Today in 2025, we have six locations, two and a half mobile units, and we are on the go.
Michelle Rathman: And you are, I think, what I read, like 7,100 patients serving or maybe over 7,000. And, for our listeners, you know, sometimes there's some, we, we love our acronyms, so be sure to visit our resource page on our website. 'cause we're gonna put links to some of these terms that we're talking about here.
And I think is important, you know, for all of us to really understand what we're talking about here because I think there might be a bit of a misunderstanding about FQHCs. And so, we won't educate folks on that today, but be sure to look for that. So yes, we are gonna talk about Medicaid cuts, and I would imagine that for those who are out there, who are, may be tired of hearing about it, too bad. Because I'm sorry, as bluntly as I can say, it's not going to the problems that are going to be before us. I mean, they might not be visible on the surface right now, but people like, you know all too well what it's gonna look like. So before joining us, we had the really for me, a privilege of having Carole Johnson on, of course, former HRSA administrator and we did touch on the impact of cuts to Medicaid to rural hospitals and community health centers. And what I read Toniann, is that various estimates in your state show between, 130,000 to 170,000 Missourians could lose their coverage, under the state's Medicaid program known as m MOHealthNet.
A lot of people don't know that that's short for Medicaid or more, maybe not so short, but rather hidden in the name over the next decade.
So as someone leading a community, six sites plus mobile, uh, providing all sorts of comprehensive services and, and those that are in jeopardy, what do you think, let's go a little deep here. What are some of the policy pain points that you're at right now, from both a federal and state level considering these cascading effects? I mean, how are you all preparing to manage that? That's a big question.
Toniann Richard: That is a big question. So I, what a privilege to get to talk to Carole. She, I mean, she's a celebrity in her, in her own right and has did so much for access during her tenure and also just really, truly understood rural communities. And I think that's where this whole conversation about access and Medicaid and funding can get a little bit uncomfortable, for us in, in rural states because, or in rural communities because of how it's funded and being able to navigate some of the misconceptions of Medicaid as well and who Medicaid really is set to serve.
And so Missouri's really unique and I can definitely send you some follow-up information. But Missouri expanded Medicaid through a ballot initiative, not through a congressional bill. And so that adds another layer of complexity to our expansion population. And so right now we are really trying to unwind or dissect the details.
And so, who will this affect first in terms of patients? Who's going to be responsible for some of the compliance measures, where will the responsibility fall for that? And then payment. How are payments going to be affected? And so, you've got sort of these three big areas of consideration and knowing how healthcare people are,you know we will take care of people in our community. We have a responsibility for that. In partnership with our critical access hospitals and, community-based providers, private practice providers as well.
So, not to lose any focus on that throughout the conversation is exhausting. So first, let's tackle, how we expanded Medicaid. So, because we expanded through a ballot measure, there will be responsibilities on the state, to continue to serve the population. How they choose to allow those services to continue is what is really unknown right now.
And so, one big critical piece, that was funded in our expansion was the adult Medicaid, for oral health was, was a pretty major player there. A lot of advocacy organizations worked, worked for years to get this added. We're, we're concerned about the future of that. We're definitely concerned about our kids, who are receiving Medicaid really in special populations. And so, our foster kids, age out kids, kids that are already vulnerable, because of the environment that they're, that they're in. And so, what, what does that mean?
Kids that are aging out of the foster system. We just had one today that called and said, “Hey, I don't know if my Medicaid's gonna keep, like originally thought.” Foster mom is saying, I don't know where to start. And so, unwinding some of those details. And then there's also the concern about just payments being reduced, considerably. And, and while that won't affect HCC Network in in our ability or responsibility, I should say, to continue to accept Medicaid. What will happen is it will drive private practice, out of the market, to continue to accept Medicaid. It will drive some community-based providers out of the market because they just simply can't afford to operate and not be paid a reasonable and customary amount.
And so, do we have the workforce to absorb the additional patients? Do we have the capacity? Do we have the specialty? Those are, those are things that we're worried about. So that's kind of bucket number two. Bucket number three is on the regulatory side. Who, what, when, where, why, how. I'm sure that you've I had the privilege, I say that with a loving heart, privilege of seeing a lot of different timelines, about this rollout, what this, what this means, what's maybe problem.
Michelle Rathman: just say Toniann. And it's, it's not, it's not just the timelines that we've seen, it's the details that we have not seen that have, have me concerned.
Toniann Richard: Absolutely. It's the generalization of, you know, December 31st, 2025 and these changes are effective the next day. Our questions are, is that, does that fall on, as it, as we think about redetermination for Medicaid as we think about re-enrollment, those types of things, does that fall on the state?
In generally speaking probably yes. I don't think the state of Missouri is much different than a lot of other states is where that capacity is also not there. Is the, is the technology there, is the funds there, uis the workforce there, those types of things. And so how that will end up delaying people's access to care, payment to providers, credentialing and enrollment.
It, you know, it's just this slippery slope effect. And so just trying to be as prepared for that as we can. Having a lot of conversations with our legislators about what this really means for people in their communities.
Michelle Rathman: You know, I'm glad that you mentioned that because I do wonder what the response is. 'cause you know, you and I kind of travel in the same circles of advocacy and your organization has a, you know, page on your site, and we'll make sure we put it in our show notes, that it's really focused on advocacy, meaningful advocacy, because it is about whether it's your survival, really.
What are your state, I mean, when you talk to legislators, I hear people, I hear people say, well, they're listening. They're listening. How do you know? Like, what, how is it landing on them? Because, Carole Johnson mentioned your Senator Howley. I know we're talking about the federal side of things here, you know, almost immediately after, you know, saying, no, no, no to, I'll sign yes, but later on saying, let's see if I can reel some things in here for you.
I mean, that is a really unstable way of governing and so where this is concerned. So I wonder what you're hearing back from your state legislators. Are they sounding the alarms or like, don't worry your head about it? I mean, what, what, can you give us a sense of what's happening on the ground now that states are really going to have to like it or not grapple with the realities of what this has now put on their doorstep?
Toniann Richard: Right, right. So, I mean, we're talking 90 days, on some of these pretty significant things to put plans together. So, our legislators are asking us for solutions, inviting us to the table, asking us who should be at the table. And so, we're very fortunate. You mentioned our website. We have longstanding relationships, with our legislators in our service area. I don't feel like that's the norm. I don't know of a lot of health centers that are being invited to those conversations. Our primary care association, hospital association and community mental health organization, they are advocating significantly to be at the table to help write some policies around some of these solutions.
And thankfully, they're reaching out to us to gather information on that. And so just, I just feel like we have to just be consistent and and simple. We've got to keep things simple so they don't get hung up in a lot of questioning authority type conversations. The more we can keep it simple, keep moving it forward, and march to a fiscally responsible solution for everybody. The state of Missouri stands to lose an enormous amount of money through the provider tax, changes or eventually, eventually, I know they've been pushed out, but we still have to plan for that. You can't just rip that off in one year, and so it, it won't at that point, it won't just be Medicaid that suffers. It'll be our entire general revenue.
Michelle Rathman: Yeah, absolutely. And, the cascading effects of that, and I love made me think when you said a moment ago, there's nothing like a good crisis to bring people together. I mean, there's this realization that the ripple effect of all of it. I was reading something today about, you know, I, was it the 115 waivers? 115 waivers have been Medicaid's Open Canvas, an invitation for states to try things that might actually work like SDOH or now, as we're saying non-medical things. And, and you know extension of postpartum coverage, behavioral health supports dental vision and so forth.
I mean, if we have not realized, if we have not seen the connection between all of those things and overall health, I mean, I just don't know what it's gonna take.
Okay. Let, let's do a real quick shift here because, and we talked about this earlier and I talked about in the last episode as well, because, you know, this is what, if you, if you Googled or use whatever search engine of your choosing Rural Health Transformation Fund, you would learn about a fund that was established at the, basically kind of that Hail Mary pass at the end of the One Big Beautiful Bill Act.
All of that to said it allocates what looks like a really impressive number, $50 billion to improve healthcare access and sustainability in rural areas over five years. As Carole Johnson points out, that's five years where these cuts are forever, until something else changes. So, what are your thoughts about the fund?
And its ability to do what the name says, which is to transform rural health given kind of like the quicksand that we're walking on. You know, when you're staying on quicksand, it's really hard to reach for something because you keep sinking. That's the analogy that keeps coming up to my head for what it's worth.
So, tell me about your thoughts and how you're being called to the table to talk about, “Hey, don't forget us. We're hungry too.”
Toniann Richard: Right. So I think the first thing that I, when I get asked about the role transformation fund is, first of all, it's rural, it's for rural communities and the identification of rural, the National Rural Health Association has really spent a lot of time with the Federal Office of Rural Health policy identifying what is a rural community. There's already been some language put into this that takes it beyond a true rural organization. I know that there's conversations about that. That's not something that I have been, haven't spent enough time in to totally understand it. But I know that this fund was intended for rural communities.
And the other thing that is important for people to understand is that it is not a, fund replacement. It's, it's not a, it's not a relief fund. It's not, it's not COVID relief dollars. And so, you submit your losses after the first year and you're gonna get made whole.
Michelle Rathman: Nothing like it at all.
Toniann Richard: And when you do search for the fund information on the fund, it reads like it's going to be sort of a relief fund. And so, making sure people understand first and foremost that it is for rural communities and the intention was for rural communities and, that it is not a relief fund. I have a lot of thoughts about it. Number one, I do think that the intention was hospital focused. I think the original intention was that critical access, community-based hospital, a lot of the concerns around how the provider tax, implications would be if they were, especially in year one, or year two of this. And so, I think that's probably what started some of those conversations.
What I'm finding and what I'm, what I'm pleased about is that this, at least the state of Missouri, is entertaining conversations with hospital, the hospital association, was the primary care association, community mental health associations and saying Hey, come together and, let's put a plan together where we have a, I hate to say and everybody wins, but, a hold harmless, kind of a no foul intention, plan put together that Missouri could put forth to be considered, for funding. So, I think unfortunately, or fortunately, I think a lot of it will be driving IT vendors, into the operational
Michelle Rathman: that is my sense as well.
Toniann Richard: Yeah. And I, I don't wanna take away from where AI and IT is going. I just don't think that's going to be the low hanging fruit that, that these organizations that need to benefit from these dollars. I don't think it's in consulting. Which is they're gonna have major capacity issues, right away. And so, finding those solutions is so important.
Michelle Rathman: At the same time, so much of their patient population are, either now gonna move into the underinsured or uninsured category and having to make decisions about cutting services and losing providers and so forth. And so, it just feels like you know, there's, you plug the hole and then there's another drain on the other side.
So, I mean, I have so many analogies today because I just, I'm trying to make, you know, to just, again, punctuate how important this is. Even if you don't think it's gonna affect you and the patients, the 7,000 plus patients you all serve, it might be very difficult, you know, for them to understand how to navigate and that you know, Toniann, and that must also put a burden and unforeseen burden on your workforce because now you're gonna need more navigators to help folks, you know, maintain like the work requirements and so forth. I mean, what's being asked to be put together with no time at all would take years and years to build the infrastructure to support that. Right.
Oh my gosh. So, I wanna talk to you a little bit about, things that, again, these are, again, we say often on this podcast. They're not light subjects. So, we do hope to enlighten as someone who leads six community health clinics and community wellness is your number one priority, you know, patient care, number one priority.
I've been taking a look at KFF Health News released a piece today, about the, measles outbreak, for example, on Texas and the spread to Oklahoma, New Mexico, and so forth. We know that, under RFK Junior, uh, the Food and Drug Administration has signaled that it will only approve updated COVID vaccines for individuals this is the recommendation 65 and older, and for younger people considered to be at higher risk for severe disease.
So, you know, people where they live will now once again, have to kind of prove their worth of getting a shot. How are you all, what is the messaging? I know it's really challenging, but as the community's protectors of that, which that which does cause illness, you know, known factors and whatnot. How are you managing preparing for that? Because we are dropping this in September and last I checked my watch. It's that season again.
Toniann Richard: Right, right. We actually just had a couple COVID cases, present today. Yeah, I, this is gonna be interesting. Missouri is, they have been very vaccine hesitant. They're a very vaccine hesitant state. In our rural communities, those numbers are even higher, in terms of vaccine hesitancy. And so, I also know that we have an aging population.
We have more compromised, populations with regard to, different levels of disease and chronic disease illness. Right. Our nursing home numbers are really high, so it will be interesting to see how we navigate that. We have been so fortunate that our local public health department has taken the vaccine space by the horns. When the COVID vaccines first came out, after the you know, during the recovery part of the pandemic, we had so many challenges because we didn't have the capacity from a freezer standpoint, to hold the vaccines. We had to really rely on our health department. So, we all sort of worked toward this investment plan, to make sure that they had the resources that they needed to, get the vaccines.
We were also limited in the number that we could get, those types of things. And so, we're gonna have to lean pretty hard on our rural public health departments, to try to get the vaccines. It'll be a good conversation you bring up, you bring up this issue and it's making me think about the conversations that we need to have internally, especially with our providers, that say, “Hey, what are those buzz words that you're going to have to use in conversations with patients?” What are they, what are, what are the qualifying pieces going to look like? And are we appropriately screening for those? Are we appropriately checking for those? Are we sending a message out, that these are the things that we're looking for in order for people to receive the vaccine? I do hope and pray that being able to receive it, being able to get the vaccine it is not a huge barrier for our population. I think we're getting ready to face a lot of challenges, and I would hate for that to be one more area of concern. We are fortunate, as an organization, as we, we reside in the catchment area of two really fantastic, healthcare foundations that have really stepped in, and to help in the testing vaccine response space.
So, we'll probably be leaning on them as.
Michelle Rathman: Yeah, and that's what you have to do. You have to lean, you know, at the same time it's, and advocacy at the same time. It can be exhausting, but the purpose, the, it's a mission. Because failure to me is just not an option. And we're failing. We're failing in this space. And so II do encourage, I think it's great advice.
I mean, lean in and make it so that it, to the best of your ability that your communities understand that you want to be, and you, you work at your working to always be the most trusted resource for information because the noise, what's on people's feeds is it's a little exhausting.
Okay, so before I, I let you go, you know, it's really important for people to, I have a lot of conversations as you can imagine, and people go, I didn't really, really, I didn't, didn't really realize that was happening, or, I don't understand what the impact is, so for our listeners who wanna understand how they can help navigate these incredibly choppy waters, what advice do you have for them to just be their own best advocate? Because I tell people you have to build your bench. It cannot just be your local clinic or your local community health center or your local hospital out there, you know, beating the drums and bang in the pot and pans.
So, what are some of your advice to build your bench? Hence your name is Network. What does that look like to help them come alongside and lift you up and advocate for the things that you know are best for the health of your community moving forward?
Toniann Richard: It's a great question. We use the toolbox analogy. We wanna fill people's toolbox with information that can help them make informed decisions and, fill your bench. I like as well. And it's, I do. So much of it is about where people are receiving information.
And so, we have worked really hard to vet, some of the media outlets, trusted sources, those types of things.
And so we direct our staff, our staff are very good megaphones of information, and so giving them some trusted sources that are really, trying to stay in the bipartisan space, trying to stay in the, what's in it, what's the best place for, rural communities to receive information. And that information is on our website as well.
But, yeah, just trying to, trying to not go down rabbit holes of despair either we, uh, one way or another, I should shouldn't just say despair, but we also have a kind of a 24 to 48 hour pause moment as well. So, when big information comes out. It's my job and our leadership team and our board's job to reach out to some of these really well trusted sources and say, “Hey, what does this mean?”
What is the opinion on this? And then for us to get some messaging out on our socials really to say, we're aware of this. This is how we're responding to that. And I think that gives people a sense of calm, just knowing that we are paying attention, we're monitoring it. I had a staff person the other day that, it's probably one of the best compliments I've ever gotten.
She came up to me and she said, “you do not know how much it means to me to know that you're paying attention to this for our organization, for our communities, because it gives me one less thing I feel like I have to keep track of.” And so just continuing to be that resource. But also, like you said earlier. Information is flowing so heavy every day, and so just weeding through that is really a full-time job.
Michelle Rathman: Absolutely. Absolutely. That's great Sage advice, as I would say. And I liken those in leadership positions as the shock absorbers, and that's why you, you need some, some support of your own to lean in, so, oh my goodness. Toniann, it's been wonderful to have you here. Calming voice. Measured leadership is so important through all of this because onward we must go, we, I mean, we're, we're already going so far back.
We have to, you know, it maintain some momentum where we have some control over it. So again, thank you for joining us today.
Toniann Richard: Thank you for having me.
Michelle Rathman: Okay, we're gonna continue our focus on rural health policy in the months ahead. And, you know, you know that you know me enough to know that's true and we'll be following and sharing your advocacy efforts as they unfold.
And for the rest of you, please sit tight, 'cause we'll be right back with some closing thoughts and a preview of what we have in store for you next. Stay tuned.
Michelle Rathman: Again, I just wanna say my thanks to Alexa, to Carol Johnson, to Toniann Richard for providing us with such important insight into the world of rural health policy. These are some very challenging times that we are facing where rural health policy and other rural policy is concerned. And so with that, I just wanna say there's some information that you want to hear from us.
If you've got some policy areas that you would like for us to cover, we always welcome hearing from you. And to stay up to date with us, all you have to do is make sure that you subscribe. So go to the ruralimpact.com, hit that subscribe button. It takes just a matter of seconds to put your name on the list.
We won't fill your inbox with a bunch of junk, just some updates and information about upcoming sessions and series that we've got planned and in the works for you. I also wanna make sure I say a great big thank you to Brea Corsaro and to Sarah Staub for all the work that they do behind the scenes. Be sure to follow us on social.
You can find me very active on LinkedIn to be sure as well as we're on Blue Sky, Facebook, a little bit still on X. And from there we just always invite you to make sure that you pass on information that you find is helpful, make sure that you take really good care of yourself and to the best of your ability, those around you.
We will see you again on a brand new episode of The Rural Impact.
