Tracking Transformation: Opportunity for Some, for Others Pain with Joan Alker, Dr. Shannon Dowler, Alan Morgan and Carrie Henning-Smith, PhD, MPH, MSW

Season #10 February 26, 2026

In part one of this episode, Tracking Transformation: Opportunity for Some, for Others Pain, Michelle sits down with Executive Director and Co-Founder of the Center for Children and Families at the Georgetown University McCourt School of Public Policy, Joan Alker, as well as Dr. Shannon Dowler, who is a family medicine physician, serves on the Board of Directors for the American Academy of Family Physicians, and an expert leader in Medicaid programs and expansion.

Michelle, Joan, and Dr. Dowler unpack the scale and scope of recent Medicaid cuts under H.R. 1, examining how nearly $1 trillion in reductions compare with investments in rural health and what that imbalance means for communities on the ground. They explore the disproportionate impact on rural populations and how these cuts intensify existing racial, economic, and geographic health disparities. The conversation breaks down the political landscape, separating rhetoric from the reality of rural health funding, and explains the mechanics of provider taxes, state-level Medicaid financing strategies, and how work requirements contribute to coverage churn. Finally, they highlight actionable strategies for healthcare providers and advocates to educate policymakers and the public, underscoring the urgent need to reverse federal Medicaid cuts and protect essential rural health services.

At the close of the episode, Michelle shares some special excerpts from interviews she had while attending the National Rural Health Association (NRHA) Policy Institute, with NRHA CEO Alan Morgan and President Carrie Henning-Smith. Alan Morgan argues that the “slowing of growth” in Medicaid is effectively a cut that will harm rural hospitals, which are already struggling due to a high concentration of patients with complex health needs and limited ability to pay, not because of low volume or poor management. He emphasizes that Medicaid is the primary tool keeping rural hospitals open by helping offset uncompensated care and bad debt, and he urges postponing the proposed reductions. Dr. Carrie Henning-Smith adds that rural health policy must focus on strengthening the overall foundation of care, addressing longstanding disparities, stopping looming Medicaid cuts, reinforcing the safety net, investing in the workforce, and making temporary support programs permanent through statutory action.

Episode Transcript

Episode 77. Tracking Transformation: Opportunity for Some, for Others Pain with Joan Alker, Dr. Shannon Dowler, Alan Morgan, and Carrie Henning-Smith
Hello, one and all, and welcome back to a brand-new episode of The Rural Impact. I'm Michelle Rathman, and we are thankful that you have carved out time from your very busy schedule to join us for another conversation that works hard to connect the dots between policy and rural everything.
Well, today’s a big show because we are continuing our 2026 series we're calling 'Tracking Transformation,' and in case you've not been following along, welcome. We're glad that you're here again. But simply put, we are following the flurry of activity resulting from last year's passage of H.R.1, known first as the One Big Beautiful Bill Act.
Which, as you will hear if you have not heard this already, doesn't look pretty for rural anywhere, anywhere you turn. And that is just a fact that needs to be said plain and simple. So, if you don't believe me, the guests I have here today might convince you otherwise, because for this conversation, I've invited back to the show one of my favorite people on the subject of health policy, and that is none other than Joan Alker.
Joan is a Research Professor and Executive Director at the Georgetown University Center for Children and Families, and we are also joined by Dr. Shannon Dowler. Now, Dr. Dowler, who is not only a remarkable family physician, and you're gonna hear about that in just a moment. She also serves on the Board of Directors for the American Academy of Family Physicians and is a wicked smart health policy consultant who was immersed in the state of North Carolina's Medicaid expansion, which, if you recall, just took effect on December 1st, 2023. So not that long ago.
And as of February 2nd, I went ahead and did the tracker. Had a look at the North Carolina's Tracker as of this year, February 2nd has given over 700,000 North Carolinians access to affordable healthcare coverage, so that is no small number.
Now, I heard Joan and Dr. Dowler speak on a panel about H.R.1 and Medicaid cuts, and each of them will join me in just a few minutes to share their invaluable insights.
Now, after a quick break and my conversation with those two, you're gonna hear parts of just a few of the many conversations I had while I was in DC just a few weeks ago at the National Rural Health Association Policy Conference. I've shared with you before that I have the privilege of being a member of that organization, and I also sit on the policy Congress is really important work that they're doing to help advocate for better rural health policy, and that includes a conversation that I had with another phone-a-friend, Alan Morgan.
And Alan is the CEO of the National Rural Health Association, of course, as well as my conversation with the Association's 2026 President and the Associate Professor and the Division of Health Policy and Management at the University of Minnesota School of Public Health, Carrie Henning-Smith.
And I just wanna share with you, I read an interview that Carrie did, as her incoming term, and this is something that she shared that I wanna share with you. These are her words. "This is a moment of incredible change and volatility, and it feels more important than ever to have a strong community where we can share ideas, support one another, and move policy, programs and research forward in a way that truly has the best interest of rural and the voices of rural residents at its core."
So, remember that as we have these conversations that continue throughout the year, as we track transformation. Again, it's another big episode here on The Rural Impact. We are so glad you are here. So now it is that time that I invite you to sit back, tune out that background noise because it's gonna be there after your time with me, and hear my conversation with Joan, Dr. Dowler, Alan, and Carrie. Are you ready? Here's my mug. Are you ready? I sure am. So, let's just go.
Michelle Rathman: Dr. Shannon Dowler and Joan Alker, our trusted phone-a-friend, Joan, I really mean that for coming back to us. We are so grateful for you both for joining us here on The Rural Impact. Welcome.
Dr. Shannon Dowler: We're excited to talk with you today.
Joan Alker: Yeah, great to be here.
Michelle Rathman: I know you both are so busy. So, listen. As our listeners learned in our introduction, we are continuing our commitment to tracking Rural Health transformation. And of course, we are not gonna talk about the $50 billion taxpayer fund established for this purpose. We are gonna focus on the flip side of the coin, which is costly to say the least, which is H.R.1, specifically the impact of nearly hmm a mere, $1 trillion in cuts, or is there saying, reductions into Medicaid coming out of the budget and other policy shifts that were written into this law that will impact both patients and health professionals who care for them. So, Joan, I know you follow this so closely. I saw the two of you presented a panel, just last week, this drops a week later, at the National Rural Health Association Policy Institute. And it was standing room only. I mean, like many people, deep because this subject is, I mean, I know there's a lot of other things going on, but this one is probably one of the most pressing in my lifetime, I think.
So Joan, I'm gonna start with you because you have receipts, as they say. You really laid out for us what this means from the big picture perspective, H.R.1’s Medicaid cuts, and the real health equation. So, let's focus on that. Let's refresh some of the numbers so our listeners who have not tuned in before really understand the implications here.
Let's start with the Medicaid cuts in general and then cover the metro areas versus small.
Joan Alker: Sure. So, unfortunately, when, last year, the so-called one big, beautiful bill by President Trump passed. At the heart of this were a number of policies, including tax cuts, um, also including a tripling of the budget for ICE. And while the bill added to the deficit, there were concerns about looking like, they were doing that, which they were.
And they had essentially, the President had taken Medicare and Social Security off the table during the campaign, and that meant what we feared would be they'd be coming for Medicaid. And indeed they were. And we ended up with almost a trillion dollars in Medicaid cuts that is about 11% cut in Medicaid.
So that's pretty big. And you know, I think one thing that's really important to understand here, and I think rural communities certainly, certainly get this. We have a healthcare cost problem in our country. There is no question about that. Healthcare is too expensive, and costs are going up. But this bill doesn't do anything to address those underlying problems at all.
In fact, it just takes money out of what is actually the lowest payer in the system, right? So, the part of the system that is, you know, being the most cost-effective for better or for worse, right? I mean, that's one of the strengths of Medicaid, that it is relatively lean, but that also can lead to access problems.
And certainly, for rural communities where we know that families and adults are more reliant on Medicaid for their health insurance in rural counties than they are in metro counties. And that's what a lot of our research has reinforced over the years, that these kinds of cuts could be very devastating. And we can talk about some of those specifics at a moment, but that's the big picture.
Michelle Rathman: Yeah, and I'm gonna, I'm gonna go on a limb and say, not can be. They will be. There's just no other part that I can parse this out to come up with a different number. I wanna talk for a moment, Joan, before, before we move on, just about some of the data that you share about women in childbearing age with Medicaid coverage.
Because this is, again, to me. We say one thing, but then we do another. We're talking so much about the need to protect women and children, but what happens when you take away that coverage? Give us some of that. What's that big picture look like?
Joan Alker: Yeah, so Medicaid is incredibly important for children across the country. You know the data is sort of complicated, but as many as half of children are covered by Medicaid, and they tend to be more likely to be covered in rural counties. Medicaid is also incredibly important for women of reproductive age, especially for when they're pregnant.
So what we see, we did some research looking at women of childbearing age, and we see that in states that have some large rural populations that have picked up the ACA Medicaid expansion, that, you know, up to 40- 50%, some counties I know is higher, of those births are being paid for by Medicaid in states like Louisiana was actually one of the top states, New Mexico, Kentucky, other states.
And so, this is incredibly important, and we know that we have a crisis in this country, related to maternal health, and that's especially acute when you're talking about rural areas. Where, you know, not only can you perhaps not get the prenatal care, but most importantly, you can't, there's nowhere safe to go within driving distance to deliver your baby.
And unfortunately, there have already been instances, you know, I've I tragic story in Mississippi, which has not expanded Medicaid. But in any event where a woman died on the side of the road because she was trying to get to a hospital, and her husband was frantically calling 9 1 1. Now, you know this was a woman who had private insurance. It doesn't matter what insurance you have, if there's nowhere, to deliver your baby safely.
Michelle Rathman: Yeah. Oh my gosh. And this story is not getting any better. I mean, it just, and the walls feel like they're closing in because there's so many other competing kinds of crises that are brewing. Before we move on, the last thing I wanna ask you before we have Dr. Dowler join us here is, you know, last week, and I, I said this, I, I did a little bit of a short and I told our audience, you know, some of the remarks I heard last week at this policy Congress lit Congress literally blew my mind. Uh, we heard Dr. Oz and his remarks, of course, the head of CMS. That the $50 billion funds was the largest investment in rural health in our history. But in fact, your data it does tell a different story because it just does. So like, just do juxtapose of that $50 billion and then all these cuts, I mean, we're not ahead.
Joan Alker: Yeah, that's right. And this is analysis, by KFF, that even if all of the money in the Rural Health Transformation Fund was is an exact one for one replacement of the Medicaid dollars, which is not gonna be, there's actually a lot of limits in the Rural Health Transformation fund in, in what rural hospitals can get, which is really kind of shocking, to me because a lot of the political pressure around this was because people were, members were concerned about rural hospitals closing.
Yet the Trump Administration put in a 15% cap. That's not actually in the legislation. They added that when they gave out the money. So, but even so, it, it would be only accounting for a third of the losses that rural areas are expected to see.
And remember, this is a five-year fund. And the Medicaid cuts are, you know, they're a 10-year window here, and they get worse in the further as long as time goes on. So, this is, you know, I really, really hope that this provides some exciting advances for rural areas in the next few years. But this is in no way a long-term solution to the challenges that rural communities face.
And I think, you know, rural communities, just to say, I mean the sort of big marquee policy here is the work reporting requirement. We can maybe talk about this later, but I think there are reasons for rural communities to be especially concerned about what's gonna happen.
Michelle Rathman: Yeah, that's a great point. And we are gonna be starting to talk to county officials because you know there is a domino effect here and county budgets are going to already stretch thin, are going to find themselves in quite a pickle.
So, alright, Dr. Dowler. I'm so elated that you are with us, you have such a perspective that I dare say that many policy makers, even those who are physicians, do not have, and that is a family physician living in a rural community serving a rural population that has historically been categorized as underserved, I say under-resourced.
So, before we dive into the policy piece, share more with us about your work, the patients you serve, and some of the most formidable challenges that you foresee as a result of H.R.1. Tell us a little bit more about yourself first.
Dr. Shannon Dowler: Well, always happy to talk about myself and to be with you guys again. It was, it was great to meet you last week at the meeting. So I'm a family doctor, as you said. I've got over 20 years of experience. My career has really been in the service of underserved populations. That's been sort of my, my guiding force as a family doctor.
I'm currently providing HIV care in a federally qualified health center that serves 18 Western North Carolina counties. I also volunteer at a free clinic as well. And prior to my current situation, I spent five years as the Chief Medical Officer for North Carolina Medicaid, where I really learned the Medicaid program in a different way.
And I will say that proudly, my last act before I departed the state was getting to help lead the Medicaid expansion work, which was a long time coming, but it finally happened.
I think when it comes down to the work requirements specifically, which targets that expansion population, it just doesn't promote the objectives of the Medicaid program. And there's really clear data that demonstrates that these very costly requirements, it's very expensive to implement them, actually don't have an impact on employment rates because you know, most of our expansion population are already working. They're just in very low-income jobs. And what it does is lead to higher costs and burden for states and employers, by creating barriers to care.
So, really these work requirements at the end of the day aren't good for anyone. The Medicaid programs at the state level have to implement these, and I mentioned it's costly, it's so nuanced, managing a Medicaid program, and if you don't do it well, the repercussions are significant, so you wanna do it really well.
So those states are gonna have to implement these sort of vague guidelines all the way down to maybe the county level. Depending on who is doing the enrollments in a community, you know who's gonna do that work? It's double the work that they had before. It's gonna be very expensive, and everyone is, particularly in rural America, is struggling with workforce.
So, this is gonna add burden at the community level just to implement them. And you know, part of the problem is that these work requirements are targeting people who are already working. They're just working in very low-income jobs. Sometimes they have to have two jobs at once to make ends meet. And so what's gonna happen is people are gonna fall outta coverage, and we'll see churn.
So churn in our Medicaid language is people that fall on and off of care. When you're privately insured, that happens a little bit less often. Of course, once you're older, you get Medicare, and you keep Medicare. But with Medicaid, people come in and out of care. And so, this is gonna really impact our offices, our clinics, our hospitals, our pharmacies, because people are gonna walk in the door and expect care, and they're gonna find out that they don't have coverage anymore.
They may not even know that they fell off the books of Medicaid because they didn't understand that these work requirements were things they had to respond to, or maybe their address changed, or maybe they don't have access to the internet, and I think that's an important point piece of this. Not everybody in the world has the same health, written digital literacy, and not everybody has access to broadband and devices and the things that you need. If states decide to implement these work requirements through an attestation process or some sort of digital process, and even if there's a way that you could go into your state, your county office. I mean, where I live in the middle of, you know, on the side of a mountain deep in the Appalachians, it's a 30-minute drive for me to get to a county office, for the most part.
So, if you don't have access to ready transportation or if you work during banking hours, when those places are open, there's another barrier that's gonna keep people from getting to stay on the books. And so, what we'll see is unnecessary emergency room utilization go up. We'll see medical debt go up, and we'll see work absenteeism go up as well because people will not be able to take care of themselves, and they're gonna end up getting sicker.
Michelle Rathman: Yeah. You know, one, another part of this equation that I wanna touch on really quick is that a big part of this also included the permissibility of legally present immigrants to have access to healthcare. And I had a conversation that was, I mentioned, with a federally qualified health clinic leader in our last episode. And she was talking to me about how, already, the impact they've seen on just people coming in and foregoing their care completely. So, as a family physician, you know, doesn't that seem to go against the entire philosophy of all this, Make America Healthier Again notion, when we in fact are putting up so many new roadblocks for people to access care.
And I wonder if you wouldn't mind just touching on that as well and maybe what you're seeing early signs of this happening, and a little crystal ball of what you foresee in a very short period of time. I would imagine.
Dr. Shannon Dowler: Yeah, I think you're right on. As a family doc, I wanna take care of everybody that walks in my door and everyone that lives in my community. I really don't wanna worry about who their payer is. I mean, we have to, because it's the world we live in. But as someone who's worked in federally qualified health centers and health departments for the majority of my career, like for me as a physician, that part is not important to me. I just wanna have a door that they can walk through safely and be cared for.
And what we're seeing is that people don't feel safe coming in, particularly, I notice this more actually in the urban center than rather than is where I am super rural. When I'm in the clinic in Asheville, people are not coming in. They're asking for telehealth visits, and these are people that are coming into us in the city from outside, from the rural areas, because they're afraid of coming into the denser population centers, where they think that probably there will be more immigration resources deployed.
And so, I'm trying to get people to do telephone visits and telehealth visits as much as possible so they can stay plugged into care and stay connected to care. But again, going back to what I was talking about earlier, this requires that they have digital literacy and digital access, and those are barriers that unfortunately not everybody has.
Michelle Rathman: Yeah, I, you know, Joan, you said earlier that, that you're hopeful that, you know, some good things will come of this. And so again, I just, I feel personally I want, I'm such an optimistic person by nature. At this point, I'm digging deep to try and find some positivity where this is concerned.
I do wanna talk a little bit about provider tax restrictions because that is something that I think, you know, because it's not something you're gonna read about on social media, except for the policy wonks, you know, who are paying attention.
You're not gonna see down the evening news, certainly not now, but can you give our listeners a Cliff Notes version of what we need to be bracing for where this is concerned? And then Shannon, anything that you've got to add, because you are included in this equation as well. I mean, your bread and butter, your ability to keep your lights on, is affiliated with this little-known thing called the provider tax. So, Joan, give us a synopsis so that people really understand.
Joan Alker: Sure. So, Medicaid is a federal state share program. And so that means that states have to put up a share of the cost, and that depends on the state, but, on average, the federal government's paying about two-thirds of the cost, but it depends on the state. And, so states have to have revenues to put up their share, right?
That's how states get money. They have taxes, okay? They have sales tax, they have fees when you get your driver's license, they have fees to register your car, helps 'em pay for roads, right? So states have all these ways of raising revenues that they have to do, and one of the very, very, very common ways to raise revenue for Medicaid, and every state in the country except for Alaska, has done this, is what are called provider taxes.
So, these are taxes that are, you know, nursing homes, hospitals, really any provider can be taxed, through a provider tax. And this has been a really important source of revenue for states.
So, the bill does a number of things to clamp down on those, and over time, that'll get tougher for states. We talked about how, you know, the long haul here is gonna be even uglier. And in particular states like North Carolina that have expanded Medicaid under the ACA, and a lot of this bill was really directed at, you know, let's take a thousand cuts on ACA Medicaid expansion.
A lot of these same folks wanted to repeal the Affordable Care Act and they failed. And so now let's kind of come in through the back door
Michelle Rathman: Death by a thousand cuts.
Joan Alker: So, these restrictions are gonna be even tougher in states that have done the Medicaid expansion. So, this is, this is another way that we're, it's a double whammy. Because there's cuts in the federal money, there are cuts to eligibility that are gonna happen as a consequence, as Dr. Dowler talked about, people not meeting the work reporting requirement. Not 'cause they're not working, but because they don't get through the paperwork maze.
And then this is a way to sort of restrict states' ability to raise their own funds to, to pull down the federal fund. So that has like a multiplier effect. So, you know, this is, this is a wonky topic, but it is very important, and it's all part of the squeeze here. And, I'll just say, you know, at the start of this process, last year, the House budget committee wanted to block grant cap, Medicaid, take away the entitlement, and cut a third of the program.
And that would devastate the program as we know it. And there are people who wanna do that. So, you know, depending on what happens in the elections, I think we should expect to see that kind of proposal come back. It's very possible. So, this is sort of a long-term plan to really, to really squeeze Medicaid and end it as we know it.
Michelle Rathman: On your slide, I'm reading, you know, the big hits will come to California, Illinois, the state I'm in, Massachusetts, Michigan, New York, Ohio, West Virginia, a different layer of hurt. And as I read this last bullet point, $225 billion over 10 years in spending cuts.
Joan Alker: Yeah.
Michelle Rathman: With no way to make up for that.
It's just insane to me. I can't speak to the rationale behind it. I just know it makes no darn sense to me. Okay. I wanna talk about something, and I'm gonna continue to use this. I tell people you'll have to take the word out of my dead, cold body before I stop, which is the term around health equity.
You know, you talk Dr. Dowler, Shannon, about one of the topics that is very near and dear to your heart is that Medicaid historically has been a lever for health equity. H.R.1 creates a barrier, which is probably an understatement. How has this impacted you and your fellow physicians? I know you don't speak for all, but I wonder, you know what's the conversations you all are having in the rooms that we're not in?
Dr. Shannon Dowler: Yeah, so I think I've got sort of two thoughts on that. One is going tagging onto what Joan was just saying about the financial devastation that's coming to states around their Medicaid programs, is they're going to have to cut services. And they can only cut optional services. And optional services are big things like dental care, medications, pharmacy is optional, physical therapy, occupational.
So, there's so many ways that states are going to have to just cut, and eliminate, and restrict access to care for people, that it's gonna hurt. And it's, at the end of the day, gonna hurt the people who are receiving the care. And when you think about health equity, so the second part of this is I think of equity from a really broad perspective.
I think about race and ethnicity, but I also think about economic disparity, geographic rural versus urban, gender disparities, and age disparities. In North Carolina when we expanded Medicaid, we saw clearly, 'cause we measured this from the beginning, and we have a public-facing dashboard, there was a disproportionate positive impact on our rural populations. We enrolled more people who benefited from Medicaid expansion that live rural, as a percentage of our population than urban. And so, unwinding that is gonna create more health disparities. We already see worse outcomes in our rural communities. That is gonna just get exacerbated again.
I think the other place I think the disparities are gonna really show up is around age inequities. And what we see is that a lot of the people that qualify for expansion are either childless adults or childless older adults that aren't quite ready to qualify for Medicare yet, but they're accumulating the health problems and the chronic disease, that makes it really hard for them to get to work and stay healthy.
And so, once we expanded, we saw all of these people that weren't quite Medicare eligible yet. They're not disabled; they're still in the workforce. They were suddenly able to get some support paying for their insulin or their other high-cost medicines or seeing specialists that they neglected to see to take care of their chronic diseases.
And so, we are gonna see that population of people lose coverage again, potentially, or at least have their benefits limited. 'Cause at the end of the day, we're gonna take benefits away from the pregnant women and children last, most likely. Which, which is I mean, that's probably, if I were still the CMO of Medicaid, I would be thinking about it that way too.
But it's really gonna hurt, um, this other working population that are in that sort of pre-Medicare population where they're old enough to be sick and to really have health problems, but not make enough money to be able to afford marketplace insurance or other insurance. And so we're gonna see their outcomes get a lot worse.
Michelle Rathman: I think your state is gonna be a really interesting one to watch because you were just starting to be able to measure some of the gains that you made. We did. We actually interviewed Maggie Sauer from the North Carolina Office of Rural Health when you guys did your expansion a couple years ago at another policy conference, and everyone was cheering about it, and so you've just being able to start to see some of those gaps close, and now you're gonna watch them widen. So, we have to pay attention to that.
Okay. Before, I wish we could, I have so many more things I wanna talk to you about, but before I let you go, I, as we always do, I mean this po podcast is all about policy and connecting the dots between policy and rural quality of life. You know, we've got policymakers listening. We hope, if not, we're gonna, you know, put a little bug in their ear.
But we've got a lot of advocates out there listening as well. What is the conversation that we need to be having with them? What message do we have from them? Because we cannot put the toothpaste back in the tube. How do we advocate to mitigate some of these harms of these Medicaid cuts?
What, you know, Joan, I know you at Georgetown, you guys are doing so much research, and you're putting out the data. What does it matter if no one's listening? So how can we compel people to not say, well, there's nothing we can do about it, because we must. Not doing something is not an option in my book.
Joan Alker: Yeah, I mean I'd say two things. I mean, I think of the big picture. No state, you know, no matter how rich or how well-intentioned, is gonna make up for these federal cuts. So ultimately, we have to get Congress to reverse the cuts, right? And that's the big picture message. You know, elections are coming up, and Medicaid is very popular with the voters. I'll just say.
That was, you know, oftentimes you see this where legislators are outta step with the voters, and we absolutely saw that. I think last year's Medicaid cuts were not popular with republicans, Democrats, or independents. And the President's own pollster, told 'em that.
Michelle Rathman: And they did it anyway.
Joan Alker: They did it anyway, but they're trying, they're trying very hard not to talk about it. They deny there are any cuts, and they're just gonna, we're gonna hear about Medicaid fraud from now until the election, so that the conversation has shifted.
So, we gotta keep our eye on the ball to highlight how important Medicaid is for rural communities, all communities in this country. And ultimately, Congress is gonna have to reverse the cuts.
However, in the short term, I think it's critically important for rural communities to work together, providers, schools, churches, to educate themselves about what's coming down the pike because this, you know, in particular, this work requirement that's coming in January 1st, 2027, that's not far away, and there are all these exemptions. Right?
But are people gonna know about them? Is the system gonna work to give it to them? Right? So, there's a lot of education that has to happen here to minimize the coverage loss.
Michelle Rathman: Yeah, that's great. You know, physicians are neutral conveners in many ways. I've been working in this field, people know for many, many years. So, as a physician, where do you see your abilities, less of a role, but your abilities to elevate the conversation and educate people on the things that we're talking about here today?
Dr. Shannon Dowler: Well, we've seen, at least speaking for family physicians over the last couple of years, more and more involvement in policy and reaching out to legislators to say, “Hey, this doesn't make sense.” We have a meeting every year, the Family Medicine Advocacy Summit up in DC, and we had the highest attendance last year in the history of doing it.
So we're seeing people get more excited. I will tell you as someone, I only spend one day a week in the clinic right now, and it is exhausting. I was up till almost 10 o'clock last night finishing my charts from the patients I saw yesterday, so physicians that are full-time doing this in the clinic, I just don't know how they would have the bandwidth to do much more, but we've gotta get 'em thinking about it.
One of the things I would say is that we've got to reverse this belief, that I think is being put out there by the administration very intentionally, that these rural health transformation dollars are somehow a fix for H.R.1. They're completely unrelated, and they in no way equal each other. And so I think we have to be really clear about dividing that out.
And then I will say after five years at the state, working in the Medicaid space. There is definitely fraud, waste, and abuse. I have no doubt it is from my experience, whether it's from my lived experience in rural Appalachia or all the way to my seated state government, it's not happening with the average person. Fraud, waste, and abuse is not happening with the people that the administration really seems to think that it's happening with. There are so many ways we can reduce waste in our healthcare system right now and save dollars. Implementing work requirements at the tune of hundreds of millions of dollars is probably one of the biggest waste cases I've ever heard of in my career.
So how can we work smarter to find money, to save money from the program and help everybody end up, you know, being happier at the end of the day?
Michelle Rathman: Yeah, I appreciate that and listen to all of you. You know, disinformation and misinformation is winning the day, and the reason why these narratives are so popular is because they are elevating their people's algorithm. So, when you hear something that you know is inaccurate. It might be easier to walk away and say, I can't even. What's harder and more fruitful, I think, is to make sure that rather than, you know, not say, tell someone they're wrong, but present them with the correct information and then guide them to resources like the two of you have to make sure that people are well-informed versus misinformed.
So, oh my gosh. Before we let you go, Joan, where can people follow you? Because they must follow your work.
Joan Alker: Well, visit our website, which is ccf.georgetown.edu, and we have a weekly newsletter. I am on a lot of platforms: BlueSky, X, LinkedIn. But come visit our website. We have a lot of state data too, and we have a whole rural health project with a lot of data there as well.
Michelle Rathman: Excellent, and we'll make sure that that goes into all of our show notes and on our resource page, you'll be able to link right through and not even have to remember anything. And where can people, 'cause you're work, you know, Dr. Dowler, we have to have you back because you've got another whole chapter I wanna talk about, but where can they follow you?
Dr. Shannon Dowler: Well, I would say from the broad policy, what are family doctors thinking about afp.org or family doctor.org or great resources? For me personally, shannondowlermd.com is my website, which I update every now and then. I am also on all the socials, and you know, boring that you can find me hanging out with my goats on the side of the mountain up here in Madison County.
Michelle Rathman: I wanna come hang out with you and your goats. You heard that here? Oh my gosh, Joan and Shannon. I really mean it from the bottom in the middle of the top of my heart. Thank you so much for your time today. You both are so busy, so welcome back anytime that you have something new to share, you, there's a seat at the table for you.
Dr. Shannon Dowler: Thank you so much.
Michelle Rathman: Okay, well, we have to say goodbye to our two great guests. You stay tuned because we have more of this dot-connecting conversation from my time in DC.
Next, you're gonna hear from Alan Morgan, CEO of the National Rural Health Association and the 2026 President of that same organization, Carrie Henning- Smith, Associate Professor of the University of Minnesota School of Public Health. We will be right back. Stay tuned.
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We are back, and as promised to round out this installment in our tracking transformation series, I wanna share with you just a few excerpts from the many conversations I had while in DC, attending the National Rural Health Association Policy Institute, which was in mid-February. This is an annual trek that I do every year and have been doing for many, many years.
And this year, as you can imagine, there were a few topics that dominated all of the conversations. So, after a very busy morning hearing from leaders at HRSA, HHS, members of Congress, as well as the Department of Veterans Affairs, and the administrator of the Centers for Medicare and Medicaid himself, Dr. Mehmet Oz, who shared with a standing room only group of rural health leaders, that “there were no cuts to Medicaid,” And that is a direct quote.
So shortly after his remarks, I had the opportunity to sit down with Alan Morgan, NRHA’s longtime CEO. And we discussed a wide range of, pressing policy matters, including the organization's position on the explicit Medicaid cuts written into law in July of 2025. And of course, you heard me say that before, that is H.R.1 in case you're looking for a reference.
So, after we hear from Alan, of course, I'm so grateful for him. But we were also very fortunate to have a few minutes with the association's new President, Carrie Henning-Smith. Although she is a well-known longtime rural health leader, and Carrie and I also discussed critical policy priorities, and she shared a few of her thoughts on what she hoped to see in action this year.
So first you're gonna hear from Alan and then Carrie.
Alan Morgan: Yeah. And Michelle, what you're referencing is earlier on a program, Dr. Oz said these are not cuts, as you're actually slowing the growth of the program. Um, tomato, tomato. At the end of the day this, these are reductions and funny that would come to providers.
And I firmly stand by the data on this, Michelle, that hospitals are closing because they have a disproportionate share of patients with high health needs and the inability to pay, period. They're not closing because of low volume. They're not closing because of bad management. It's this clustering of a population and then expecting the providers to pay for. Medicaid is a state, federal program dedicated to laser address this issue.
Until we get another mechanism to address bad debt, this is the best tool we have to keep the doors open. So, we disagree with the administration on this. Every rural hospital disagrees with the administration on this. These are cuts, and they have to be postponed going ahead.
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Dr. Carrie Henning-Smith: In many ways, I think the policy priorities remain what they always have been, and that's about strengthening the foundation of rural health and addressing rural health disparities that are so longstanding that requires sound policy, as you say. There are some immediate issues that require attention.
First and foremost, I don't think we can talk about rural health without talking about the looming Medicaid cuts, and so anything we can do to delay or hopefully stop those cuts altogether. It's critically important for rural health. We also need to continue to strengthen the safety net. We need a policy to focus on the workforce. We have all of these measures that have been put in place temporarily, and so we need statutory action to make sure that those can continue longer term.
I'm thinking of the CDC Office of Rural Health. I'm thinking of the flex program. All of these programs that are critically important for understanding what's happening in rural areas and strengthening what's happening in rural going forward. And so those are the association's priorities. Those are really things that I hope I see real action on as President this year.
Thanks to everyone who spent time with me in DC in a future tracking transformation episode. I really do hope that I'm able to bring you a few more voices. We heard from the National Association of Community Health Centers because I also went to their Annual Policies and Issues Forum, where I discussed, with some members, some movements in the delivery of Healthcare on Wheels for Rural, which is through the well-equipped mobile.
Health clinic. So a wave of the future. Stay tuned for that, a couple of those conversations at a future time. But for now, let me once again thank Joan, Dr. Dowler or Carrie, and Alan for their insights into these not-so-light subjects because, as we say, often all roads to quality of life are paved by policy.
We're going to keep having these conversations, okay? We're gonna keep these issues front and center. Coming up, we are gonna be shifting gears because we're gonna bring you the latest on rural education policy. There is a lot happening in that space. And we're also working on an episode that delivers straight talk on policy shifts for the United States Postal Service, the impact on rural economies, access, and elections.
Okay. We're also gonna be working on an episode that brings you the latest on the farm bill movements and so much more. Now as a reminder, the content that we bring to you is made possible through our sponsoring partners and supporters like you.
Every donation is appreciated, and now, when you make a purchase from our well-stocked merch space that you can find on theruralimpact.com, you can not only wear your support on your sleeve, you can wear it on your hat, carry it as a tote. You have a look at the story and see what you think. We'd love to see you take pictures of yourself wearing our gear. Quite frankly, that would be fun for me personally.
To Brea Corsaro and Sarah Garvin, for all you do, I thank you. To the rest of you, be sure to follow us on social, mostly LinkedIn and BlueSky.
You can also find us on Facebook as well. And finally, to all of you, this is a heartfelt invitation. These are some very challenging times that we are walking through together. So, with that, a sincere invitation for you to take the best possible care of yourself. And to the best of your ability, all those around you.
We will see you again on a brand-new episode of The Rural Impact.