82. TT: Federal Funding Forecast and States' Use of RHTP Funds Interview with Maya Sandalow, Chris Nelson and Carrie Cochran-McClain
Hello, one and all, and welcome back to a brand-new episode of "The Rural Impact." I am Michelle Rathman, and as always, I do appreciate that you have come back for another conversation that does work hard to connect the dots between policy and rural everything, as you hear it, us say it so often, rural quality of life.
Well, today we are continuing our 2026 series that we're calling Tracking Transformation. And of course, if you've been following along, and we thank you, all of our subscribers for doing so, what we're specifically talking about is the Rural Health Transformation Program, which is, of course, the $50 billion fund that came out of the H.R.1 legislation signed into law almost a year ago, which is really hard for me to believe.
Much has changed since then, and so of course, we're tracking transformation because this investment, you know, holds a lot of promising practices for states. At the same time, there are a lot of competing priorities and more headwinds to come, and so we're really working here to make sure that we bring balance and attention to these subjects because, you know, we cannot be like, "Look over here at what's happening on one side," and then really kind of facing the real realities of what's happening where rural health is concerned.
So, we have three new guests joining us today, all of whom have a different perspective, and I'm just so excited for you to hear them as we move on. And just a really quick reminder, you can, if you're listening to us on our website, we love that you are doing that at theruralimpact.com. But just know you can watch us on YouTube, and we are pretty much everywhere you find podcasts, so be sure to subscribe there.
We do appreciate it when you do. And leave us your comment. If you've got questions about the conversations we're having, we want you to feel free to leave those as well, and we can answer those in future episodes or maybe reach out to you directly, depending. So, to do that, just subscribe, and we'll make sure we can connect you that way.
All right, housekeeping note aside, I want to just tell you that I start off the conversation today because again, rural health transformation has many layers, many different moving parts where this is concerned. And one of the big, promising practices, if you will, coming out of this is what technology can do to help, I shall say, augment rural health delivery.
And, you know, hopefully at the end of the day, with all these investments that we really see remarkable improvements in health outcomes, because in my mind, health transformation does not happen if the outcomes for patients does not improve. Otherwise, it's just spending more money. And of course, we have seen many of our previous funds from different programs, grant programs with short cycles, kind of fizzle out after the magic happens.
All right, so to joining me today to get this conversation started, we are gonna hear from Maya Sandalow, and Maya is from the Bipartisan Policy Center, and, we're really gonna focus on some of a brief that she and a fellow colleague, Daisy Kim, put out focused on kind of the bigger picture of technology investments.
We're gonna talk really specifically about four buckets about where that is going, and then we bring in Chris Nelson. Now, you know, we can meet a lot of great people on LinkedIn, and Chris just happens to be one of those people. I wasn't aware of him until I started reading his blogs, if you will, on LinkedIn, breaking down what states are doing state by state, just really taking their applications and putting into summaries and some narratives around how they are making investments.
And many of those investments, if you look at those applications, really do focus on technology. And because Chris has such a strong focus on Indian health and veterans' health, and women's health, we talk a little bit about how states are investing to improve health outcomes and transform health for those populations using technology.
And after we talk with Chris Nelson, we are going to hear from one of my favorite policy people, and that's Carrie Cochran-McClain, chief policy officer for the National Rural Health Association. Of course, Carrie and I are talking about RHTP from a policy, very deep, deep, level policy perspective, but we're also gonna talk about the president's FY27 budget, and we're gonna talk about Medicaid cuts, and we're also gonna talk about the farm bill.
And so although this drops on May 7th, I know that things might have changed since that time, and we know just give it a moment, and things are gonna change again. But at the end of the day, I know that Carrie's gonna provide you with some insight that, on this topic and others that you may not know before, but you certainly will be enlightened on now, as we say often.
These are not light subjects. At the end of this conversation, if we have not enlightened you, then I just don't know what. So, with that said, I invite you to put yourself in that podcast listening frame of mind and hear my many conversations, very impactful conversations, with Maya, Chris, and Carrie. Take a deep breath.
Are you ready? I am most definitely ready, so let's go.
Michelle Rathman: Maya Sandalow, Associate Director of the Bipartisan Policy Center, welcome to "The Rural Impact." I mean it when I say we are so glad that you could join us because this is an important conversation.
Maya Sandalow: Yeah, Michelle, thank you so much for having me. I'm really glad to be here, and I'm also glad that you're devoting, you know, several episodes to this Rural Health Transformation program.
Michelle Rathman: Well, as I was sharing with you earlier, I just came back from last week. We are recording this on April 20th, and I was at the Colorado Rural Health Center, which is their state office of rural health, and they had a many, many sessions, several of them focused on rural health transformation.
We heard from a lot of healthcare and hospital CEOs, and of course, as you can appreciate, and I've read your stuff, you know, there are varying perspectives, lots of moving parts. And so yes, we do wanna connect the dots and focus today on rural health transformation, but in that context on the technology component, because that is, in my lens, that's probably the... I mean, there's a lot of things that we need to tackle, but technology is very much on the radar screen where everyone is concerned.
And so with that said, you have written quite a bit about it, and one thing that really caught my eye, and one of the reasons why we really wanted to have you on, is because you and your colleague, Daisy Kim, a Senior Policy Analyst also at BPC, wrote a brief titled "Advancing Technology Innovation Through the Rural Health Transformation Program." And so again, we really wanna have you focus on that today. If you wouldn't mind, just start us off, this explainer, I, I think we'll make sure we put the links on our website, but why don't you just give us kind of the impetus behind that, kind of the high level overview and there, and then we'll kind of dissect those four major, I'm gonna just call them buckets, if you will.
Maya Sandalow: Yeah, absolutely happy to. And, I’ll get into the analysis, and I think it's important also just to, like, step back and add some context because we're always thinking about, you know, the broader healthcare landscape when we're doing our work. My organization is called the Bipartisan Policy Center, and we've been working in healthcare policy, specifically rural health, as well for many, many years now.
And that's because one in five Americans lives in rural communities, right? And we know that oftentimes they have to travel much farther just to access the care that they need. So, really, any focus on rural health is something that the BPC is interested in exploring.
So, to your question about our work and this latest analysis, just as some context, right? Starting this year, states are beginning to receive their share of fifty billion dollars through what's called the Rural Health Transformation Program. On average, this comes out to about two hundred million dollars per state per year. It's a five-year program. And this is happening within kind of a broader funding context, right?
This program was created as part of last year's reconciliation package called H.R.1, which makes many changes to Medicaid, and analyses estimate that those are gonna, you know, reduce federal Medicaid spending, especially in rural areas in the years to come.
And this Rural Health Transformation Program isn't designed to directly replace those cuts. Rather, the program's stated purpose is to transform the way care is delivered in rural communities. So, it's really looking for kind of more transformative proposals. And we noticed-- we reviewed all 50 state applications and noticed that every single state plans to use these funds or at least a portion of them to invest in technology innovation, right?
And, the Center for Medicare and Medicaid Services, CMS, which is the federal agency that oversees this program, they really call out technology innovation as one of their strategic goals. So we were really interested in seeing, you know, what types of technology initiatives are states planning. It's important to note that the level of detail in these applications really varies, and it's not fully clear yet how the state initiatives in reality will change from their original applications, which is what we had access to and reviewed.
But that being said, we identified kind of four broad themes that I can go into detail on, but I'll state them first. So, the first is that states plan to use these funds to modernize their health IT infrastructure and kind of strengthen their cybersecurity readiness. So, some kind of foundational infrastructure components.
The second is states using these funds to invest in expanding virtual care, such as access to telehealth and remote patient monitoring. The third is the word that is involved in every health policy conversation these days: artificial intelligence. States planning on using it to scale AI. And then the fourth is something called Rural Technology Catalyst funds, which is, states are allowed to invest up to ten percent of their funding towards those funds.
Michelle Rathman: Yeah, I read through all of it, and I will just say as a side note, at this conference I was at, the focus on AI was there, and I learned some things. I mean, you know, obviously, you're talking about implementation at the state level, but when it comes to how health facilities will be able to adopt that, and that's another conversation for another day.
I mean, that is just gonna be something totally different state by state, and then within a state, facility by facility, depending on their capacity, their expertise, and so forth. But from a broad picture, 'cause we're having other conversations to kinda get into the granular level with the states, I wanna talk about the IT infrastructure.
It's a broad term. In particular, your brief talks about the fact that it's meant to increase EHR adoption, electronic health record adoption. We know that, you know, a lot of investments have been made. A lot of investments have already been made in EHR adoption, and it's an ever-evolving thing.
Anyone knows if these things change as technology changes? Then you also have enhancing interoperability and strengthening cybersecurity. If you could kind of spell out for us, this might not seem like work that's actually gonna transform. I mean, I think people have some expectations that they're gonna see some immediate tangible results. But this is not about that. This is about investments for the future. Is it not?
Maya Sandalow: Yeah, I mean, so these health IT and cybersecurity investments are really foundational for any broader transformation initiative, right? We know that modern healthcare runs on data, right? But right now, many, many rural providers can't afford always to have the systems in place to kind of easily share that data with other facilities or, you know, to keep the data secure.
That can look as if a patient sees a specialist in another town, their information might not travel with them, which can lead to things like duplicative care tests, which are costly, and delays in care. We also know that rural providers are especially vulnerable to cyberattacks, but similarly, they might not-- and that's because they might not have the foundational infrastructure to invest in dedicated IT staff, or afford strong security tools.
And a cyberattack can be really detrimental and definitely get in the way of broader transformation, right? It can shut down hospital systems.
Michelle Rathman: It has shutdown hospital systems.
Maya Sandalow: I think a lot of It has, it has shut down hospital systems. You know, I think a lot of people, myself included, are more acutely aware of the threat of a cybersecurity attack after watching the latest season of "The Pit," in addition to all of the recent stories of actual cybersecurity attacks, to your point.
But in this latest season, a cybersecurity attack shuts down hospital systems, and clinicians really can't access their patient records or schedules. I think it painted a good visualization of it. So, what we're seeing states do through this program is really focusing on closing that gap, including helping providers upgrade or purchase modern EHRs, making sure that the systems can actually talk to each other.
Also, funding like technical assistance so that providers have the support that they need to really use these systems effectively. And then cybersecurity, things like threat detection tools and training staff. So, this, in and of itself, might not be a transformation, but it's really a necessary foundation for any broader transformation.
So, it makes sense to me that states are focused on this in part.
Michelle Rathman: Yeah. And with that, I mean, at the end of the day, as we know, any technology is it's not like a one and done because there's constant maintenance, there's constant updates, there's, you know, one of the things I've been thinking so much is that these initial investments will need to be maintained, and players come and go.
And because every state is different, I am, again, that's why we're tracking transformation because it's not as easy as it may seem on the surface. Let's talk a little bit about expanding access to telehealth and remote patient monitoring. We're gonna talk with a couple of other guests later, specifically about this in state-to-state, but there are some really hard-to-reach communities, territories, for example, Indian Health Services. They've got their work cut out for them, super remote, you know, when it comes to, you know, OB deserts and things of that nature.
So, talk about some of the investments that you're seeing, you know, just a high-level overview of what you're seeing states focusing on because there's also a coverage component, and I don't mean coverage as in technology, but health insurance coverage component of this as well that we cannot disregard.
Maya Sandalow: Yeah. Yeah, absolutely. And you know, it's not surprising to me that states are investing in virtual care because, to your point, there are some really rural areas and people who have to travel really far to access the care that they need. So, technologies like telehealth and remote patient monitoring have the potential to really help people access care closer to home.
I think there's a patient story that kind of illustrates the potential here. I, I spoke with a patient named David last year. He's eighty-three and lives in rural North Carolina. And he has congestive heart failure, and he uses a connected blood pressure cuff and scale at home. And every morning, he checks his weight and his blood pressure, and then those readings are automatically sent to his care team.
And then if something looks off, a healthcare provider will call him and adjust those medications. And he told me that this has kept him out of the hospital. So, you can imagine that it could be hugely transformative for folks in rural areas. And there's also an affordability component here to your point.
You know, at a time when there's a lot of discussion about healthcare affordability, this really matters 'cause, for example, avoiding hospital visits isn't just really good for patients' health, but it also reduces the cost of probably more expensive care for both the patient and the broader healthcare system.
Michelle Rathman: I mean, the emergency room visits are the most expensive level of care that we can have, and if they don't have a primary care, you know, accessibility, this makes all the difference, I would imagine, in the world.
Maya Sandalow: Yeah, absolutely. And we do know that rural areas have been slower to adopt telehealth and RPM historically, just because of some of that infrastructure that's required to do so. So, we're seeing, just to speak to a few of the trends that we saw, as we were reviewing the Rural Health Transformation Program applications, is one common approach is states are proposing to create what are-- what they're calling telehealth hubs.
So these are local care settings where patients can access virtual specialty visits and also get set up with things like remote patient monitoring programs that then they can do at home. There's also a policy piece that's really interesting to note here. Providers, for example, interstate licensure is one policy component I'll talk about.
Providers typically have to be licensed to practice medicine in the state where their patient is. And this can, of course, be a barrier, especially in rural areas where there are limited types of, you know, of providers. And through this funding, CMS is encouraging states to join what are called interstate licensure compacts, and that allow providers to practice across state lines.
So, this can really help to expand access to care in rural areas.
Michelle Rathman: Yeah, I read that, and that to me, I've sat through many health policy conferences and meetings, and this has been kind of a sore spot for quite some time. It's that you've got this technology in place, but then you've got these licensure barriers that just kind of like blow the whole thing out of the water. And it was like, "Oh, great idea, but..." So, this, that this does work to address that.
Let's talk about increasing the use of artificial intelligence. But first, can I tell you a story, Maya? So, this session I was at was with an ER physician who talked about the use of Ambient Scribe and things of that nature. And, you know, we, AI is here in healthcare. It's here to stay. It's how it's, how we harness it for the least amount, the most effective in the least amount of damage- you know, potential liability involved. And he was talking about the fact that, you know, AI is not perfect. It's not thinking. It's an algorithm and it, you know, there's many, many kinds of it, and I think we have a lot to do in terms of educating our communities, not that they, it, it can't be taught.
We need to really focus on emphasizing what AI is in healthcare versus what people are seeing on social media, 'cause it's, it's new, right? Well, he was talking about the fact that there's been an extra cost for hospitals as he's seeing having to take out liability insurance just for your AI tools because of the error factor and so forth.
But that's the bad news. Let's talk about the good news, the good news about increasing the use of artificial intelligence and how that's done responsibly, because I think that's an important word.
Maya Sandalow: Yeah, definitely. Yeah, and like you said, Michelle, AI is getting a lot of attention right now. And it's here to stay. It's been used for a while in areas like medical imaging, and then it's really ballooned in other areas, including administrative use cases such as Ambient Scribes. Those using AI for clinical documentation is really one of the fastest growing technology adoptions right now.
And early evidence-- if we're talking about good news here, early evidence does suggest that those tools, Ambient Scribes, can really help to reduce provider burnout, which is a really big problem, especially in rural areas, right? So, definitely promising. The story here is similar to other types of technologies that we've already talked about, and that rural providers have been slower to adopt because of some of those resource constraints.
So states are investing in AI in a variety of ways through the Rural Health Transformation Program. A big focus is on using it to reduce administrative burden, including to help providers adopt tools like AI scribes or AI, that's used in scheduling platforms to kind of automate things like scheduling.
We see a few states proposing some more kind of flashy clinical applications. So, Utah is one state to keep an eye on in general in this space. And, they are proposing to use AI for clinical applications like making treatment recommendations and automating prescription refill requests. They have something called their Office of AI Policy that can test these tools in a controlled environment and, you know, temporarily waive certain regulations to pilot new approaches.
And a lot of states are investing in broader support systems. So, you know, another example here, Maine is proposing to create what's called-- what they're calling a rural AI hub, and that's gonna provide technical assistance and kind of oversight to rural providers as they're implementing innovative technologies.
So, really a variety of approaches here.
Michelle Rathman: Yeah. And, you know, there's-- It just brings to mind there's so much that we don't know, and all of this will require policy. I mean, statewide policy, hospital, you know, whoever's using it, they're, they're, in my view, they need to have a really, robust and, AI use policy and communicate that with their patients and, and, and with their staff because adoption, and we'll talk about that in a moment, really the, the building it, building the plane is easier than it is to fly the plane. Let's just say it like that.
Okay, the last one, which I mean, futuristically looking at this, because if we are gonna invest all this in innovation, we have to be able to build on that. So the, the fourth kind of bucket, if you will, is to incubate innovation through a catalyst funds and pilot programs. So, go through the list and things that we need to know about that.
Maya Sandalow: Yeah. So, this Rural Technology Catalyst funds, it's encouraging states to test new and patient-facing technology solutions, in particular with an interest in using these solutions to kind of prevent and manage chronic diseases. And states are allowed to set aside up to ten percent of their overall funding towards these types of funds.
And how this looks is that states can partner with experienced organizations, like could be a startup incubator of some kind, and then they will vet technology vendors who are developing innovative solutions to rural health challenges. And these partners are also allowed to bring in private investment, so it's an opportunity for states to essentially combine public funding with outside capital.
And we noticed that a handful of states do propose to use some of their funds towards Rural Technology Catalyst funds. The level of detail was relatively sparse in a lot of these applications, so it's definitely something to keep an eye on and monitor how states use these funds. One that stood out, that was interesting to me, is that Alaska is planning on using these to pilot drones to deliver medications to rural areas.
So that's just an example of kind of a broader transformative idea.
Michelle Rathman: Yeah, and what that could do for, for access. I mean, it just, it-- the potential for, the way I see it, is huge. But there's also, with every, opportunity, there are risks, potential risks, and I think that's gonna be so important for us to monitor. I just wanna kind of go back a little bit to catch us up where we are, because you also wrote a piece, developed a piece with I think with Daisy as well, on, it was a December 12th piece, "Health Technologies: Where We Are Now and a Look Ahead." Well, we are a look ahead in 2026, noting a few items. Number one, impacts are not straightforward. So, what does that mean in your terms?
Maya Sandalow: Impacts are not straightforward for the Rural Health Transformation Program?
Michelle Rathman: And you, yeah, you write, impacts, "Health technologies could expand access and improve quality, but benefits are uneven, and adoption remains lower in some rural areas that may benefit the most. Past evidence suggests new technologies do not consistently reduce healthcare spending." And I think that's an important point to make because all of this infrastructure, again, is cost it... We have to invest in it.
Where does the funding come to maintain it? And then, is it proprietary? And I, these are questions I know that we all don't have the answers to, but I wonder what your thoughts are on that.
Maya Sandalow: Yeah, absolutely. I mean, impacts are not straightforward in a variety of ways. One way that I think is important to note is that oftentimes, the people who could stand to benefit the most from these technologies aren't the ones who receive them, right? And so that's something that we're talking about here with the Rural Health Transformation Program, that hopefully this will help to bridge the gap in rural areas.
The second is that even if some of these technologies in theory could deliver care at a lower cost, in reality, they might not, or they could lead to duplicative care, right? So, one of the key research questions that was studied at the beginning of the COVID-19 pandemic, when telehealth flexibilities were broadened is, are patients using telehealth on top of in-person care or in lieu of in-person care, right?
And that's gonna have cost implications. So, there's a variety of implications and, and kind of outcomes to keep an eye on. I do think when we're talking about researching and measuring impact, it's always really helpful to compare these tools also to the current standard of care, right? Like in many rural areas, patients are facing significant barriers to accessing high-quality care.
So, the question isn't just how these technologies perform in ideal settings, but how they compare to the realities on the ground.
Michelle Rathman: That is an excellent point because we talk about using AI and triage. And one chart that I saw, you know, I don't wanna misspeak the numbers, but significantly different in terms of when AI did the triage versus, you know, someone who is fatigued and is working, you know, well into a second shift.
So very interesting. The last thing on this subject I wanna touch on is you talk about the fact that implementation determines effectiveness, we get that, and payment should reward value. Can you talk about that for just a second?
Maya Sandalow: Yeah, absolutely. And I think in terms of something to keep an eye on in 2026, there are some really interesting innovative payment models that are being launched that are trying to link payment with outcomes through something called outcome-aligned payments. So, one is CMS's ACCESS model that launched this year, and that's piloting paying for patient-facing technologies, based on the, the value and the outcomes here, right?
The devil is in the details. It's something really to keep an eye on. But we do know that, for example, AI and other types of healthcare technologies are really just highlighting the need for broader payment transformation. They don't really fit into our traditional fee-for-service model very well. And so that's something that is being given a lot of thought, including through the Rural Health Transformation Program.
Some states are talking about investing in value-based care and broader payment transformation, and that's actually something that the Bipartisan Policy Center is looking into and will be including in an upcoming report. So, stay tuned.
Michelle Rathman: Lots of conversations to be had with a lot of providers, and a lot of coders have their work cut out for them, I predict.
Maya Sandalow: Definitely.
Michelle Rathman: Before we let you go, this brief that you wrote was in March. It's now the latter part of April, and I know the clock is ticking because, let's just say, things happen a lot faster.
The timeline, you know, things move super slow in rural health policy, but this is moving really fast. So, kind of what's the next steps for states in your estimation, and what are others are, you at the Bipartisan Policy Center, what are you keeping your eye on where this is concerned? I know you're gonna keep talking about it
Maya Sandalow: Yeah. Yeah, definitely. I'll start with what's next for states, which of course relates to what's next for BPC. But right now, a lot of states are just getting their budgets finalized, right? And that's the real start date. CMS has spent the past few months working in earnest to review state budgets and approve them.
And states can't actually publicly post things like this opportunity or spend down any of the money until those budgets are approved. And then we're also hearing that even after funding is approved, states are facing delays at times because of essentially procurement challenges. Those processes can be slow.
In the technology space, we've heard of, for example, state agencies being required to use pre-approved vendors and follow strict contracting steps, and even some states are working with their legislators to update these rules and make it easier to move forward. So that's what's been happening actively right now.
But we do know that funds that aren't obligated by the end of this budget period will actually be taken back and can be redistributed to other states. So, it's a short turnaround. Once states' budgets are approved, there's a lot of, you know, moving quickly to probably obligate those funds and then actually to demonstrate outcomes to CMS in time for the next round of funding.
So, the first annual state reporting is due this August, and CMS is in the process of finalizing the templates for those reports, so it's not totally clear yet what exactly states will be asked to report on. But we do know that that will determine next year's round of funding, which CMS has to determine by October 31st.
So a quick-moving timeline
Michelle Rathman: Very quick-moving. I heard someone describe it to me a few weeks ago as the Hunger Games of healthcare spending. So yeah, they have their work cut out, and I wanna make sure we're gonna, Maya, we're gonna make sure that we link your work, on our website, but tell people where they can follow you so that they can make sure that they stay up to date, because it's really the way you all, outlined it, I think is in clear terms, is important.
Even if people don't think it's important or relatable to them, it is, I promise you, because as my friend Kate Hill from the Compliance Team says, "All policy is health policy."
Maya Sandalow: Yeah, absolutely. I love that saying. So, I'll just outline three things that are on BPC's rural health docket in, in the few months ahead, and then where they- Folks can follow us. So, we're doing a similar analysis right now to identify how states plan to use these funds for workforce initiatives to recruit and retain physicians and invest in wraparound, wraparound supports such as community health workers, and that should come out in the next few weeks.
We’re also hosting a virtual event this summer to bring together experts to talk about all of these topics. And then we'll be releasing a more in-depth report later in the summer focused on rural health priorities and practical federal policies that can help states make the most of this funding.
So, you can follow our work at bipartisanpolicy.org, and you can also find us on social media at BPC_Bipartisan, that's on Twitter, or at Bipartisan Policy Center on LinkedIn.
Michelle Rathman: Absolutely. Again, we'll make sure that we put those links in. Maya, I'm so grateful for your time today. We're so glad that you were here. And keep us posted. Send us things that we need to know, and we'll make sure that we have your back and at least inform our listeners of what, what's we should be looking at next.
'Cause again, this is a part of a series, so this conversation is going to continue.
Maya Sandalow: That would be great. Thanks so much, Michelle. It was great to be here.
Michelle Rathman: Thank you. All right, although we do need to say goodbye to Maya, up next is my conversation with a federal insider and strategic government affairs leader with more than 27 years of experience advising at the highest levels of federal health policy and operations.
His name is Chris Nelson, and we get into those details on how several states have prioritized technology in their RHTP plans. So, let's connect some more dots here next with my conversation with VA and tribal health expert, Chris Nelson.
Michelle Rathman: Hey, Chris. Just before you joined me, we heard from Maya Sandalow, Associate Director for the Bipartisan Policy Center's health program. You know, we covered, as I mentioned to you, so much about her March 18th brief, written with her colleague Daisy Kim, Advancing Technology Innovation Through Rural Health and Transformation.
But Chris, you have a very unique perspective about all this, so we did high level. Chris Nelson, I want you to help us dial it down and really talk about, kind of the, sort of the big picture, the smaller picture of what states are talking about, where technology is concerned, and RHTP. So take a breath, Michelle. Welcome, Chris. We're glad that you're here.
Chris Nelson: Thanks. I really appreciate it a lot and glad to glad to be here and visit with your clientele and your audience here. So, yeah.
Michelle Rathman: Thank you. Well, as everyone knows, we're in the middle of our, you know, our 2026 series of tracking transformation, and as I mentioned, you know, Maya told us a lot about IT infrastructure, AI, exploring models that involve the future use of wearables, apps, drones, all of that, which sounds fantastic.
In you know, big picture. But I also shared that I learned about your work, because you're really doing this snapshot of RHTP state by state on LinkedIn, and we're gonna make sure everyone knows how to find you there. But you provide summaries of how states intend to invest their first installments of that millions of dollars in technology.
So I'd like to start there.
What are you seeing in state plans breaking down investments even further for us? How do states like Alaska, which you've covered, Hawaii, South Dakota, and others? Talk to us a little bit about some of the trends you're seeing where they're going to really pursue technology solutions to improve rural health.
Chris Nelson: Well, you know, one of the biggest things that you're gonna see across the board there in every state is electronic health record implementation. You know, a lot of times, what I'm really excited about with this RHTP program is things that traditionally get cut first, like your training, like your electronic health records, like any new type of modernization, get cut first in these little hospitals, 'cause they just can't afford to have them on board.
So now with these specific pillars, like we talked about earlier, you know, that's where they're actually gonna be able to have that funding and really focus on something that can't be cut because they need to fulfill the needs of that. So, you're gonna see a lot of the electronic health record, a lot of the remote patient monitoring.
Both really are needed, not only in rural country, but also in Indian country as well. And I think that's really gonna help improve the health of all their members.
Michelle Rathman: So, in what you're seeing in their plans, because you do break it down, in some of the profiles that I read, you talk about some of the roadblocks that they have. You know, the investments from what I'm seeing, it looks really good on paper, a lot of investment in infrastructure.
How do you, in your work, how do you foresee that actually kind of getting to a place where, at what point it will start to, we'll start to see a difference in the way- these health centers, many of them f- federally qualified health clinics that operate in, in real places. So, the money's going into infrastructure. Do you have any insight into actually what that looks like on the landscape today?
Chris Nelson: Yeah, you know, each state's doing it a little different, right? They're targeting exactly what they can out of those particular pillars and then fitting it to their actual state. So, you know, a few of them that are quick out of the chute were Delaware, South Dakota had some early RFPs as well come out. So, you know, the faster they get that on the road, the faster they can actually start implementing that thing.
You know, change always takes time, so an immediate implementation does not mean anything. But I would say you're gonna see at the end of these five years a substantial change in rural health.
And one thing I really like about this program is, and I've seen people complain about it as well, it wasn't based on the population of the state, okay? You know, which there's a reasonable explanation behind that. You know, let's take a state like North Dakota, like my home state. Now, there's only 37 recipients in that state for those dollars.
And for example, even if you look at, like, their workforce development dollars this year, if they all apply, they're all gonna get 270,000, which is great, and none of that was based on that population of the state, which is very low. Now, the reason why they're getting so much money is because of the distance in between those facilities that people have to go and the actual lack of facilities in that state.
So, you know, states like California aren't gonna blow up the money because they have so many people in it, because they have a lot of facilities to choose from. But these really desperate states, these real desert states, are really gonna have an opportunity to expand and really improve healthcare in those small states as well.
Michelle Rathman: Yeah, I mean, and I'm taking a look right now. Again, we're recording this on the 20th of April, so I wanna note that for our listeners. But you, you wrote your piece, that kind of summarized Mississippi, for example, and you talk about, you know, we're talking so much about workforce, for example, and so Mississippi Workforce Expansion Initiative, the WEI, has a major focus on recruitment, retention, and training. Goals include recruiting and retaining 2,150 clinicians and support staff, and creating 235 new training positions. I mean, these are big, big-ticket items that they're talking about.
What, what are you hearing in terms of that’s goal, but how do you get that done, considering other things that might be at work? I mean, we are all facing workforce shortages. I hear that over, and over, and over again. Can you talk a little bit about the trends that you're seeing in terms of workforce and maybe how technology can actually be used to, I don't wanna say replace, but to enhance?
Chris Nelson: Yeah. Yeah. Yeah. Actually, you know, so when you look at technology too, we should really look at our telehealth platforms, especially when everyone is spread so thin. And one of the major problems they have in rural health, I'm sure as you know, is you're moving to a rural area. You know, you're gonna have to give up some of the luxuries of life.
There probably isn't gonna be a theater within an hour where you can go and see a play on the weekends and things like that. So, you're gonna have to kind of settle for a simpler life, which has always been a huge, you know, a huge barrier for a lot of recruiting issues as far as that goes.
So, you know, we got some great things out there. We got some telehealth platforms that are really gonna help bridge that gap. A, a really cool thing that I saw at HIMSS with a company called VSee was their robot that'll actually roll around the medical facility and get close to the bed where you can do a telehealth appointment, actually with your doctor from there.
So, these are the type of things that are gonna help us bridge that gap. You know, we always want the one-to-one and really want that human connection, but when you get into rural health, you know, that changes a lot, you know. When you have such a far distance to go to these places and your recruiting gets to be, you know, such a challenge for you.
You know, I worked all over the country, and I've worked in northern parts of Nala- Alaska as well, where they do incentives, you know, to get people to come there, where some places are paying for their school, they're paying for their apartment, and they're paying them while they're going to school, so they owe them some years after they come back.
And I mean, when one of their recruiting measures is like, "We pray they fall in love when they get to our small town with a local and stay," you know, that, that's just what kind of barriers you're dealing with when you get very, very rural and very, very, out in the kind of, you know, out in the middle of nowhere to some people, but it's, you know, peaceful to others.
Michelle Rathman: Yeah. And, you know, one of the things I wanna make sure that we talk to you about in our time together is you have your, this background in veterans and tribal health that's been... I wanna make sure that everyone knows the context. So, I wanna focus on tech investments and how they, how you foresee it transforming rural health because I just wanna share some of the research I've done.
Veterans and indigenous populations, knowing that there are more than four million veterans residing in rural communities across the U.S., and this includes many indigenous veterans, and that Native American health is disproportionately worse. This is not anecdotal. This is the, these are just facts. Than other racial groups in the U.S., with extremely higher rates of heart disease, diabetes, cancer, and, of course, many other challenges in accessing care.
I would be remiss if I didn't say, like, if we do not, like, crack this nut, if through all of these investments we are in, we're, we're doing it wrong. and, and so let's, let's talk about how the de- the deployment of technology, 'cause it's not just, hey, we're gonna send a, a, a drone out. I mean, you need that cultural connection, that lived experience. So, talk to us a little bit about how you foresee it really making a difference where it matters the most.
Chris Nelson: Yeah, you know, and, if you just go over regular kind of health budgetary issues, and let's say you broke down, you know, what, what America puts into each person in the United States, it comes out to be about $13 a person, you know, if you average it out. Now, if you go to what we put into Indigenous populations, it comes out to about $4 a person. So you can see what a disparity we're dealing with there as well.
Yeah, exactly. Exactly. Now, the, you know, a majority of the facilities, 75% of the facilities in Indian country now are managed locally by the tribe via their 638 treaties, okay? And those facilities are really nice. They're very well run, and they really need to invest the time into applying for these dollars.
They're gonna be eligible for all these dollars that come out, especially in Alaska and large states like the Dakotas and Montana. They're gonna have a lot of chances to absorb these dollars and really change tribal health in their communities. You know, whether it's through an EHR, whether it's through better remote patient monitoring, you know, whether it's through telehealth to make sure that we can serve those populations better.
And the other thing about Indian countries traditionally hadn't, you know, jumped on the technology bandwagon quite as fast because of data sovereignty and things like that.
But we're seeing a real change in that with those facilities. They're really starting to invest in and adopt all of these technological advancements that can really help them in their remote patient monitoring and things like that, so they can reach more people at a time.
You know, I've dealt with medical facilities down in the Southwest that they literally have someone taking blood pressures at people's homes every day, and they can maybe see five, six people a day because of the distance in between on the Indian reservation itself. So, you know, there's a lot of barriers there.
You know, some Indian reservations don't even have home delivery for mail yet to this day and age. And so got a lot to get over there, but I really hope that these tribal health systems are able to apply, and they do apply, and they get after that money, and they really help it to improve their healthcare.
Michelle Rathman: Yeah, and it seems to me with you saying that we really g- we've got to do a lot in terms of education and, and respectful and mindful education, and with that really doing some significant, and I don't mean in any derogatory way, handholding, walking alongside. I say it all the time, you know, walk the land to understand what the barriers are, and it's not just in distance, but it might be in shifting some mindset about, listen, this is technology that's mandated through federal funds, and so we've gotta find a way.
We can't make people understand it. We have to lead them along the way. Chris, before we go, 'cause you, you're not just state to state, but I was really pleased to see a piece that you wrote about women's health and, in particular, I'm kind of looking at the numbers that were put out, with respect to Mississippi, 'cause it's the one that you just released yesterday.
51.2% of counties have zero obstetric services.
Chris Nelson: Yes.
Michelle Rathman: Versus 32.6%, and this is not getting better. In Idaho, you can go anywhere on the map for the most part, and we can see that's another conversation for another day. But at the end of the day, you are talking about the fact that every state has got to invest in improving women's health, and, in the realm of technology, what are you seeing there to help advance that initiative?
Chris Nelson: Yeah. You know, again, we're getting back to that remote patient monitoring and things that we can do. You know, another thing that, besides the obstetrics, which is-- it's, honestly, it's, it's criminal that we have some of these states where women have to drive over an hour to see a, to see a doctor, you know.
And that, that's just so dangerous for the mother as well, you know, prior to and post-pregnancy. But, you know, let's, let's look at the menopause as well. You know, there's been a lot of advancements there, and women are at two times, you know, risk of stroke and heart attack during that period in their life.
And, you know, the interesting thing about women, men, we have crushing chest pain, right? When we have a heart attack. Women will actually feel like they have gas. I talked to someone who worked in a morgue for 20 years, and they said whenever a woman had a heart attack, they would open up their stomachs, they would find Tums because they didn't think they were having heart attacks and things like that.
And so this resurgent back to really focusing on women's health in America is great. And it, and, you know, it kind of started about eight years ago, and now it's getting kind of pushed down and pushed down. And so now that we can get this into rural communities, hopefully they can make a great impact with this obstetrics money, with diabetes, with heart care, you know, and really work on the things that-- those sentinel events in women's life where their risk for heart attack and stroke and everything just goes up. And we really wanna keep women a lot safer in our healthcare now.
Michelle Rathman: I'm so glad that you brought that up. I-- This is a very true story. I was working in Oklahoma, with a hospital, and the CFO, she, on her way into work, actually thought she was, you know, just having some bad indigestion, and she ended up having a heart attack and having to have open heart surgery. So, and this was many, many years ago.
I know this is a crystal ball question, but the reality is the investments will be made, and the infrastructure will be in place. I think the bigger thing that we're gonna have to track on this podcast is, yes, let's talk about the outcomes and let's talk about sustainability, because someone has to pay for this ongoing, and that is not what that money is for.
Chris Nelson: Right. That, that, that's correct. You know, and, and, you know, on sustainability, you know, this is one thing I have to say, you know, to those rural health facilities that, that are, are applying for these dollars. The vendors are gonna come out of the woodwork on this, guys. I mean, you know, you put a pot of money like that out there, the vendors are coming out of the woodwork, and people who think that they can make the jump into this.
You know, just make sure, number one, you have someone who can do something of this scale. 'Cause a state's a big area to do, and even a new health system's a big area to do, you know? You know, and also, you know, look at their track record. Are they able to handle stuff like this? And make sure that you're really picking something that can fill your needs, that you're not getting an emotional sales pitch out of it. You're actually looking at and sticking to those results that you actually need in your medical facility.
Michelle Rathman: Yeah, that's great advice, 'cause I, I'm, I don't even, I don't run any hospital d- dollars, but I'm getting pitched on it, and I say, "Transformation does not happen at the speed of light."
This is going to be a, a, a long-term investment, a long-term commitment from, from folks like you and those who are working diligently in the states, and we're gonna keep track of all of it.
I'm so glad that you were able to join us here today, Chris. It's been great to learn about your work 'cause I want people to know to, to read your stuff on LinkedIn. Tell people where they can find you.
Chris Nelson: You know, you can just find me on my-- under Chris Nelson on LinkedIn. I'm the guy in the cowboy hat in the picture. You'll be able to recognize me. And I post a couple of states a week and some other articles as well, you know, on rural health transformation. So, look me up. Would love to converse on the side there as well.
Michelle Rathman: Well, we'd like to have you back as we continue tracking this transformation. You're what, we'll add you to one of our Phone a Friends.
Chris Nelson: Thank you so much. I appreciate that.
Michelle Rathman: Wonderful. Hey, you guys, do not go away because as I promised you, this dot connecting conversation is not over because our next guest is gonna give us the skinny on what's happening at the federal policy level. She's someone we've had on before, so I'm gonna just tease that for you. Stay with us. We will be right back.
Michelle Rathman: Well, as promised, coming back from this break, I am so pleased to be joined by Carrie Cochran-McClain, Chief Policy Officer for the National Rural Health Association. Thank you for coming back to another, joining us for another conversation on "The Rural Impact." You are like a serious phone a friend, and I'm so grateful.
Carrie Cochran-McClain: Oh, well, Michelle, we are so thankful for everything you do to lift up issues around rural areas and rural healthcare, and always happy to be on.
Michelle Rathman: Well, I appreciate that, and we're gonna see you soon, at the national the annual conference in San Diego, where a time we can all get together and commiserate about all the things happening. We have to, you know, we have to be amongst our people.
So Carrie, you know, before our break, our, our guest, our, our, our listeners heard that I had a conversation with Maya Sandalo. I know you know the name from the Bipartisan Policy Center. And we talked about, and also with Chris Nelson, whose work focuses on health transformation for veterans and the Indian Health Services, and also expanding, y- the healthcare services for women in rural areas. And specifically, he talked a little bit, we touched a little bit about on heart health, for example.
And of course, we know that we've got a, a quite a state of affairs for women's health where it comes to maternal health. But for those conversations, we wanna find silver linings in the Rural Health Transformation Program.
We focused a lot on how technology will play a key role, with the emphasis being on how states are gonna be spending their portion of that $50 billion.
So for our conversation in the position you're in, I thought, you know, provide us with some of your insights around the progress with RHTP, because it is such a big pol- it was born out of policy, what you guys are tracking, and from there we'll kind of get into some of the timelines, and I've got some numbers I wanna cite so people, like, really get a visual on the calendar about the, the stuff, the, the shift that's about to happen.
Carrie Cochran-Mcclain: That is right. Yeah, I mean, everything with our-- the Rural Health Transformation Program, I call it RHTP, is-- has been fast and furious, right? Since the, since the, HR1 or the One Big Beautiful Bill passed, on July 4th, folks have just hit the ground running implementing this program.
So we saw, I mean, I think unprecedented timeframes, both on the federal government and state level in terms of developing a brand new program, developing 50 different state Rural Health Transformation plans, you know, making those applications through state government, through federal government, and getting all those war-- those dollars out by the end of the calendar year.
So where we are now is that, all of the states, I think, have officially revised and agreed upon kind of the revised amounts of their annual budget for this first year with CMS, and states are getting that money out the door. So that is happening in a range of different mechanisms depending on your state.
A lot of states are doing kind of the typical RFP process where they put a proposal out, and people have a very short timeframe to apply for whatever pool of funds are being, distributed at the time for the, you know, in that particular state. Other states are partnering with, community foundations to do that allocation of funding.
We've heard, consultant groups be in charge of that process. So it varies state to state, and it's really important that listeners kind of understand what's happening in their individual state. States are very focused on getting that money out right now because they have to have allocated and said-- meaning they have to have said, "This organization will be getting $100 million of the funding," just as an example, before their annual reporting begins, which happens on August like August first, I think, is when the
Michelle Rathman: Yeah. I, I read that. I mean, aside f- from the real, really rushed application process, all that was, can't go backwards. I tell people, you know, we can't drive home looking in our rear-view mirror. That's done. It's over. So we have to look ahead. And what I am reading is that by the end of October, this year, which could be a very spooky Halloween for people, the funding levels will be announced because it's based on the review of those applications and how much progress.
And I don't know about you, Carrie, but I'm a little struck that transformation is having to happen at the speed of light.
Carrie Cochran-McClain: It is. It is. You know, and I think there's kind of-- it's kind of a double-edged sword. I, you know, I appreciate that CMS is holding states accountable to what they said they were going to do. CMS is one of the facets of-- that is, I think making this sub-award or allocation process even more complex, is that CMS is reviewing every single distribution of funding that states are putting out.
So again, that's an opportunity for accountability to make sure that we're not having funds go to areas that aren't going to benefit rural America. However, that adds a, a huge amount of kind of process to the equation.
And then to your point, Michelle, this first year in particular is a tough one in terms of getting dollars out. Now, obviously, activity doesn't have to be ca-- accomplished by that timeframe. So states actually have a full year to kind of accomplish that sub-award activity. So if I'm giving you $5 million to work on a program, you have the following year after allocation of funding to do that actual work.
But CMS wants to see that states are making progress in getting the dollars out, and part of that is because of a statutory requirement that this funding, you know, when the time period is, associated with the funding is over, it's gone. It goes back to the treasury. So the program really has to have kind of that pressure.
That said, you know, this initial round of activities, we are seeing states really look at a lot of kind of how do we lift up or expand things that are already in the works, and some of the low-hanging fruit? 'Cause to your point, transformation is not an easy process, otherwise we would have already done it.
And so, you know, I think years, two, three, four, five will hopefully see more of that kind of true transformation as many of us think of it, getting more underway.
Michelle Rathman: Yes. And I am so, a bit dumbstruck, if you will, about, you know, the subjective nature of what transformation is.
So again, we're, we, we're talking today about technology, and one of the conversations that I'm having with many people, I've mentioned in our previous conversations, and I told you earlier, I just came back from Colorado.
You know, every state is doing their, their annual meetings, and it's a gathering of rural health stakeholders, CEOs, CFOs, you know, boards, all sorts of vendors who are, who are really kind of putting their, you know, putting their hat in the ring for receiving some of these dollars for, you know, with, for-- 'cause with technology you have to make advancement, advancements.
And rural hospitals are, and health clinics are no stranger to what it means to adapt to technology because of the investments that they've had to make in electronic health records and so forth. With all that said, to your point, at five years, the investments in the technology for transformation will be there, and the big question is: how does it actually transform health outcomes in rural communities, and how is it paid for, and so forth?
And so I, I kinda wanted to shift a little bit about you- you know, just taking a look at the coverage landscape, Carrie, because, you know, many of the RHT plans, they are technology-driven solutions. We know that they're looking at ways-- I read something yesterday about Texas using Robots for ultrasound and, and I mean, there's all sorts of things going around.
Didn't sound very hands-on to me, but, at the end of the day, we are looking for solutions. How will-- Do you have any sense of what policy levers or what's moving through the halls that you walk in that we have no idea in terms of how all this will be, you know, administered, paid for, for the patients who are now gonna be the recipients of the benefit of the technology?
You get my-- You get where I'm going? Let's connect some dots.
Carrie Cochran-McClain: Right, right. Well, so I think, you know, when you're thinking about maternal healthcare, there are a couple, aspects of what we need to work on in order to sustain access to maternal health services in rural areas. And, you know, part of that is facility payment related, and part of that is kind of workforce related.
And I think there's the, there's the most opportunity in the sense of being able to really expand the capacity of our healthcare providers related to maternal health through the investments in the RHTP. So what I mean by that is, y- you know, I think we definitely saw states, in propose activities that are looking at how do we use kind of, perinatal regional networks or rural-- telehealth maternal-- tele-maternal health networks, to be able to do remote monitoring, to be able to have women be able access, access to the specialty care that may not be available in their local communities, to help our rural providers really stay, to feel more kind of supported and connected as they're providing these services in rural communities.
So we've seen, I would say probably, um- Over half, maybe two-thirds of states talk about maternal care and the development of these regional networks to be able to make sure that we've got the appropriate levels of maternal care in our rural communities. And I really think that part of that is using technology, like I said, both in terms of telehealth from provider to provider, as well as telehealth remote patient monitoring technology, between patient and provider to be able to make sure that we can keep people healthy and in their local communities as long as, as possible.
Michelle Rathman: Mm. And implement that on a large scale, and of course, you know, no- remove all the roadblocks, 'cause what would be the point? How do you transform if we still have a, a new roadblocks at that? And so because I have to, let's talk a little bit about the, the big, big, big, you know, cloud hanging over all this.
Because as much as I wanna be enthusiastic about, you know, listen, if, if you and I could live to see the day where we are no longer referring to rural health as older, sicker, poor, I'm so...
Carrie Cochran-McClain: Wouldn't that be lovely?
Michelle Rathman: It, it, it, it, that's transformation. You know?
We're r- we have to make that shift, right? But let's talk about that, and then we're gonna just talk a little bit about the FY27 budget, and then a little bit about the Farm Bill.
But let's just talk about the cuts because
Carrie Cochran-McClain: Yeah.
Michelle Rathman: the CEOs, the leaders, the people I'm talking to at county, every level that I can think of, this is the one time where I'm seeing a lot of ears perk up because the realities are coming to fruition a- about what the, what is go- the implications for a massive amount of uninsured people in rural areas, and then knowing that their safety net hospitals are, some of them are on quicksand.
More than we, more than we want. So what can you tell us about what you all are keeping your eye on and what you're really advocating for and educating people on where this is concerned?
Carrie Cochran-McClain: Right. Well, you know, for better or worse, this issue, and I'm gonna use some of the maternal health conversation as an example. You know, the closure that we've seen of maternal health services and units within rural hospitals across the country has been something that's been talked about now for, oh gosh, at least a decade in, in popular media, in The New York Times, and in The Washington Post, and in USA Today, and platforms that we
Michelle Rathman: specials
Carrie Cochran-McClain: PBS specials. Like, yes, we, we know this is an issue.
You know, and, and I talked about the financing, I talked about the workforce. I mean, the truth of it is, i-i-- unfortunately, these services are seen, by, by hospital leaders, as optional services. They are services that, in theory, you could go to another upstream facility to be able to access.
And when those hospital leaders are having to make really tough choices about how to keep their doors open, this is a service that we are frequently seeing cut. And to your point, Michelle, as our provider community, as our hospitals and clinics are staring down the barrel of, both, I think, two big coverage pressures, in addition to what we already were living with, right?
Our-- We have our greater reliance on Medicare, Medicaid, and the marketplace coverage, given our populations, given employment, factors in rural communities. So we have already been very reliant on public payers, who tend, by the way, not to pay as well as commercial employer-based payers. And now what we're seeing with the expiration of the enhanced premium tax credits or the additional subsidies under the marketplaces.
That's already come and gone. That's in place. You know, I think that means that folks are either individuals living in rural communities are either going to be foregoing their insurance, and therefore delaying needed care, or they're gonna be showing up in the facilities, hospitals, and clinics, a- and, and being, uncompensated care or being able to pay part of their care and having to take bad debt for the rest of it and medical debt for the rest of it.
So that's the, the marketplace piece. And then we all know that these Medicaid policy changes and cuts coming down the pike are gonna be devastating. The Kaiser Family Foundation estimated $137 billion that rural areas will lose $137 billion over 10 years in federal payments, right?
And so, that translates not only to loss of coverage for the individuals in our rural communities, but reduced reimbursement for the providers who are taking care of them, and increased, again, uncompensated care. We're gonna take care of these people who live in our neighborhoods, who go to our church, who work in the grocery store with us, but we still need to be able to get paid for those.
Michelle Rathman: U-until you can't.
Carrie Cochran-McClain: Until you can't. Until you
Michelle Rathman: And you make those tough decisions
Carrie Cochran-McClain: And you make tough decisions like maternal healthcare no longer being something you can offer in your community. Exactly right.
Michelle Rathman: And I'm hearing, you know, and I-- if you are listening out there as a hospital, rural hospital CEO or a clinic CEO, we wanna hear from you, because I'm hearing from many that they're cutting services kind of preemptively because they know what's coming and, and, and, and with that, you know, just communicating why it is, you know, you don't, you don't, wait to put, life j-jackets on until you're, you know, sinking already.
I
Carrie Cochran-McClain: Right.
and
and
Michelle Rathman: advise it.
Carrie Cochran-Mcclain: right. And before-- You know, so right now we're trying to track those service line cuts. And then after those service line cuts come the full closure of facilities, which we do anticipate will be an, an issue that we see over the next several years, despite the best efforts of the RHTP.
Michelle Rathman: And call me crazy, but that is not rural health transformation. It's rural health transformation in a very different direction, and, and, and, we don't need to go there.
Carrie Cochran-McClain: Our NRHA's former, pre-, or I guess outgoing president, most recent past president, Kevin Bennett, I was on a-- I was talking to him, and he said it so well. It is like running a race and giving a 30-second or two-minute head start in that race, but having your leg amputated before you get started, right?
Like, how well are you gonna be able to run that race if you don't have the foundation to be able to do it? And that's, that's
Michelle Rathman: Many analogies. It's like, I mean, it's a great analogy. Oh my gosh. All right. So let's go on to another, really enlightening. Again, we take-- these are not light subjects. This one, what NRHA has helped me to do, and NRHA is not paying me to say this, is that,
Carrie Cochran-McClain: We don't have the money to do that,
Michelle Rathman: I like Chicken, like Chicken Little, you know, because I see the budgets and you all talk me down off a roof because, you know, the budget is, it's, as you've said, I mean, in my head many times before, it just gives us a sense of, you know, what the administration, what direction they wanna go, but then Congress steps in.
And what's different this time is that even congressionally allocated funding l- is not, earlier this year was not making it to places. So that kind of throws a wrench in it all. But with that said, let's talk a little bit about the budget and the realities, because you all got some big wins.
Carrie Cochran-McClain: Yeah, we did.
Michelle Rathman: time around.
Carrie Cochran-McClain: So yeah, let's start with the good news.
So, for FY26, the fiscal year is FY; those operate, just as a reminder to your listeners, from October to the end of September every year. So we started fiscal year '26 in October of twenty twenty-five. I always have to do some mental math to catch, catch up with myself on these when I'm talking fiscal years.
So we are in FY26, and we were so lucky that despite the president's budget, which proposed to cut core rural health programs out of the Federal Office of Rural Health Policy, among others, we were able to get those programs reinstated, and we actually had an increase in many of our core programs in the Federal Office of Rural Health Policy.
So Congress said, "Not only are we going to ensure that these programs continue, but we see the value and the importance of what they're doing for rural America and the need in rural America, so we're gonna actually give you more money." That was a really good year. I don't know if we'll have that year again. I will say we had
Michelle Rathman: Was it to soften the blow?
Carrie Cochran-McClain: I don't know. I mean, we had such an incredible turnout from our advocacy community about why we need programs like the State Offices of Rural Health or the Medicare Rural Hospital Flexibility, or Flex Program. So I do think that was part of it. I will say, Michelle, I feel like there was a little guilt.
I think people realized that HR1 is gonna be really hard on a lot of healthcare and a lot of individuals, and in rural America in particular. And so I think there was-- we all did our job in telling that story, and so there was an increased focus on rural. Unfortunately, for FY27, the president once again, you know, proposed to eliminate many of our core programs and those programs that help rural hospitals in particular.
So the budget, which you said, and it's a great reminder, and I'm glad that, folks, it is always really scary when you see this come out. But it is a good reminder that the president's budget is the beginning of the annual, discretionary budget process. So it is where the president says, "This is my vision for how I'd like to run the administration in the next year."
It is a starting point. It is a proposal. Congress may or may not listen to them, especially depending on how the party alignment goes. But this year, the president has proposed a total investment of three hundred and sixteen million for rural health programs in the Federal Office of Rural Health Policy. That is, a little over a hundred million less than what we have this year, so a quarter cut, more or less.
And in that, he is proposing, or the administration is proposing to eliminate, once again, the Flex program, which goes to critical access hospitals, EMS, rural health clinics, state offices of rural health, which are our core hubs at our state level for information sharing and technical assistance.
The Rural Hospital Stabilization Program, which is a newer program in the last couple of years that's really aimed to help rural hospitals, I would say kind of stabilizes their operations and looks to see how they can add services that benefit the community and help their bottom line long term, so that they aren't as vulnerable.
And then the last program is new in FY26 that the president's already proposing to eliminate. It's the Rural Hospital Provider Technical Assistance Program, and it is specifically focused on rural PPS hospitals, so non-critical access hospitals that have a low volume of services and therefore are more susceptible, in terms of their ability to recruit and retain providers.
low wage index. We can get into that if folks have
Michelle Rathman: Yeah. Well, I mean, we-- you and I have to have a completely different conversation
Carrie Cochran-McClain: whole other can of
Michelle Rathman: A whole other... But I, I am noting here that that program, if I'm looking at it right, is under the USDA Rural Development program,
Carrie Cochran-McClain: That's actually-- No, that's actually under the federal office. It's a brand-new program. It hasn't been released yet. And, it's fourteen million dollars, so it's a pretty
Michelle Rathman: Oh, right. Okay, I got that. And then within that, under USDA Rural Development programs, there's also the Broadband ReConnect Program at $350 million. And, and we ta- we, we have to really take into account, again, I'm just, before we kinda close out here, I just have to, again, connect a few dots here because if we are talking about a m- a major emphasis on technology being the, one of the triggers that will help transform rural health, we have to have broadband because you can't just stand there with foil on your head and put your finger in the air.
So, 350 million for that, and we know that BEAD program funds were, you know, cut la- we, we know. So we have to connect the dots. I mean, if you have to find the money in other places, but at the end of the day, we need that as well.
Okay, so real quick, before we go, my kind of my last question to you is just anything new on the farm bill? Because it's a can that continues to get kicked down the proverbial road and, you know, you all are advocating for it again. What do we need to know?
Carrie Cochran-McClain: Yeah. So for the Farm Bill, the good news is, is that we're seeing more activity, both in the House and Senate, looking like they might be able to, um- pass or at least get more conversation going around the Farm Bill. If you remember, Farm Bills are supposed to be renewed on average every five years, and the last renewal we've had was in 2018.
So we are way overdue. And as you mentioned, the Farm Bill has so much for rural healthcare. In addition to broadband, it's got support for rural hospitals, capital development, important nutrition programs, mental health programs, and the Farm and Ranch Stress Assistance Network. So we are very excited about the conversations that are happening.
There's actually supposed to be some activity in the House next week, the-- or I should say there, there should be by the time this airs, hopefully there was activity the week of the 27th, where we saw some markup. So, everyone should be kind of looking at the Farm Bill, and we have an advocacy campaign on our website if folks want to come to the website and send a note to their member of Congress about the importance of investing in that for rural America.
Michelle Rathman: Yes. Thank you. All right, so I'm going to just put the plug in here, and we're gonna make sure that we put links to all the resources that we think are really important, again, just to stay up to date and in the know to the best of your ability.
Carrie, there are so many other things that we could talk about, which means you have to come back because this is a, this is an ongoing conversation we have to have, and, you know, we are gonna be tracking things state to state, but it's always really, really important for me to have my finger on the pulse of what's big, happening at the bigger picture, and you are an incredible resource for that, so thank you.
Carrie Cochran-McClain: Yeah. Thank you.
Michelle Rathman: Well, alright, we have to say goodbye to Carrie, boo-hoo. But for the rest of you, please stay tuned because I'll be back for just a few closing thoughts. We'll be right back.
My thanks to Carrie Cochran-McClain, as you just heard from, Chief Policy Officer at the National Rural Health Association. Also, before our break, we heard from, of course, Maya Sandalow of the Bipartisan Policy Center, and Chris Nelson, who's doing an excellent job cataloging rural health transformation programs by program, state by state.
And we'll be sure to put links on our website, theruralimpact.com, to the policy papers and other really interesting things that you heard here. Okay, before we move on, I do want to share something kind of personal and professional with you. I am recording this closer on Monday, May 4th, and it's late. I'm out in the studio because I was gone all last week, and I had the privilege of working with two rural hospitals in the great state of Washington.
I've been there many times in, in the past. And I just want to say to you that if you are living in a rural area and you are relying on your rural hospital, community health center, or rural health clinic to be there, now would be a really good time to take an interest because while I am, truly looking forward to understanding what a one-time $50 billion investment in rural health transformation will look like in the end, at the same time, because my policy is always on I should say autopilot, I am also making sure that I keep an eye on the other policies that are making shifts happen in rural health.
And you know, this podcast is about making an impact in rural education, food policy, farm bill policy, and so forth. But because this is my passion as well, I am putting a lot of attention on here because I think I shared this before, someone I know, at a conference, just shared with me, all policy is health policy, and it could not be more accurate than the time that we're in.
So, my invitation to you, if I am so allowed, is to get yourself familiar with rural health policy in general and understand how it might just impact you, and then it might motivate you to be more involved. And I hope you don't think that's me on a soapbox. I'm just hoping that it, it's, you, something you've heard here today, compels you to follow through.
Okay. With that said, I also want to remind you that when you visit theruralimpact.com, when you hit that subscribe button, you will not miss a single one of our episodes coming into the multiple series that we've launched, because there are so many things that we are talking about and following, and you will not miss a single episode.
And when you're on the website, if I may also ask you to do, visit our merch store, pick yourself up We've got recyclable bags. They say Shop Rural, which I strongly encourage, whenever you can, as well as reusable water bottles. So, you're gonna do good for the environment and also help us continue to have these courageous dot-connecting conversations.
With that, you can listen wherever you like to subscribe. When you do listen to us outside of our website or on YouTube, be sure to rate us and leave a comment. We really love to hear from you. I want to thank Brea Corsaro and Sarah Garvin for all their support behind the scenes. And until the next time we are together, and it will be soon, I invite you with one last invitation to take the best care of yourself and to the best of your ability, all those around you.
We will see you again very soon on a brand-new episode of The Rural Impact.
