Episode 84. Views from The Field: Farm Bill 2026 with Dakkia Bradshaw, Blaire Bryant, and Bruno Sabatier
Hello, one and all, and welcome back to a brand-new episode of "The Rural Impact." I'm Michelle Rathman, and I mean it when I say I'm so grateful that you've joined us for another conversation that does work hard to connect the dots between policy and rural everything, as we say so often, rural quality of life.
Now, if you are new to the podcast, we are in the middle of several different series that we're producing as a result of really, like, tracking transformation and following the impacts of federal policy at the local, state, and county levels. And so today, if you're a returning listener, we are back to our series focused on the impact of policy to rural counties, and they are plentiful.
So, we have a jam-packed episode for you today. Several guests that are going to bring some really unique perspectives to the challenges and potential opportunities that they face, in the face of major shifts. Before we go on, I just wanna mention to you that one of our guests today comes to us from the National Association of Counties.
And back in July of 2025, so just about a year ago,, the date you're listening to this, of course, is in early June of 2026, so almost a year ago, there was a piece written on the NACo website that, again, the National Association of Counties, and the title of that document was "The Big Shift: An Analysis of the Local Cost of Federal Cuts."
Well, we're a year into this, and I think it's safe to say that not panic, but a reality is really setting in with regard to how much resources are no longer available. It's been a rollercoaster ride, to be sure. But I wanna read for you some of the key takeaways from a year ago, and then when you hear our guests talk today, you can kind of juxtapose that to what they're saying the reality is for them today, again, a year later.
So, one of the first takeaways is this: as counties lose forms of federal support and shoulder additional costs, they will need to weigh various trade-offs and options, including cut or scale back critical services, including public health, dare I say, nutrition, emergency response, and rural development. We have seen this play itself out in real time, multiple places in multiple ways over the past year.
Another takeaway is this: continue to deliver services at a new cost, and given the elimination of funding and statutory requirement to uphold certain services, this will require them to raise local taxes or fees to cover new costs. I'm going to put this into context with some of the work that I do with rural public hospitals.
So many of them rely on levy support. Many of them are really working to find ways to not have to increase their levies or maybe scale back their levies. But the reality is, without that levy support, it will be a real struggle to keep these public rural hospitals open, and that includes their EMS services for those who are operating those.
And many rural hospitals, I don't think this is a widely known fact, but many rural hospitals, if not most, who are operating their own EMS are doing so at a loss, but they are doing so because they know it is an extremely important public benefit to keep it going, even though they are making no money. So, in case you were thinking your local ambulance service is awash with cash, that would be false.
All right. Another kind of key takeaway is that they're going to have to delay or cancel infrastructure and resilience investments. I don't know about you, but everywhere I look in rural America, counties cannot afford to go back in time, also absorb long-term economic and social consequences of underfunded programs, and the list goes on and on and on.
So, I am not a rural county official. I've worked with many of them, but still, I can only walk alongside them. I've never been in their shoes. And so for this conversation today, I'm really pleased to have with us three experts who can and will, as you will hear from them, shed a whole lot of light on what's happening and what they are looking at through their, kind of their rear view mirror, and what they're anticipating they're going to be need to be doing, and the impact on the communities that they are working so hard to serve.
I will just say this. I am a super fan of anyone who goes into public service with the intent to really serve the people, and those who you hear from today, I think you'll hear it directly from them. They embody what it means to be a public servant. So with that, I want to share with you that we have Commissioner Dakkia Bradshaw from Telfair County, Georgia, and we have a really great conversation with Dakkia and her work around advocating for better health services, of course, environmental impacts, and she's also, if you look her up, we're gonna make sure we put links on our website.
If you look her up and see the kind of work that she did to really advocate for resources after that community was hit hard by a hurricane. We also hear from Blaire Bryant, and Blaire really eloquent in her words about protecting rural health access. She is the senior legislative director with the National Association of Counties, NACo for short.
And then after we take a quick break, and you hear about a really interesting, inspiring, an event that I've been looking so forward to sharing with you, you're gonna hear from Mr. Bruno Sabatier, I love saying that name, a District Supervisor in Lake County, California. And, Supervisor Sabatier has a lot to share with us.
Honestly, I could listen to him all day long. He's full of energy, insight, and, truly, you can see he has such a passion for the work that he does. So with that, you know, I'm going to invite you to sit back right now and tune out that background noise that will absolutely be there with you, for you, around you, after our time is done, and hear my conversation with three individuals who have a really good handle on what's happening with respect to the impact of federal policy shifts in counties across rural America.
I am ready. I hope you are too. So, let's just go.
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Michelle Rathman: Blaire Bryant, Senior Legislative Director focused on health, thank goodness for that, at the National Association of Counties, and Commissioner Dakkia Bradshaw, please note when I say from Telfair County, Georgia, which is not where you are right now, but that's where you're from and who you represent. Welcome to you both. We are really appreciative for your time here on the Rural Impact. This is gonna be a great conversation.
Dakkia Bradshaw: Thank you
Blaire Bryant: Thanks for having us
Michelle Rathman: All right. Well, Blaire where I did all the proper introduction to give everyone your great accolades and all the great work that you're doing, but I, we are kicking out kind of a two-part conversation with you because your focus provides, we're doing a lot of work around rural health transformation, and again, I'm grateful that you're focusing on that.
But your lens is kind of the wide lens, if you will, on matters of interest, including the topic on the table today, which is connecting some more dots, 'cause that we, that's what we do here. Like, looking at the 2026 Farm Bill and the provisions or asks related to strengthening rural health access, rural healthcare access, I should say.
And with that, later on, we're also gonna cover SNAP because I would imagine that's another conversation that's keeping a lot of folks in your shoes up at night. So, let's start with access to healthcare. In February of this year, you and your colleague, Owen Hart, who we really appreciate on this show, wrote a policy brief focused on enhancing funding for local rural health programs.
So first, let's have our listeners know some essential things to gain insight on why this topic is of the utmost concern for county leaders, not just limited to those who are in health.
Blaire Bryant: Yeah, absolutely. I think that the big picture here is in rural communities, we are dealing with challenges that affect a wide swath of individuals. We're talking about more than 46 million Americans who live in rural communities. That's over 13% of the US population, and they face higher rates of chronic disease and greater mortality from causes that are entirely preventable.
So that alone is alarming, but county leaders also have to confront some of the structural challenges that are happening beneath those statistics. So not only are we thinking about sicker people, who are very populous in small, sparse communities, but the structures in place to improve health access are also collapsing.
So rural communities are dealing with provider shortages and healthcare facility closures. We've seen several important and anchor hospitals in rural communities close over the past couple of years, and then of course, alongside that long distance, long travel distances to reach care, making locally available health services more critical than ever.
And then when those local services are threatened, there's often nothing to fall back on. So, when you take a hospital out of a rural community, it's not like someone can go to the next hospital or a clinic. Those are typically the mainstays in terms of healthcare provisions. And then the financial picture for rural hospitals is particularly dire, which is causing many rural hospitals to close.
In 2023, nearly half of all rural hospitals, which is about 48%, operated at a financial loss, according to the American Hospital Association. And this is what's driving many of those hospitals to shutter their doors, in addition to some of the economic pressures that are being felt across many different fields.
In addition to that, emergency services are telling the same story. Rural counties are more likely than urban counties to have what's called ambulance deserts, areas where ambulance stations are more than 25 minutes away, and four out of five counties have at least one of these ambulance deserts.
And as a result, rural residents may wait up to 30 minutes, half an hour for emergency services to arrive, which is critical time that could save someone's life. And so, that wait time is very critical, and we're seeing them rise because of the reduction in services, particularly EMS services. And then there's Medicaid.
Counties manage Medicaid services across rural, urban, and suburban areas, and Medicaid covers about 18% of non-elderly adults and 41% of children in rural regions. Any cuts to the Medicaid program or reductions in services by the state it doesn't just affect the individual as a patient. They directly threaten the financial viability of providers and facilities that rural counties truly depend on.
So, these are some of the things why it's important to address rural healthcare broadly.
Michelle Rathman: Just a few things. If you're not watching us on YouTube, you know that I'm about to snap a disc because my neck is nodding so, you know, wildly because everything that you're saying or the things that we're talking about here, and then, you know, just, and Dakkia, I'm gonna bring you in here in a, for a moment because I think what's really important is all the things that you talked about are so directly related to the delivery of healthcare, and then there's these other implications, okay?
The dominoes that fall, because when you do take a look at the impacts to rural counties, you know, because you want to attract local businesses. You wanna attract businesses and industry. Who wants to go there if there's no healthcare? How do you attract? And so, there's layers and layers and layers of that.
Before we move on, I just wanna talk for a moment, you know, just before we started recording today, I mentioned to you, and our audience knows this, I just returned from an entire week at the National Rural Health Association Annual Meeting, and I happen to sit on the policy congress. And all the talk, a lot of talk, CMS was there talking about this, so many sessions focused on the Rural Health Transformation Fund, and I won't regurgitate what people already know.
It is the $50 billion fund that was put together to transform rural health. We know that there has been a considerable amount of maybe under-information, misinformation about what it is and what it's for. But as you and I were talking, this is not going to fill those gaps. This is not gonna put an ambulance in a bay.
This is not gonna provide insurance or payments for providers 'cause there's all sorts of provisions for that that we'll put; we make sure we put on our website. But we do know this: every state has received at least its funding notice. Many states, not all of the states, have selected their sub-awardees. Some things are beginning to be implemented and so forth. What are you hearing, and I think this might be the million-dollar or $50 billion question, what are you hearing as to how, you know, NACo is advocating to see some of these funds invested into truly making an impact where it can be seen at the county level?
This is a conversation we have yet to have, and I'm wondering if you could shed some light on that.
Blaire Bryant: Yeah, absolutely. Counties, we see ourselves as intergovernmental partners, and so we see ourselves as key partners with states and the federal government in investing and stewarding these funds in the way that they should in order to create meaningful change at the local level. However, although we see ourselves as those critical partners, the state has to recognize counties, and county facilities as a partner as well, in order for that meaningful change to take place and for some of the initiatives that were outlined in the various state applications to be realized.
What we know for sure is that, as you said, there was an average of about 200 million of funding distributed to each state. We were happy to see this funding kind of released in a equitable and broad scale way, and hoping that states will come to recognize counties as key sub-allocates and partners in spending these funds.
States are moving quickly right now. Many have, as you mentioned, released their RFPs to identify sub-recipients, and they face a deadline to obligate the first year of those funds by October of this year. They also begin their progress reporting in August, which will inform next year's funding decisions.
And they're now updating their budgets and evaluating which of the initiatives that they outlined in their applications they want to pursue. Counties are playing a role, but mostly as partners rather than direct recipients. So, in the places where counties are being recognized as partners, they're not necessarily being funded as partners.
And so we think it's important that counties have a voice in this process, but also important that counties be recognized as a financial partner in the sub-allocation of these funds as well.
Michelle Rathman: Let's hope so, because infrastructure, you know, so much of this is infrastructure. Oh my gosh. Okay, so the hot potato to you, Commissioner Dakkia Bradshaw. Let's talk a little bit about this, but before we go on, I just would love for folks to understand, because your perspective is invaluable, and I've been studying you. I've been reading about you, your perseverance, and the things that you're advocating for, but you are as on the ground as it gets. So, let's... Tell us what we need to understand about Telfair County, Georgia, a place I've never been, but I'm curious.
Dakkia Bradshaw: So really, Telfair County is very rural. It's as rural as it can get. As you stated, I have been on the ground. There have been a... even from the Hurricane Helene thing, you know, it's been boots on the ground. So now, right now, we're facing broadband issues that, initiatives that I've been working on with NACo through the Gates Foundation, where they provided us $50,000, to work towards an initiative.
So, it's been somewhat of a struggle. And especially when you live in rural areas, you get, you tend to get a, a bit of pushback. But Telfair County and many rural communities, it's a lot of hardworking individuals in those communities, and we do have strong communities, but we often have less resources than some of the other communities in our areas because every one size does not fit all. We know that when we come together to support one another, we can figure things out, but we also face real challenges when it becomes, you know, when it comes to things like healthcare, transportation, infrastructure, and technology.
One of the things that Blair mentioned was the ambulances. We do have an ambulance service in our county, but it's still based off the timing because a lot of times you, we have over 400 miles of dirt roads. So, if you have an incident in one area and you have an ambulance trying to get there, it may be like a 20 to 25-minute, you know, travel time to get to the other end of the county. So, we face a lot of challenges, but we're working hard to try to address those challenges.
Michelle Rathman: Yeah, and I mean, I've been to Rural Georgia, I've worked with Rural Georgia, and, you know, at some point, Rural Georgia was kind of like the epicenter of hospital closures. That was not lost on me, and that wasn't too long ago. And, you know, so we're thinking about how this, you know, how this makes it the resources that you need because you can't just be thought partners, you know, the things that you all do, and I know county government funding is shrinking.
It's not growing in many, many places. You know, Blaire, you can attest to this. There's a lot of caps on what counties can do for property tax and so forth, so where does it come from? And so, we know that during, I read that during the first budget period, now Georgia's program, just for reference, is the Rural Enhancement and Transformation of Health, or they call it Great Health Budget, came in at, I'll just say the number. Ican't even imagine what this pile of cash looks like, $218,862,169.63 to be clear.
And there's an emphasis on leveraging technology for healthcare innovation. So, you mentioned that you've got to focus on, you know, making sure that broadband, and I always go on to connect the dots because without the infrastructure and the technology, the deliverable part of this is we might as well be like using orange juice cans and string. After all, it hasn't advanced us any further.
So from your perspective, from someone who is a strong advocate for expanding these kinds of things, broadband access, sustainability, where that is concerned, cost, affordability is a part of this, what are I mean, if you had your dithers about you, what would you like for people to know how that kind of funding, because it's not just about connecting people, you know, so they can go on the internet.
This is an, this will be an integral part of healthcare delivery, including in the clinic setting, where if you have a lot of remote care locations, that's also going to be a challenge. What would you hope that folks would see, those in the state, and some advice for other commissioners about what we should be asking for to make sure these resources make it to the places where they need to be?
Dakkia Bradshaw: So, I really want people to understand that broadband, it is no luxury. It's no longer a luxury. It's essential for infrastructure, especially in the rural communities. Connectivity can literally impact healthcare concerns, and we're a living testament of that because we don't have a hospital. So, if we're talking about telehealth, remote patient monitoring, electronic medical records, or even AI-driven healthcare tools, none of those work effectively if you don't have efficient internet service. And you can't build modern healthcare facilities or systems while those parts of rural Georgia are still struggling with weak services or limited access. And I think sometimes, people hear broadband, and they immediately think, about the convenience or the entertainment.
Michelle Rathman: Right
Dakkia Bradshaw: But it's much deeper than that.
So, it's about whether a senior citizen can attend a doctor's appointment from home instead of having to drive long distances. I know in some cases, individuals, they have to go to, drive to the next city over, the next two or three cities over, which is at least 50 miles. So that's gonna make a huge difference. It's all about helping rural hospitals and clinics. We were just in a discussion a few minutes ago, about possibilities of how we could obtain another hospital, you know, get a hospital to come to our area because it's a dire need. It's life or death, and you can save someone's life just by giving them access to healthcare.
But honestly, like with rural leaders, we need to have a seat at the table. That's the only way that when decisions are being made for individuals to understand things, us having a seat at the table because we are actually boots on the ground. We know where the gaps are. We know what solutions, that will truly help our residents.
Michelle Rathman: They are your constituents, and they are calling you,
you know? And I, and I think, and I'll put this out there, and you can agree, or disagree. I just think that you carry such a heavy, like the weight of the world. And if your constituents understood that this is not a decision that you can make.
I mean, the depletion of resources, you know, for healthcare in your community, is a direct impact. And let's talk about other resources. I wanna move over to SNAP. I'm, you know, we, again, the rooms I'm having conversations, we are all talking about nutrition assistance. Hospitals are grappling with changing guidelines and so forth.
But at the end of the day, I don't see our rural grocery desert situation magically disappearing. And so, we're having a lot of conversation about eating healthier, and I will skip over all the nonsense piece of it. Let's just talk about the practicality of it. We know that the House version of the Farm Bill and SNAP, where that's concerned, we also know H.R.1 provisions. Again, won't regurgitate what our listeners who are routinely listening already know. The two ends are not gonna meet, and county governments are gonna be, I'm projecting based on what I'm reading, in a world of hurt, for a technical term.
So, I wonder if you both could opine a little bit on that, and kind of maybe Blaire, from a big picture strategy of what you all are focused on. And then Commissioner Bradshaw, what are you guys... I mean, I'm asking people, how are you planning for what we now know, but we don't really understand the breadth of the impact?
Blaire Bryant: I'd say from a NACo perspective, with regards to the Farm Bill, with any other piece of legislation, there are some wins and then some things that concern us with regards to county government. So, we were happy to see many of the provisions that were included in the rural economic and community development space.
And so, things like affordable broadband that the Commissioner just talked about, we saw provisions in there that would strengthen that, strengthening access to rural healthcare, so funding for rural health centers, under the Distance Learning and Telemedicine and Community Facilities Program, that will go a long way.
Supporting EMS and then making rural energy more accessible, as well as expanding childcare programs. All of those things are beneficial to rural communities, but it was more so the things we did not see in the Farm Bill that are concerning to us, as we move forward with regards to advocacy. So, the Supplemental Nutrition Assistance Program, as you mentioned, is going to be a big deal in combination with some of the H.R.1 changes to Medicaid as well.
We did not see the administrative cost shift or what we consider to be an administrative cost shift to counties addressed in the bill. So, there's no provisions that would delay or modify H.R.1 changes that would reduce the federal share of SNAP, and administrative costs for localities. And so that was something that was a huge importance to us, particularly in states that are county administered for the SNAP program.
There's about eight or nine states that would really feel this pain because they are county administered. So, we hope to see that in the Senate version. And then, new flexibilities around work requirements for able-bodied adults without dependents. We saw some very intense restrictions on work requirements included in H.R.1 that we would hope to be rectified through the Farm Bill, and it was not.
But that is a priority for us as we move forward, in the Senate version as well. Our goal is to mitigate any loss of coverage under SNAP as well as Medicaid for these programs,, which would not only be a loss to counties in terms of their ability to serve residents in terms of healthcare and access to food and nutrition services, but it would also place a tremendous burden, administrative work burden on counties to implement some of the provisions regarding SNAP and Medicaid broadly.
But specifically, when we're talking about rural counties that are facing workforce challenges, there's nothing that would create a sense of relief for rural counties that need help in the administrative workforce to run these programs. And so that's what we're looking to see as the bill moves to the next chamber.
Michelle Rathman: And, Commissioner Bradshaw, as, as all this is happening in rooms that you're not in, that I'm not in, and thankfully Blaire you're in many of those rooms, what are some of the things that,, you know, in your, you know, we-- I tell people you can't look in the rear view mirror and expect to get very far, so what are some of the things that you and your, your colleagues at that level are talking about where mitigation, you know, is, is more of a local plan than in, in kind of an immediate provisions?
Are you, are you talking, having these conversations about what to do next, knowing what's coming at you?
Dakkia Bradshaw: Well, you'd be surprised. Our board has not had those conversations, so we have to be proactive to sit at the table and start having these conversations because I know a particular family, and she has to go, even with the SNAP. We lost one of our major, which is a Harvey’s, a grocery store.
So, the grocery store that's there, she can't get the proper foods that she normally gets, that she would normally get from the other grocery store.
So, she has to go to different counties to get those. So, we just wanna make sure that we ensure that we're providing these resources for our constituents because we have to take care of home first. We have to take care of our constituents that live in our county and ensure that they have the proper resources. That is again, one thing that we need to sit at the table and we need to sit down and discuss where do we go from here. Because we don't wanna be in a situation when it happens, or if it happens, we're blindsided, and then we're stuck with no kind of avenue which way to go. So I think we, we definitely need to sit at the table and have this discussion.
Michelle Rathman: Yeah, it's an uncomfortable one to have, and it's one, you know, again, our listeners hear me talk about this. I say this is the year of building your bench, if ever, and that we have to do it really fast because it's not just food. I mean, if we are talking about a healthy rural America, we are also talking about all of those non-medical unmet needs.
So, I'm sure both of you have stories upon stories around shelter, housing, safe housing, clean water, all of the transportation, mobility. Commissioner Bradshaw, you just talked about how far people have to go just for that which is required to survive, let alone thrive.
And so with that, I mean, I want to, you know, a lot of policies can, I say, they can lift us up or let us down, and it's difficult for me to find some silver linings these days. I do know how hard, and I'm not in your shoes, how hard you are both working to bring light, bear light, and bring people with you to, to share what you think is the most prudent advocacy pursuits at this time.
And so, I always want to close by asking for each of you some nuggets of wisdom, because we have a lot of broad listeners out here. Everyone lives in a county or a town, or a city where these issues are concerned. Just basic access, not just to survive, but to thrive. If we're gonna innovate, what does that look like?
What do we need our listeners to be advocating for, and not just going, "Yeah, good idea," but something that they can tangibly do to get their skin in the game, and that doesn't mean showing up at a county commissioner's meeting complaining about what they don't have. I had to throw that in there.
Blaire Bryant: I'm happy to start. I think that you were mentioning a phrase that I really love throughout the podcast, and it's connecting the dots. I think when we think about health in general, but specifically rural health, we think about it in a vacuum, and that shouldn't be the case. We wanna connect the dots between rural health and the broader system in which rural communities exist.
So how do we connect better rural health with rural transportation, with rural economies, with workforce issues broadly, not just in the health space, with telecommunications and technology? So, we talked a lot about broadband access, and that being kind of the foundation for improving healthcare delivery systems.
I think when you connect the dots and connect rural health to all of these different structures in the rural setting, you make this more real and tangible, whether you're in a Federal Office or you're in your commissioner's office. When you can paint the broader picture of how this connects to all of the different things that rural communities may be facing and worried about, then I think your impact will be greater, and I think the story will be more robust, and it'll be more resonant to the listener.
Michelle Rathman: And you know, I was just thinking about this the other day. I think the pursuit is always so it's we have to profit, we have to profit, we have to profit. And we, instead of we have to help people prosper, we have to help people prosper, we have help people prosper.
Commissioner Bradshaw, I'm in a different lens. I mean, your audience is a different audience than what Blaire's audience is. And so what is the message for those residents who live in rural, who may have differences personally, but collectively can all agree that these things that we're talking about are not an option- they shouldn't be an option for some and a privilege fofor others.
So what, what are some of your advocacy nuggets that you can share with us? 'Cause you do a lot of advocacy work. I've watched.
Dakkia Bradshaw: I would say, just to never underestimate your voice, especially if you come from a rural or smaller area. Sometimes, people feel like just because they come from the small areas, they're not heard. But exactly what we have to do, we have to have people to speak up. So, advocacy is really about relationships and consistency, building those relationships, being in those rooms. I always tell people, "If you're not at the table, you're on the table."
So, you have to make sure that you're in those rooms, building those relationships. And I also encourage people to advocate not just at the local level, but at every level, state and federal. Bend the ear to anyone that will listen, so that you can influence policy or try to get some funding or some type of opportunity. But when you get that opportunity, be informed, be genuine, and be persistent. At the end of the day, nobody can tell you about your county story better than you, that's sitting at that table and someone that lives it every day.
Michelle Rathman: Yeah, and I would imagine that you bring a lot of your constituents' stories with you, and those land. I've seen them land. I've seen light bulbs go off, and, you know, we have. I have; I have this process in my head. We think certain things, we know certain things, but we don't do certain things until we feel them. And I think that the stories that you can bring with the work that you did after the hurricane and broadband and so forth, put a real human face to these, you know, very systemic challenges that we all unfortunately still have to talk about. But maybe there'll be a day when we come back again, and I hope that you do, where you can say, "Michelle, oh my gosh, these were wins."
I wanna hear wins too. Oh, my, I'm so appreciative of you both. Although we do have to say goodbye to Blaire and Commissioner Dakkia Bradshaw, I want all of you to stay with us 'cause this dot-connecting conversation, that's what we do here, is not over. We will be right back after this quick break.
Interview with Bruno Sabatier
Michelle Rathman: As promised, we are back, and we are now rounding out this very important dot-connecting conversation. I am happy to be joined by Mr. Bruno Sabatier, a District Supervisor in Lake County, California, who also happened to serve as NACo's Health Policy Steering Committee Chair, I guess, at the organization's February 26 Legislative Conference.
I wish I was a fly on the wall for that. Bruno, we are so glad to have you with us. Welcome to The Rural Impact.
Bruno Sabatier: Michelle, thank you for the invite. Appreciate it
Michelle Rathman: Well, you know, as you know, we're, again, we are a second part of this conversation, and we heard from a few people you know, I suspect, and that is a fellow county official, Commissioner Dakkia Bradshaw. And we also heard and she's from Telfair County, Georgia. And we also heard from Blaire Bryant, whom you know is the Senior Legislative Director with NACo. And each of them kind of laid out the priorities around access to healthcare, something certainly on our mind, and so many other people who are living and serving rural Americans, and also nutrition services.
So, I'd like to have you share some of your priorities in those areas, but first, I really want our listeners to know where you are situated. California's a huge state. I was just in San Diego. Tell us about where you're from and who you serve.
Bruno Sabatier: So, I live in Lake County, California, where I serve District 2, which happens to be the most urbanized area of a very rural community. So, there's 15,000 people that live in the city of Clear Lake. That's the majority of my district is that city. Lake County finds itself a little bit north between Sacramento and San Francisco.
We are surrounded by mountains. Our natural beauty is phenomenal, second to none. It is just an amazing place to visit. It is a jewel in Northern California that is hidden, between major highways, again, between two metropolitan areas, which is great 'cause that means we have a lot of access to, two hours away to the Bay Area, two hours away to the Sacramento area.
But where we are, the isolation is also a burden, and part of that burden is access to healthcare and our overall health metrics. That is why I take interest in being part of the Health Steering Committee over at NACo, because I wanna change that in my community. I apologize that my dog has joined our podcast, but
Michelle Rathman: love dogs. We don't even worry about it. You know, I, you know, think it's interesting because again, where you're surrounded, I love your area. I don't know, is Graeagle close to where you are?
Bruno Sabatier: I'm not sure. There's no gray eagle in Lake County.
Michelle Rathman: But it just, it's a beautiful area, and I think that folks can sometimes, you know, kind of gloss over that you are also facing so many of the challenges that our colleagues in the rural South are facing, in the Midwest are facing.
So let's talk about priorities where healthcare access is concerned because, you know, we know, and we've been talking a lot about One Big Beautiful Bill, also known as H.R.1, and some of the major, major, major financial cuts that come as a result of, of course, the RHTP, Rural Health Transformation Program.
I don't have to repeat what folks or this listeners of this podcast already know. But talk to me about some of the concerns and the challenges with access to healthcare for your population.
Bruno Sabatier: So, I'm gonna talk about two specific things that have really blossomed, in not a good way, but blossomed since COVID.
Since COVID, the health the mental health of our community have taken a huge hit. During COVID, we had about a 40% increase in calls for substance use disorder, for example.
Michelle Rathman: Wow.
Bruno Sabatier: This has been a huge, it’ss been a huge impact on our community, on our services.
How can we help these folks? Where can we get them the help? The number of beds that are available is very limited. The amount of folks that provide the services is limited. There's a workforce issue when it comes to behavioral health, where we're not finding all the folks we need to fill those positions with.
And so, our community has been looking for access to those services, and it's been difficult to connect them in an appropriate way, in a timely way. And so that's one thing that has been huge and is a priority for all of us. And as we're seeing the impacts, whether it's H.R.1, whether it's the economy and the state's specific budget and how that's gonna impact us, we're not feeling the support that we should be receiving in order to really provide a soft landing for some of these folks to be able to come back from where they have found themselves.
And so that is one huge priority for us here in Lake County, for me here in Lake County. The other one is food access. We have seen since COVID, our lines at our food banks, at our food delivery, areas just grow exponentially, and that was before we really saw the groceries, the cost of groceries really going up and skyrocketing.
And so already that's that burden on the folks, finances, being able to afford rent, being able to afford food, being able to afford medicine, and having to make those choices. They were starting to line up in our food bank deliveries, and those lines were huge, and they still are. And now, with all of the other burdens that have happened in between then, today, we are worse off than ever.
And what we're seeing is that we are going to have a huge hit from H.R.1 when it comes to the SNAP program, which in California we call that CalFresh, where now that burden of some of the costs will be passed on to the counties, and we can't afford to continuously pay that amount in order to make sure people have access to food.
And access to food is such a foundational part of health. If you don't have access to food, whatever else you're trying to do in your life, it's probably gonna be that much more difficult for you to do, whether that's if you have cancer or not, whether you have diabetes or not. That access to food is such a critical foundational stage for any human being, whether you live in Lake County or whether you live in Georgia, wherever you are.
And so those, those are two of our huge concerns when SNAP was canceled for about a month, from the federal government, because of the shutdown. We started providing a general fund to help support that. We're not flowing in huge amount of cash where we have general funds to be able to offer that, and I doubt most rural counties have that eligibility to provide general funds.
And so already we've seen a depletion of our general fund to support that, and as we continue on the every six months there's some new layer that's peeled back of H.R.1., we're gonna have to figure out how do we not lose people to fall through the cracks because these cracks are getting to become massive canyons, massive valleys, rather than a very tiny crack for people to fall through where hopefully we can catch the few.
This is gonna be a tsunami of change at the very bottom foundational level.
Michelle Rathman: I think it is imperative for people to hear your voice because you are not sitting out in Washington. You are literally serving people where they are, and there's no safety net big enough to catch those who are gonna fall through. And I'm gonna note here because as of this day, we're recording it on May 28th, 2026, that earlier this month, of course, I'm gonna say it,, the administration announced that they were withholding 1.3 billion, with a B, in Medicaid payments to California, citing the favorite catchphrase right now, waste, fraud, and abuse, and the impact on those, for example, who need in-home supportive services, or IHSS as it's called to the counties and residents.
So, you talk about kinda double whammy, triple whammy. I wonder if, if this is something that is on your radar screen as well, because it's, you, have a population that I'm definitely sure is served by these programs as well.
Bruno Sabatier: 100%. In fact, Lake County has a huge IHSS caseload. For such a small rural county, our caseload is enormous. We have a lot of elderly people. We have a lot of frail people. Therefore, those services is what keeps people out of institutions, which is a much lower cost in providing that service than it is to pay for the institutional services.
I believe it's 1.2 billion that is being withheld right now from IHSS, with the 1.3 in reimbursement. When it comes to reimbursement, there's always a gap between when services are provided, bills are submitted for reimbursement, so we're used to kind of shuffling the deck a little bit in order to survive between services provided and reimbursement coming in.
I sure hope it doesn't last a whole lot longer than just one month. I know that California is trying to change the behavior of the federal government. And I mean, I guess philosophically if something is bad, if something is wrong, we should absolutely be fixing it, and we should absolutely be going after those things.
But to do a blanket going after everybody, not everybody is guilty of doing something wrong, and especially the people who are receiving the services are not guilty of doing anything wrong. They just happen to be a bystander of circumstance. I don't know anybody who chooses to be poor. I don't know anybody who chooses to have zero resources.
There could be some mental issues. There could be some generational issues. There can be some.
Michelle Rathman: It's systemic. I mean, we have systemic.
Bruno Sabatier: So many reasons to be at the bottom, unfortunately. But to take it away because we're finding things that are improperly used, go after those people. I will help you go after those people.
We should be going... 'Cause that leads to mistrust, not just of federal programs, it also leads to mistrust of state programs. It goes on to mistrust of local programs. Those things aren't good for anybody who's involved in public service. So, we want to go after those things and clean it up 'cause our services should be on the up and up and doing the best that we can.
It doesn't mean we're perfect, but we should be; we should have at least a B+ rating or higher, and not somebody who's taking advantage of the system. And so, I don't disagree with the going after the fraud and the abuse and the waste, 100% in full support, but you can't make a blanket statement to an entire state of people when there are thousands and thousands, there are 2,000 recipients of IHSS in Lake County.
Michelle Rathman: Mm-hmm.
Bruno Sabatier: Those people didn't ask for that.
Michelle Rathman: And, you know, some might say, I mean, from a policy perspective, that there might be fundamental differences in the way people think about who should and who shouldn't receive. But at the end of the day, those who are the most need are gonna suffer the greatest. And I wanna circle back to SNAP and shifts to administrative financial burdens, work requirements, budget cuts.
One of the conversations that I've been having with other county officials is the fact that some of the systems are just not built yet, to administer these work requirement reportings and so forth. Can you give us a little bit of a landscape of where you're at and what you're bracing for, what conversations you're having about being prepared for individuals? 'Cause you said, you know, kind of the tsunami, but January 27 is gonna be like a, there's some really big milestones coming up, and not in a good way. How are you all preparing to, I guess, shore up your capacity? I don't know if you build more capacity, because that takes people, you have to hire people, and so forth.
What's it look like where you are?
Bruno Sabatier: So right now, about 25% of our population in Lake County are served by SNAP CalFresh. And we already have an, an idea or a percentage of what we anticipate will be kicked off of the rolls.
So already we're probably gonna lose 'cause the state of California allowed this. This will no longer be allowable for those that have unsatisfactory immigration status.
So that's about 525 people out of the folks that are receiving CalFresh, and then another potential 1,100 able-bodied individuals who may or may not meet the requirements.
Maybe they didn't put in the right paperwork in time. I mean, there's a bureaucratic process for folks who struggle with bureaucratic process, right? We're adding obstacles in places that shouldn't be. So, we're already doing some of these checks on an annual basis. Now they want us to duplicate that and do it every six months.
So right now, our eligibility workers are, they have about 700 cases per eligibility worker. That's a pretty large caseload to hold onto. But when you stretch that out over the whole year, then that's a possibility. Well, now we're seeing it as in you're doubling the effort, therefore, that's now 1,400 cases per caseworker, 'cause now you gotta do two cases per year to review these things.
We don't have the bodies in our social work, in our social services department, to be able to cover that, and the added cost that will come from that; we don't have a reserve to be able to supply that. We already have 20% vacancy in that department because it is difficult to fill those seats. But now we're adding more workload on top of those who aren't there, with no extra money in our pockets to be able to make it happen.
So we have obviously been advocating at the federal level that this is not the way that we wanna go, that we need help. We're about to kick people out who well, we're not gonna kick them out, but we're gonna lose people from a program that they truly actually need because they're gonna miss a filing deadline.
They're gonna... all kinds of possibilities, which you are absolutely supposed to get this service, but because of these technicalities, you will not, and those are our community members. Those are the people that we are going to see have the impact literally before our eyes, just happening in real time.
And so we've been advocating at the federal level, we've been advocating at the state level, and every state is probably gonna handle this in a very different way. And I'm sure that every state has a different economy as far as how they're doing. Are they seeing greater revenues, less expenditures, more expenditures, less revenues?
Everybody's in a different status. We're, we're not seeing the support coming from our state, so we're doing a lot of advocacy in order to make sure that we are gonna see the least of the impact. I don't think there's a way to not have an impact from this.
Michelle Rathman: Yeah, you're right. And I will say, I applaud you for knowing your numbers because I do talk to other county officials who are not having that conversation yet, you know, Bruno, to understand the amount of people who will be impacted, children, elderly, veterans, other, you know, more marginalized populations.
I really do not like to say vulnerable because we put them there, so marginalized. And, one other, you know, kind of dot to connect is what I also understand is that this is a domino effect because we're also talking about local grocery stores that are gonna be losing revenue as a result, and so forth.
I mean, the layers and layers and layers. Oh my gosh.
Bruno Sabatier: Yeah, I, I appreciate that you mentioned that, 'cause to me there is a domino effect, right?
Number one, we're a rural community. We struggle to create new jobs. Where are these folks supposed to get jobs? So you're able-bodied, but there's no job available, so how... I mean, yes, they can volunteer and so on and so forth.
My goal is I want people to get off of these programs because they've graduated out of the programs, not because they were dropped out of the programs. To me, these programs should be stepping stones to the next level of financial independence, not let's just pull that stepping stone away from you so we can watch you fall.
But then there is the, as you said, the economic impact as well. We're looking at potentially about $3 million economic impact to our community from the loss of the amount of SNAP benefit, CalFresh benefits that would be coming in. And that has nothing to do with Medicaid, which for us is Medi-Cal.
That has nothing to do with the IHSS situation. That's just the SNAP program.
Michelle Rathman: That's a big number. And, you know, I look around, like philanthropy is not stepping in. I mean, we don't have a plan B in so many areas. All right, I wanna switch to another subject because, you know, all these, we classify them as non-medical needs, but they are unmet nonetheless, and we talk about the fact, you said it so eloquently, food is medicine, and so too is housing. And you are, you do not let paint dry, sir, 'cause I've checked out your background here, and you have really led conversations. One thing I'm looking at here is working together toward permanent housing. Can you talk about that component in your community? Because again, you are like, you know, you're slaying it.
You got healthcare, you got nutrition, and housing is another... You can't have one without the other and expect things to go well. So, talk about your efforts where that is concerned.
Bruno Sabatier: Yeah, and I think it's a national issue. California, unfortunately, a very much larger issue, and Lake County is not getting away from the issue either. those that are unsheltered in our community is still a large number. I think our last PIT count, which is the point-in-time count that we do for the Housing and Urban Development Department of the federal government, I think it was around 311 was our last one.
I could be off by some number, but it was approximately 300 to 350, let's just say that.
And, 'cause the final report is supposed to come out real soon. And so there's, there needs to be work. We can't ignore those 300, 350, and that's just the ones we count. We know that that number is always much lower than it, what it really is.
There's folks that are couch surfing, folks that we can't find. And so, there, there absolutely needs to be work, and we've been doing some really good work in the last few years. We've developed and opened up some new shelters. I've worked with a, a really amazing woman, Angelique Cole, here in Lake County, who has opened up a lot of transitional housing and is being very successful at it.
And actually that's really due to the, what we call here is CalAIM, and that is an innovative way to implement Medicaid, and that requires a Medicaid 1115 waiver, which is a really important waiver to allow us to do these types of programs. And so we, I think we've done some really good work, built some really good partnerships.
Right now, what we're working on is, we're working with the State of California. We just met with Housing Community Development, HCD. They have a program called Homekey Plus, which allows us to request grant funding for veteran housing. And so, we just got a, I guess not an approval, but a commitment that there is going to be a yes to a piece of property that we feel is a perfect area to build this.
HCD is on board with providing us some grant funding. They just need our application to be submitted. And we, we are very close to not only purchasing the property, but also submitting our application and hoping that we can get all of our veterans who have been counted in our PIT count into a home.
Obviously, those that say no, we can't force them into a home. But veterans should not be, unsheltered. They've already given so much, not just to our community, but to their country, that allowing-- knowing that they are out there and allowing them to continue to be out there without a specific program tailored for them, is absurd.
And, it been one of our highest priorities at the Continuum of Care, which I am the chair of. So we've turned our old juvenile hall into a shelter because we don't use the juvenile hall anymore. Again, we've helped, and our hospitals are building shelters. It, it's been-- the partnerships that we've created have been great.
I will not lie to you, we have not solved the problem.
And I think that if I can maybe take a step back a little bit, whether it's H.R.1, whatever the healthcare impacts are from federal government, state government, or whether it's, those that are unsheltered and all the problems that we're having to solve those things We are trying to solve problems within a box that doesn't allow us to solve the problems, and we have so much inefficiencies and unsustainable things.
We have to rethink how we do healthcare.
We have to rethink how we do communities, and it is not an easy topic to breach because it takes-- it's gonna take some very uncomfortable conversations to figure out what is the next iteration that works and is, I don't wanna create another unsustainable program.
But we, we have to recognize that the growth that we have seen in the cost of providing healthcare, which includes all the services for those that are homeless, 'cause that is a healthcare, a type of healthcare as well, again, giving them that foundational structure to be able to find their health, it is not sustainable.
So I have, I have no-- I don't wanna say I have no concerns. I am not unhappy about the conversation that is happening at the federal level. I don't like the way they're approaching the concept of resolving it, and I'm not sure that there's a solution at the end of the tunnel either. It's more of a let's cut this and cut that, and, and, and because it's unsustainable and it's not working.
I agree, but there has to be a solution at the end of this tunnel, that there, that we can't just cut and expect things to get better. We need to innovate. We need to create something new.
Michelle Rathman: You know, Bruno, I say a lot, we need a shift to happen, and part of that is one of the things I read, and wanna-- before we close out, I have a few more questions. I think to your point, there has to be a mind shift in that we gotta stop demonizing, demoralizing, blaming, pointing fingers, because as you talk about this conversation that you all had last year, the conversation also debunked common myths.
Homelessness is not typically caused by personal choice. I was mentioning to you that I was just in San Diego. My ride to the airport, he said-- Oh, I said, "You have a beautiful city." And he goes, "Yes, it was before the homeless," and they, they, they. Just the, the mindset that individuals are making this a choice.
Most do not have mental health or substance use disorders. Shelters do not attract homelessness. And so, we have to understand the whys behind it, and then we build from there. Why it's happening, how we've allowed it to happen, what needs to be done, and it is indeed all roads to quality of life are paved by policy.
And I think policy is obviously not you know, created out of a bubble. There are individuals who get together in a room like yourself, and you go this way or that way, and I appreciate that you lift. I say that- policy can lift or let down, that you are focused on policies that lift.
Even if it's uncomfortable, go deep. To your point, have what I like to call courageous conversations, as uncomfortable as they are. I'm gonna ask you two more things because I know you are paying so close attention to this.
Our HTP funds have been released and awarded. Some, you know, my state of Illinois, just today, I read an email that finally the application for subcontractors was released. In your state, California has a 2026 award of about 235 million, give or take. There are three overarching initiatives. One is the transformative care model, another is workforce development, I think that's everybody, and then of course, technology.
Noting that you or your county's not gonna get handed a bucket of cash, but to those who are listening, policymakers who are dis-, directing where these funds go, can you kind of outline in a few words or thoughts about where you think this could go to do what you're saying, which is we have to change the way healthcare-- If we're gonna transform, what does that look like in your opinion?
Bruno Sabatier: Well, I know that our health services, our public health officer, and our hospitals were really engaged in the application that was submitted to the federal government for the Rural Health Transformation program. And what I think is necessary in any county is if you don't have a collaborative of healthcare providers, I mean, that could be your general hospital, that could be your nonprofits, that can be anyone in between, your tribal health, they all should be at the table together in figuring out how best to utilize these funds, 'cause it shouldn't go to one individual.
It really should be a lifting of all ships, right?
So, and so to me, what I'm seeing is happening in Lake County, and I'm hoping that it's not just Lake County, it's everywhere else, and I used to work in a hospital in Humboldt County a long time ago in Northern California, and what I noticed was it was very competitive where we didn't talk to other systems.
We didn't talk to the other healthcare provider that was 20 miles down the road. We kinda competed for patients in order to make sure we had our revenues, and it didn't feel right 'cause isn't this about the people rather than about the system? And I feel like in Lake County, we've kind of broken that down where we share a lot of information, and I think that we need to continue to expand how it is that we share information.
And I think that that expansion, alot of people are scared of HIPAA. I personally think that if you read HIPAA deeply, there's a good level of understanding that if you are taking care of somebody, you should have the disclosure of the information about that somebody 'cause knowing who they are and what they've been through is gonna help you better care for that person.
And so whether that's going to jail, whether that's being picked up by a police officer, whether you are in the emergency room, we should all be able to have that portability, which is one of the Ps in HIPAA. We should be able to have that portability and disclosure of all that information so we can best serve those patients.
And to be honest, it shouldn't matter if you're in Lake County or in LA County. You should have that same level of information available because that person needs you to care for them in the best of ways possible, and you shouldn't have to start from scratch or wait on the phone till somebody signs the paperwork to give you all of their information, which is only gonna be a portion of their information.
So, my hope and desire when it comes to the technology is to create a very centralized, accessible to all healthcare providers, and those that are adjacent to healthcare providers, so that we can best provide the care to the individual at the individual level with all the knowledge we should carry with us.
We shouldn't have to relearn every single time we see somebody coming into an office. And so it, I was really hoping that the Rural Health transformation would be a help for the impact of H.R.1, but instead they really want us to innovate and do something new. And so I am working regionally with a group and looking at what can a regional model look like if we start, building facilities that are accessible to the region rather than a specific county.
But I think the technology really needs to grow into how it is that we share that information, because it could be life-saving.
Michelle Rathman: Yeah, absolutely. Oh my gosh. What are you doing? You gonna run, like, for a bigger office or something? You, you really have such a great handle on all of this. I'm so appreciative. All right, before we go, I, you have so
Bruno Sabatier: The answer is no.
Michelle Rathman: Well, all right, well, you heard that here first. All right, so, you know, we talk a lot about the importance of civic engagement, and you clearly are very passionate about what you do.
Your constituents are being served very well. What kind of advice do you have for our listeners who are kind of tinkering around, "Well, I don't really, I'm not involved with my county." You know, I, Sometimes people just show up when they've got an axe to grind or a bone to pick or something like that. What advice do you have for our listeners in terms of how best to advocate for resources for their county, not just at the local level, but state and federal levels? What, can you say about getting involved and making an impact?
Bruno Sabatier: I would say don't work alone. That's probably number one. Yes, you can pick up a phone and access your congressman, person, and access your senators. That's one thing, but create a collaborative. Create an alliance of sorts where your voice can be amplified. To me, this is why I'm part of NACo.
I'm not part of NACo just to have fun, so I can go to Washington, DC, or New Orleans, which should be fun, but it's what the advocacy voice sounds like in comparison to my own, in an echo chamber, right? Mine's just gonna disappear and fade. NACo's gets louder and louder and louder.
And so be a part of your state association, be a part of NACo and engage. Don't just be a part, but ask how you can engage and be a part, I mean, I'm getting invited to podcast with you, Michelle. Like this is, this is what happens when you engage, and I'm so honored that this is, this is happening to me.
And, but it's happening because I have taken the awkward step of going in something, into something that I've never experienced before, and it's actually helping me, and it's helping my county, which means it's helping my community. And so, even at the community level, be a part of the group that wants to make those changes.
Bring your healthcare providers together. Bring all your law enforcement and first responders together. That's how you get things done. By yourself, it's gonna be very difficult
Michelle Rathman: Yeah. We say, we call it build your bench, and this is a year to do that. And I love what you said because our listeners know, coming up here on June 22nd, we actually do have an event where we're bringing together community health centers or federally qualified health clinics and rural hospitals who are doing exactly as you say. They're not competing; they are collaborating to serve their patients better.
Oh my goodness, Bruno Sabatier, it is wonderful to have you here. I wish we could talk to you more. And for the rest of you, stay tuned because I have a closing message before we close out for the day. Again, thank you so much for joining us.
Bruno Sabatier: Thank you, Michelle. It's an honor
Michelle Rathman: Stay tuned
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Well, my thanks to Dakkia Bradshaw, Blaire Bryant, and also, of course, Bruno Sabatier for their insights, and I hope you found it insightful. We know these are not light subjects. We do that on purpose because, at the end of the day, we know that all roads to quality of life are paved by policy. So, for all the resources that you heard about on today's episode, we invite you to visit theruralimpact.com.
Really easy to find. Again, that's theruralimpact.com. And while you're there, make sure that you subscribe. It takes two seconds to just make sure that you can receive our updates that come into your inbox. No pesky asks or, you know, spam or anything like that, but we wanna make sure that you receive our newsletters so that we can share with you recaps of our shows, resources, and share with you what we've got coming up next.
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And really quick, before we close out, I wanna make sure two things: that you follow us on social. You can find us on LinkedIn, BlueSky, Facebook, and Instagram. And with that, you know, you heard during our break about an event that we're doing on June 22nd.
This is something that I am so jazzed about. In collaboration with the National Association of Community Health Centers, I had the extreme privilege of developing three case studies last year that focused on the power of collaboration between rural hospitals and community health centers or health centers. Sometimes they're called FQHCs, Federally Qualified Health Clinics.
However, you define them, just know this: we're talking a lot on this podcast about rural health transformation. We're following that $50 billion Rural Health Transformation Fund. I know a lot of people in a lot of states doing amazing work to make the best use of this money.
This event is not about what's happening in the future. The event that we are going to present to you are three case studies featuring leaders from all these organizations, three different states, six different organizations, and they are gonna really lay out a roadmap for how they're working together and have been doing so for decades, what they're working on, and more importantly, the outcome that they have been able to achieve as a result of collaborating and the transformation that it has been able to, bring forth to the communities as a result of their willingness to put competition aside and really focus on collaborating to improve health outcomes where they are.
And one organization is in North Dakota, another organization is in New Hampshire, and then we have another example from Pennsylvania. But no matter where you are, if you are in the space of rural health, population health, or if you're working in the spaces of housing, transportation, nutrition, these stories are gonna really help kind of open your eyes to what's possible.
So, I invite you to join us. You can register at theruralimpact.com. It is a live studio. There's enough guests for about 100 people in studio, and then you can join us on live stream, so do not waste another moment. Visit theruralimpact.com for all that information. Until the next time we are together, I invite you sincerely to take the best care of yourself and to the best of your ability, all those around you.
We'll see you again soon on a brand-new episode of "The Rural Impact."
