Rural America May Be Ground Zero for Health System Reform

Healthcare has been a dominant issue in US public policy debates in 2026. This mirrors surveys that have found healthcare access and affordability are Americans’ top worries.¹ Nearly two-thirds of households reported being concerned about paying for healthcare expenses, more than those with concerns about food or rent expenses.² Other healthcare worries include access to primary care, navigating the complicated system, and corporate greed. There is a general sense that the health system is broken,³ spurring interest in major reforms.

The work to reform the US health system may—and arguably should—start in rural America. Longstanding, entrenched challenges face the roughly 46 million people living in remote places. These challenges have been exacerbated by health system consolidation and corporatization, facility closures, labor trends, and recent federal funding cuts. Rural residents and the clinicians who serve them will command attention from policy officials in 2027, no matter the outcome of the midterm elections.

This article reviews the health policy landscape, the status of the rural health system, and prospects for long-run and immediate policy changes. It does so from the author’s perspective of over 20 years in government service, including in a rural state. As such, some of its content is speculative based on experience rather than research. It focuses primarily on health services and less on behavioral health, public health, or long-term services and supports. 

The Current Health Policy Landscape 

Throughout most of the 20th century and the beginning of the 21st, leaders at the federal and state levels were able to take strides toward a universal, affordable, high-quality health system. For example, Medicare and Medicaid were enacted in 1965, patient protections and children’s coverage advanced in the 1990s, and the Medicare drug benefit was launched in 2006. Massachusetts enacted its health reform law in the same year, which resulted in 98 percent of its residents having health insurance. In the words of current governor Maura Healey and former governor Mitt Romney at a 20th anniversary event, “It was a tangible demonstration of what is possible when leaders of all perspectives come together, set aside partisanship, and focus on solving real problems.”⁴ 

However, consensus on health system goals has become elusive in the last two decades. In drafting the Affordable Care Act (ACA), President Obama and legislative leaders adopted the broadly supported Massachusetts approach of a largely private insurance system with heavy government regulation and financial support, funded with spending reductions and new taxes. Congress accepted hundreds of bipartisan amendments, and Obama held a summit with Republicans to get their input. Yet virtually no Republicans voted for its final passage in 2010, and partisan efforts to challenge and repeal it began immediately.⁵

The retreat from compromise has contributed to sharply divergent visions for health reform. According to conservatives, affordability can be achieved by providing catastrophic coverage and cash to people to shop for care.⁶ Liberals would, in a 180-degree turn, move more healthcare responsibility to the government to set prices via a generous Medicare for some (i.e., a public plan extension or option)⁷ or Medicare for all system.⁸ People on the right believe health coverage is an earned benefit; people on the left view it as a common good. While all agree that the United States spends too much on healthcare, there is a partisan divide on whether the government share of that spending is too high or too low. This is not surprising in a legislative environment in which change occurs primarily when the winner takes all. A simple, strident message may be more effective at generating voter enthusiasm than a pragmatic or bipartisan approach to solving problems. 

At the same time, even unitary control of Congress and the White House hasn’t enabled either side’s partisan vision to be fulfilled. In 2021 and 2022, Democrats empowered Medicare to negotiate drug prices and improved premium tax credits—but did not succeed in extending coverage to poor people in states that had not expanded Medicaid or adding hearing, vision, or dental benefits to Medicare. In 2025, Republicans reduced federal health spending by an estimated $1 trillion over the next decade—but did not repeal the ACA or block-grant Medicaid. Why? Because even within each political party, legislators, advocates, and other stakeholders do not fully agree on their goals. Within-party differences are common, which perhaps ought to be expected since neither political party has had more than a 10-percentage-point advantage among voters since 2008.⁹ 

This dynamic has consequences. Without national health policy that is cohesive and adaptable, health spending as a share of the economy, which stabilized in the years after the ACA’s passage,¹⁰ has started climbing again.¹¹ The government has neither effectively checked consolidation in the health sector nor protected consumers from contract disputes between insurers and health systems.¹² Furthermore, it has not slowed the rise of private equity,* which transfers resources from the health system to investors.¹³ Attempts to close loopholes have led to a patchwork of complexity that has itself created barriers to seeking and providing healthcare. And distrust of government has escalated.¹⁴

The Rural Health System’s Slow Demise

Rural residents experience more barriers to affordable, accessible healthcare than most other Americans. Some of this reflects broader trends. Today, fewer counties are classified as rural than in the middle of the last century, and fewer residents remain in counties still classified as rural. Young adults have moved away, raising the average age of residents who are left; rural deaths increasingly outnumber births.¹⁵ This demographic shift contributes to higher rates of overall mortality as well as potential excess deaths from heart disease, cancer, unintentional injury, chronic lower respiratory disease, and stroke.¹⁶ But that’s not the whole story.

Rural health outcomes also reflect relatively low supply. Nearly all rural counties have a federally designated health professional shortage area. Geographic access to primary care physicians is lower for rural than nonrural residents.¹⁷ So, too, is telehealth use: Only 19 percent of rural residents receive primary care via telehealth compared to 31 percent of nonrural residents, likely due to inaccessible or unaffordable high-speed internet or broadband.¹⁸ Clinicians specializing in behavioral health, dental, and obstetrical care are more likely to practice in urban than in rural areas. Travel staff have become ubiquitous in filling in gaps—and driving up costs. That said, the numbers of nurse practitioners and physician assistants have been growing in rural areas.¹⁹ About 90 percent of rural counties had either a rural health clinic or federally qualified health center in 2021.²⁰ And healthcare clinics and facilities for Native populations and veterans dot the rural landscape.

Alongside population declines, rural hospitals and nursing homes have been closing. Between 1990 and 2020, 334 rural hospitals closed,²¹ and 43 additional rural hospitals have closed since 2020.²² Since 2011, hospital closures have outnumbered new hospital openings.²³ Compounding the problem, since 2019, nationwide nursing home operating capacity has dropped by 5 percent (effectively 4,000 fewer available beds each day), with 25 percent of rural counties experiencing a decline of 15 percent or more.²⁴ Lack of rural nursing facility beds often means hospitals struggle to discharge older patients in need of step-down care, further straining their capacity. 

Rural providers tend to charge lower rates and be reimbursed for services at lower rates than urban providers²⁵—and expenses like median salary per full-time equivalent are lower for rural hospitals than urban hospitals.²⁶ In spite of this, premiums and out-of-pocket costs tend to be higher for rural than urban residents. Higher premiums result from fewer choices and higher fixed costs (e.g., staffing low-volume facilities, transportation) as well as the greater health needs of older populations and those with lower incomes in rural areas.²⁷ Higher out-of-pocket costs reflect a lower rate of employer coverage and higher rate of uninsurance among rural residents.²⁸ Rural workers are often self-employed or small business owners, resulting in a greater use of the ACA Health Insurance Marketplaces for coverage. Additionally, one in four rural residents is enrolled in Medicaid, reflecting poverty in rural America.²⁹ This translates into cost-related access problems, which are reported by 62 percent of rural residents, compared to 56 percent of nonrural residents.³⁰ 

Against this backdrop, recent changes have exacerbated rural health system problems. Supply chain costs due to tariffs and transportation costs due to higher gas prices are disproportionately borne by rural facilities. Immigration policy change has also had a swift impact. One in three home care workers and one in five nursing facility workers are immigrants.³¹ Increased detentions, mass deportations, and interior raids by Immigration and Customs Enforcement (ICE) have resulted in increased staff call-outs in some areas, putting patient care at risk.³² Additionally, 14 percent of rural physicians and surgeons were naturalized citizens or noncitizen immigrants in 2023, three times their share of the total rural population.³³ The Trump administration’s $100,000 fee for H-1B petitions and freeze on visas, renewals, and other work permits for people from roughly 40 countries are already straining systems that have relied on these professionals.³⁴ At the same time, the administration finalized a rule that denies higher student loan limits for advanced nursing degree students³⁵—a move that will make it harder for US citizens to prepare to fill the void being left by foreign-born clinicians. While such policies are in flux (for example, the H-1B fee was successfully challenged in court, but the administration is appealing³⁶), their chilling effects are real.

Moreover, 2025 congressional action, specifically the One Big Beautiful Bill Act (OBBBA), and inaction have begun to affect rural healthcare. Due to Congress’s failure to extend enhanced premium tax credits, rural residents are paying on average twice as much for Marketplace premiums in 2026 than 2025, with their average increase being 28 percent higher than that of urban residents in federally run Marketplaces.³⁷ And stricter Marketplace eligibility and redetermination system changes are on the horizon, pushing premiums even higher.³⁸ 

In addition to Marketplace changes, the OBBBA has over 20 changes to Medicaid, including the addition of a community engagement requirement (a.k.a. work requirement) starting in January 2027.³⁹ Some of those changes, like limits on how states finance Medicaid, will result in reductions in payments, benefits, or eligibility beyond what is in the OBBBA.⁴⁰ The Medicaid parts of this law are projected to reduce federal Medicaid spending in rural areas by $137 billion from 2025 to 2034.⁴¹ 

Considering the Marketplace and Medicaid changes together, the Congressional Budget Office estimates the law will reduce nationwide federal health spending by over $1 trillion over the next decade, primarily by shrinking the number of people who can access healthcare: A projected 15 million more people will be uninsured in 2034.⁴² Experts project that over the next 10 years, rural hospital revenue will be lowered by an estimated $87 billion and uncompensated care will increase by $23 billion.⁴³

In an acknowledgement of its rural impact, the OBBBA includes a five-year, $50 billion Rural Health Transformation Program. However, its amount, allocation, and strict rules on usage limit its likely impact.⁴⁴ 

Long-Run Prospects for Major Health System Change 

Slow-growing problems combined with recent shocks help explain why a record-high percentage of Americans believe the healthcare system is in crisis.⁴⁵ Efforts to solve long-standing and escalating issues like consolidation, corporatization, and complexity are overdue. The destabilizing effects of recent policy changes, some of which are soon to take effect, have added urgency. Together, they are catalyzing a climate for the type of sweeping change that occurred with the passage of Medicare, Medicaid, and the ACA—all of which necessitated presidential leadership.

Healthcare does not rank as high an issue among Republicans as among independents and Democrats.⁴⁶ The current president neither campaigned on nor prioritized health reform, instead focusing on purported healthcare waste, fraud, and abuse, and the Make America Healthy Again agenda. His one-page health reform plan supports lowering drug prices and giving government funds directly to people (rather than insurance companies) to shop for health services.⁴⁷ The Republican-led Congress has yet to effectively act on such proposals. The next Republican presidential nominee is likely to adopt President Trump’s plan since early frontrunners are either in his administration or are governors supporting him.⁴⁸ 

On the Democratic front, it is likely that the 2028 presidential nominee will have a bold plan, although it is too early to predict what it might include. That said, three themes connect the range of emerging proposals. The first is a more robust role for government, which is in part fueled by anger at for-profit and consolidated health insurers, providers, drug manufacturers, and others.⁴⁹ Nearly two-thirds of US adults in a recent survey said government should make sure all Americans have healthcare.⁵⁰ Among Democrats or people leaning toward Democrats, most support a single national government program such as Medicare for some or all. Others prefer a mix of government and private programs, which has emerged in recent proposals.⁵¹ Relatedly, policymakers are considering ideas for preventing and breaking up consolidated systems⁵² and for replacing private equity and system ownership of practices, clinics, and hospitals with publicly backed options.⁵³

A second emerging theme is simplification.⁵⁴ Complexity creates barriers to care and opportunities to increase profits in the health system.⁵⁵ One idea gaining traction is standardizing cost sharing, benefits, provider contracts, and insurance processes across programs.⁵⁶ Others would tackle parts of the care spectrum, such as making primary care free of cost sharing⁵⁷ or financed through a common fund, like a public utility.⁵⁸ Making the system easier to navigate would improve patients’ and clinicians’ experiences as well as accountability and oversight, driving out some expensive loopholes and unnecessary administrative costs. 

The third theme that is likely to characterize future health reform proposals is credibility. People seem to prefer discrete, achievable policies like a $35 monthly cap on insulin copays to more beneficial yet abstract policies like blocking health system mergers. This makes sense at a time when results are desperately desired and trust in government is near a 70-year low.⁵⁹ Health reform proposals likely will have to be of the “show me” variety to avoid being dismissed as empty promises.

What does this mean for healthcare providers in the rural United States? Under a Republican president in 2029, the current state of rural health systems would likely continue on its current path with changes at the margins. Under a Democratic president, successful health reform may yield government, rather than private, investment in rural brick-and-mortar health facilities, broadband access to telehealth, the workforce, and coordination and transportation in regional systems of care. Potentially, under a Democratic reform plan, the government would heavily regulate and standardize private insurance or run a Medicare-like public health plan that would improve affordability for the families of rural farmers, small business owners, and older residents disadvantaged by the current insurance system. Simplification of reimbursement systems could yield capitated,* all-payer payments for critical services to ensure rural residents have timely and affordable access to services like maternity and emergency care. A likely change in support for legal immigration could result in a return of new Americans to rural communities to support residents’ health. 

Envisioning an effective rural health system now will help shape such policies. 

Short-Run Possibilities to Advance Health Reform

The race for the next presidency begins the day after the 2026 midterm elections. In the meantime, if healthcare concerns contribute to Democratic gains in the midterm elections, opportunities to advance health reform could arise in 2027. The caveat is that divided government typically results in gridlock rather than compromise. It is unlikely that Trump would either sign Democratic-led bills or change his health reform plan.

Still, one opportunity for improvement would be oversight and interrogation of health system problems. A reform-oriented majority in the House or Senate could hold hearings, produce reports, schedule votes and resolutions, and otherwise use its authority to further define health system problems. This would go beyond vague claims that “the system is broken” and “healthcare is unaffordable” to deeply explore and develop a consensus on the root causes to begin a meaningful dialogue on potential changes. This is especially important given extensive lobbying and the many ways that complexity enables finger-pointing: Drug companies blame hospitals, hospitals blame insurers, insurers blame providers, and Americans blame politicians. Change is difficult; one stakeholder’s savings is another stakeholder’s profits. And voters often opt for the flawed system they know instead of a changed system built on promises. And yet, since healthcare affordability truly is a worsening crisis, concerted congressional leadership could yield a consensus on key health system problems from which solutions may flow. 

In 2027, regardless of midterm election outcomes, Congress may also be a testing ground for pragmatic policy solutions aimed at simplifying the system and improving healthcare affordability. Some proposals could be nationwide. For example, Congress could advance proposals to remove insurers from prior authorization decisions⁶⁰ or eliminate ACA plan deductibles by restoring the cost-sharing subsidy payments that were stopped by the first Trump administration.⁶¹ 

Other short-term proposals might focus on rural areas—ground zero for health system challenges. At the top of the list is allowing the Rural Health Transformation Program to pay for hospital and clinic services for rural people falling through the cracks; the Trump administration arbitrarily limited that amount to 15 percent of the total funding.⁶² Additionally, Congress could nationalize a simplified payment model like the Pennsylvania Rural Health Model, in which Medicare, Medicaid, and certain commercial insurers pay participating hospitals a fixed amount up front regardless of patient volume, allowing the hospitals to make strategic investments in their communities’ healthcare needs.⁶³ It could also restore and expand funding for the rural healthcare workforce and supports, as well as delay or repeal recent changes to Medicaid and the ACA that disproportionately affect rural America. 

A strong midterm message from voters to Congress to act on healthcare affordability, especially in rural areas, could defy the odds and result in successful legislation in 2027. This would provide proof to the growing number of skeptics that government can work. Alternatively, stalemates and stagnation could continue, increasing Americans’ anger and fueling a demand for wholesale change in the 2028 elections. 

Despite recent and current challenges, this nation has proven it can take collective action to advance healthcare. Effective policies contributed to a record-low uninsured rate in 2023 and 2024⁶⁴ and a pause in the growth of health spending as a share of the economy after the ACA was enacted.⁶⁵ They also contributed to making health jobs 12 of the top 20 fastest-growing professions.⁶⁶

Ingenuity can be found across the rural health landscape. Examples abound: Community paramedicine programs are flexing paramedics and emergency medical technicians to assist in home visits and chronic care management in Minnesota and Maine.⁶⁷ Community health workers are connecting health, public health, and other services in rural Kentucky.⁶⁸ Independent rural hospitals in North Dakota and other areas have formed a clinically integrated network to coordinate services and pool resources.⁶⁹

At a time when policy action and inaction are stressing rural residents and their clinicians, advocacy for patches, targeted assistance, and a “do no harm” approach is necessary but not sufficient. Catalyzing structural, achievable improvements in the near term will help rebuild trust that government can successfully support broader systemic reform. And developing a bold, shared vision for what our health system should deliver and how—starting in rural America—will inform the next major reform of the US health system. Rural health professionals can help shape that future.   

Jeanne M. Lambrew, PhD, is the director of healthcare reform at The Century Foundation and an adjunct professor at the Harvard T.H. Chan School of Public Health. Previously, she served as commissioner of the Maine Department of Health and Human Services, as director of the US Department of Health and Human Services’ Office of Health Reform, and as deputy assistant for health policy for President Obama.

*To learn about capitated payment models, see “COVID-19: From Public Health Crisis to Healthcare Evolution” in the Fall 2020 issue of AFT Health Care. (return to article)

Endnotes

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2. A. Kearney et al., “KFF Health Tracking Poll: Health Care Costs and the Midterms,” KFF, April 29, 2026, kff.org/public-opinion/kff-health-tracking-poll-health-care-costs-and-the-midterms.

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5. J. Cohn, The Ten Year War: Obamacare and the Unfinished Crusade for Universal Coverage (Saint Martin’s Press, 2021).

6. K. Hooper, “Republicans See High-Risk Plans as the Future of Health Insurance,” Politico, May 3, 2026, politico.com/news/2026/05/03/republicans-embrace-high-deductible-obamacare-plans-00902194.

7. J. Choi, “Group Floats ‘Medicare by Choice’ as a Democratic Health Care Alternative,” The Hill, March 26, 2026, thehill.com/policy/healthcare/5800964-medicare-by-choice-health-care-policy-democrats.

8. R. Brownstein, “This Bernie Sanders-Backed Idea Is Connecting Democrats Winning Midterm Primaries,” CNN, April 12, 2026, cnn.com/2026/04/12/politics/medicare-for-all-health-care-cost-
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9. Gallup, “Party Affiliation: Annual Trend Since 1988,” 2026, news.gallup.com/poll/15370/party-affiliation.aspx.

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11. M. Hartman et al., “National Health Care Spending Increased 7.2 Percent in 2024 as Utilization Remained Elevated,” Health Affairs 45, no. 2 (January 14, 2026): 110–20; and Buntin and Graves, “How the ACA Dented.”

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20. Horstman and Shah, “The State of Rural Primary Care.”

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23. Planey et al., “Rural Hospital Closures.”

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34. M. Jordan, “Foreign Doctors Are Sidelined Amid a Shortage,” New York Times, April 6, 2026, nytimes.com/2026/04/04/us/trumps-immigration-policy-sidelines-foreign-doctors-amid-shortage.html.

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38. M. Anderson, C. Y. Chin, and M. Cohen, Who Paid, and Who Stayed? Early 2026 Enrollment Trends in the Individual Market (Wakely: An HMA Company, April 2026), wakely.com/wp-content/uploads/2026/04/Who-Paid-and-Who-Stayed-%E2%80%93-Early-2026-Enrollment-Trends-in-the-Individual-Market.pdf.

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54. L. Levitt and D. Altman, “Complexity in the US Health Care System Is the Enemy of Access and Affordability,” JAMA Forum 4, no. 10 (October 26, 2023): e234430. 

55. L. Blumberg, K. Lucia, and K. Watts, The Complex Web of Health Care Financial Interests and Their Implications for Ever Higher Spending: An Expert Perspective (Center on Health Insurance Reforms, McCourt School of Public Policy, Georgetown University, 2025), georgetown.app.box.com/s/rtmi4pbcyz2wav084pphsmvof9085ibp. 

56. For example, J. Lambrew and J. Varcie, Skimming: How Complexity Raises Healthcare Costs—and What Government Can Do About It (The Century Foundation, June 2026), tcf.org/content/report/skimming-how-complexity-raises-healthcare-costs-and-what-government-can-do-about-it; and Kitchen Table Project, “The Out-of-Pocket Cost Crisis & the Healthcare Cost Cap,” July 2026, thekitchentableproject.org/healthcare-report.

57. Searchlight Institute, “Making Health Care.” 

58. Z. Song et al., “Primary Care as a Public Utility: The Case for a Common Fund,” JAMA 335, no. 23 (May 20, 2026): 2057–62.

59. Pew Research Center, “Public Trust in Government.”

60. Spiro et al., A Patients’ Bill of Rights.

61. J. Lambrew, “Abandon—Don’t Expand—High-Deductible Plans Linked to Spending Accounts,” Health Affairs, March 11, 2026, healthaffairs.org/content/forefront/abandon-don-t-expand-high-deductible-plans-linked-spending-accounts.

62. A. Searing, “Trump Administration Severely Limits Rural Health Transformation Funds for Rural Hospitals and Clinics—Capped at 15%,” Say Ahhh! Health Policy Blog, Georgetown University McCourt School of Public Policy, Center for Children and Families, October 21, 2025, ccf.georgetown.edu/2025/10/21/trump-administration-severely-limits-funding-for-rural-hospitals-and-clinics-from-rural-health-transformation-fund-capped-at-15.

63. Centers for Medicare & Medicaid Services, “Pennsylvania Rural Health Model,” cms.gov/priorities/innovation/innovation-models/pa-rural-health-model.

64. Office of Health Policy, “Healthcare Insurance Coverage, Affordability of Coverage, and Access to Care, 2021–2024,” Assistant Secretary for Planning and Evaluation, US Department of Health and Human Services, January 8, 2025, aspe.hhs.gov/sites/default/files/documents/9a943f1b8f8d3872fc3d82b02d0df466/coverage-access-2021-2024.pdf.

65. Buntin and Graves, “How the ACA Dented.”

66. US Bureau of Labor Statistics, “Occupational Outlook Handbook: Fastest Growing Occupations,” US Department of Labor, August 28, 2025, bls.gov/ooh/fastest-growing.htm.

67. V. Foubister, M. Hostetter, and S. Klein, “Can Community Paramedicine Improve Health Outcomes in Rural America?,” Commonwealth Fund, March 24, 2023, commonwealthfund.org/publications/2023/mar/can-community-paramedicine-improve-health-outcomes-rural-america.

68. Horstman and Shah, “The State of Rural Primary Care.”

69. A. Zionts, “How Rural Hospitals Are Banding Together to Survive,” National Public Radio, September 2, 2025, npr.org/sections/shots-health-news/2025/09/02/nx-s1-5519257/rural-hospitals-independent-health-networks.

[Illustrations By Gwenda Kaczor]