Teamwork needed to fight challenges to rural health care

Anyone who knows me is aware that college basketball season is my favorite time of year. I often travel to games to watch my beloved Kentucky Wildcats play, and this year has been no exception. Typically, I'll fly or take the train to the games, but this year, I chose to drive to one of the games in my original hometown of Lexington, Ky. This drive takes me through a wide swathe of rural America—in Maryland, West Virginia, and Kentucky—across the beautiful Appalachian Mountains. But while these mountains are beautiful, it is no secret that many who live there, as well as in other rural areas of the country, experience significant disparities in health and access to health care.

ACP's new policy paper, “Improving Health and Health Care in Rural Communities,” published April 1 by Annals of Internal Medicine, discusses these disparities in depth. They stem from social, economic, and geographic factors that are characteristic of rural communities. Rural areas cover 72% of the country's landmass, with just over 15% of the population, or 46 million people, residing there. Rural residents have a higher risk of death from heart disease, cancer, unintentional injury, chronic lower respiratory disease, and stroke compared to those living in urban areas.

These poor health outcomes are exacerbated by disparities in insurance coverage and affordability of care. While there was a substantial decline in the uninsured rate in both rural and urban areas of the U.S. after the implementation of the Affordable Care Act (ACA), rural Americans remain uninsured at a higher rate than their urban counterparts. A recent research report by the Office of the Assistant Secretary for Planning and Evaluation, part of the U.S. Department of Health and Human Services, reported that one in eight rural adults under the age of 65 is uninsured. Additionally, uninsured rates among rural residents are much higher in states that have not yet adopted the ACA Medicaid expansion option.

In terms of affordability, a survey conducted by the Commonwealth Fund in 2020 found that more than one-third of rural Americans have reported skipping needed care because of costs. That same survey also found that nearly a quarter of rural Americans, both with and without health insurance, reported either having serious problems paying their medical bills or being unable to pay their bills altogether.

Access to health care services in rural areas is also a significant challenge. From 2010 to 2025, 150 rural hospitals closed in the U.S. due to issues like low reimbursement, staffing shortages, low patient volume, regulatory barriers, and financial challenges that were made worse by the COVID-19 pandemic. In terms of physicians, while 20% of Americans live in rural areas, fewer than 10% of physicians practice in these areas.

Further, while highly specialized physicians are much less likely to settle in rural areas, there is still a significant shortage of primary care physicians in rural America. In fact, in 2025, the federal government estimates that the deficit of primary care physicians in rural areas is 20,000. Given that access to primary care is associated with improved health outcomes and reduced health disparities, it is critical that we find solutions.

Unfortunately, ACP is currently simply trying to keep access to insurance coverage and health care services from deteriorating. Medicaid is the largest health insurer in the U.S., covering 80 million low-income individuals across the country, including 18% of adults and 47% of children in rural areas. It is jointly financed by the states and by the federal government but administered by the states within broad federal rules. It is these federal rules that are at risk of significant change in the current Congress, which is looking for ways to finance the tax cuts and other priorities that are part of President Trump's plans. Congress states that it is looking to reduce waste and fraud, which is a laudable goal, but broad policy changes such as those now being considered are like taking a sledgehammer to a tiny nail, likely to lead to the destruction of Medicaid rather than simply making it more efficient.

These proposals to change Medicaid include implementing nationwide work requirements, converting payments to per capita caps or block grants, restricting state use of “provider” taxes to fund the program, reducing the overall Federal Medical Assistance Percentage (FMAP)—or federal match rate—to states, and reducing the higher FMAP for expansion populations. Work requirements certainly seem likely to be introduced; however, a large majority of Medicaid beneficiaries who can work (i.e., those who are not disabled, medically frail, or caregivers for children or those with disabilities) are already in school or working either full- or part-time.

Additionally, reporting work hours can be difficult for these individuals (even more so for those with multiple jobs) because of lack of access to the internet and computers, and Medicaid beneficiaries in states that have implemented work requirements have said that such reporting is very confusing. While Medicaid work requirements would likely save the federal government $109 billion over 10 years, which is significant (although not overwhelming when considered relative to overall federal Medicaid spending of $7.4 trillion over the next decade), they would leave 600,000 more Americans uninsured. Also, the Congressional Budget Office has found that Medicaid work requirements would have no real impact since most beneficiaries who can work are already doing so.

Currently, the FMAP for most Medicaid beneficiaries is determined by a formula that provides at least 50% of the funding for the program and sometimes more for states with a lower per capita income. Of interest is that many southern states, whose congressional representatives and senators are in the majority right now, have higher match rates of up to 65%. States that expanded access to Medicaid due to the ACA have a higher match rate for that population of 90%, and the more recent American Rescue Plan Act provided an additional federal incentive to states that expanded Medicaid.

Proposals on the table now would make significant changes to this structure. For instance, block grants would put a per capita cap on the federal match, resulting in reduced funding support from the federal government, and other FMAP-related proposals would do the same. This would have a significant impact on the budgets of the affected states, which would either need to cut back on coverage or increase their contributions. This is why there is so much pushback happening on these proposals on both sides of the aisle. ACP, along with many others, has been calling out these issues and will continue to do so should these plans be implemented.

Another area of deep concern for access to care in rural areas is the potential of travel restrictions being implemented by the Trump Administration. A Jan. 20 executive order calls for “identifying countries throughout the world for which vetting and screening information is so deficient as to warrant a partial or full suspension on the admission of nationals from those countries.” The order further calls for this to occur within 60 days of its issuance, or around March 20.

As outlined in a recent ACP perspective piece in Annals of Internal Medicine, “The U.S. health care system depends significantly on international medical graduates (IMGs) to maintain the strength and effectiveness of its physician workforce.” This is particularly true for rural areas of the U.S., as IMGs are more likely to practice in rural areas compared to U.S. medical graduates, particularly in East South Central and West North Central states. Therefore, travel restrictions for certain countries will likely have a significant impact on the physician workforce serving rural areas. ACP is actively monitoring this situation and is prepared to advocate on behalf of our members to ensure that any travel restrictions do not reduce access to care in rural areas.

While April may mark the end of the college basketball season (go Wildcats!), it does not signify the end of the disparities in care and access to health care for people in rural areas of our country. ACP's new paper offers several recommendations on how to address these issues, including calling for public policy efforts to identify, research, and address the health and health care challenges that uniquely, differently, and/or disproportionately impact rural populations and implementing interventions that address underlying social drivers of health that disproportionately and negatively impact rural communities and perpetuate rural health inequities.

The paper also urges policymakers to consistently and sufficiently fund and support health care programs (like Medicaid) and facilities that serve rural communities and calls on undergraduate and graduate medical education institutions to incorporate education on rural health issues and the skills needed to effectively practice medicine in rural settings as part of curricula and training programs.

Additionally, the paper recognizes the important role of IMGs in increasing access to primary care and other health services in rural communities and urges policymakers and institutions to adopt policies that support IMGs, rather than restricting their ability to travel to the U.S. It is critically important that we all work together as a team—not unlike my own Kentucky Wildcats and other college basketball teams—to ensure that access to care in rural America is protected.