Tax in rural communities: missed credits and missing accountants

My old boss, an accountant (CPA) who represented taxpayers in their appeals processes, lived on a small farm in the highlands between Orange and Riverside Counties. Most accountants, however, are unlikely to trade the pen for the plowshare. According to this Vishal CPA Prep, some counties have no licensed CPAs at all.

According to the US Census Bureau, rural communities tend to "have lower median household incomes" when compared to metro communities. However, according to the same data, rural communities have lower poverty rates than urban communities. It is not too much of a stretch to infer that rural Americans would be in the tax bracket with low tax liability, but not falling below the statutory filing threshold. 

Credit: Internal Revenue Service, Publication 501 (2025)

The tax code is structured, in part, to remedy inequalities between poorer and affluent Americans through expenditures like the Earned Income Tax Credit and the Child Tax Credit. However, many of the intended benefits and tax expenditures can only be accessed if the filer knows about the benefits. As noted in this 2018 article by the Internal Revenue Service,] rural Americans stand to benefit disproportionately from the Earned Income Tax Credit. However, rural residents often do not apply because they are unaware that they are eligible. The IRS article explains that qualifying taxpayers can claim the EITC by filing electronically "through a qualified tax professional," "using free community tax help sites," or filing "themselves, with IRS Free File." The mention of Free File shows that the article is outdated, as the IRS Free File program has been eliminated for the 2026 filing season. The other two solutions require the use of either internet services or the services of a tax professional, neither of which are consistently available in rural locations. 

For low-income or elderly taxpayers, the IRS also offers services from the Volunteer Income Tax Assistance (VITA) and Tax Counseling for the Elderly (TCE) programs. The IRS provides a geographic site locator tool so that filers can identify volunteers near them. These efforts, too, have geographic limits. Searching from the zip code of 96101, which is the county seat of Modoc County (Alturas, CA) in California, there are only three sites within 100 miles. UWNC, the Lassen Salvation Army, is the closest at 76.15 miles away. When they must rely on volunteer accountants, rural communities may be underserved. 

Accountants located near Alturas, CA

Credit: Google Maps

Even where volunteers exist, the supply of professional tax help is dwindling nationwide. The United States is experiencing a shortage of new accountants. With hundreds of thousands of Baby Boomer generation professionals, many positions will remain unfilled.

Credit: Preston Fore, AICPA 2023 Trends Report

Some smaller accounting firms have rejected potential clients because they have too few professionals to do the work. Beyond shortages, some tax experts caution that potential clients need to be cautious when choosing a tax preparer due to the current low bar to qualify. When firms turn away clients, bad actors may fill the gaps.

In addition to a shortage of tax preparation services, President Trump's 2025 hiring freeze exacerbated labor shortages within the IRS. As a consequence, tax filing and processing have become more difficult on both ends of the process. For low-income taxpayers, the shortages mean refund claims, like the Earned Income Tax Credit, will take longer to reach taxpayers. IRS response times when called for information have also become slower than ever. For taxpayers with no days off of work and only an hour for lunch, they might be out of luck when it comes to getting a live response.

Nonetheless, the IRS continues to publish helpful materials for rural-coded sectors of the economy, like the Farmer's Tax Guide. The Farmer's Tax Guide and other published materials are regularly updated to remain accurate to the current iteration of the tax code. With a shortage of professional tax help, taxpayers may need to rely upon the publications themselves to stay informed and know which credits and deductions to apply for.

The 2025 tax year's Farmer's Tax Guide (Publication 225) provides an encyclopedic level of information for farmers, from general concepts of the cash or accrual method of accounting to more trade-specific concepts like Elective Farm Income. The publication also specifies farm-related deductible expenses like "Breeding Fees," "Fertilizer and Lime," and other "Prepaid Farm Supplies." 

More importantly, the Farmer's Tax Guide keeps tax filers up-to-date on expiring tax policies, like the temporary 100% deductibility of food or beverages provided by a restaurant. From personal experience working with small business owners, taxpayers often miss changes to tax policy, which can result in staggeringly large tax assessments for deficient payments, audits, and lengthy appeals proceedings.  When those procedures are ongoing, interest is nevertheless ticking up.  

While helpful, IRS publications like Publication 225 may be difficult for many small business owners to comprehend. The length and depth of the publication makes it helpful, yet, but also difficult to parse.  Nestled within the publication is perhaps the most important detail, the rule surrounding whether farm-expenses can be listed at all on a tax return. As a long-standing principle, "Hobby Farming," or "Not-for-Profit Farming" doesn't qualify. Unfortunately for less-established farmers, one major factor in the consideration of a farm as a hobby farm is whether "taxpayer was successful in making a profit in similar activities in the past." More than most businesses, many crops need years to mature to profitability, leading to a horizontal equity issue between more established farmers and newer farmers. 

Grape vines at Tablas Creek Vineyard in Paso Robles, July 30, 2025. 

Credit: Larry Valenzuela, CalMatters/CatchLight Local

Business owners still have options with the IRS publication information, even with a lack of close CPAs. A CPA is a term used for a certified public accountant who is authorized and licensed by the state jurisdiction to prepare taxes for a taxpayer. Kaizen CPA's accounting site recommends that business owners use QuickBooks if they net less than $500,000 each year. If their net income is more than that, Kaizen recommends a live CPA.  

For context, QuickBooks is a tax preparation software program offered by Intuit on a subscription basis. Intuit is the same company which offers taxpayers access to TurboTax each tax season. With QuickBooks, subscribers have the functionality to automate bookkeeping, generate business reports (i.e. Profit & Loss reports), produce invoices for the subscriber's customers, and with the most expensive subscription option, synchronize data from Microsoft Excel sheets. Most importantly for tax purposes, QuickBooks can calculate sales tax liabilities and generate Form 1099s (to report income generated outside of standard employment) for the subscribing business.  

Rural businesses might not have the option to choose a live CPA over QuickBooks. While QuickBooks does not have the functionality to facilitate the filing of income tax returns, it can organize financial information in a way to make the workload digestible for a live CPA during tax season. From there, the hypothetical rural business owner would need to take fewer trips to a CPA's office or may even merely contact them by email with their information ready. Now, with the shortage of CPAs nationwide, it might make a business owner a more palatable client to have their books in order.

There's a reason the CPA licensing process is difficult: calculating and filing taxes are often too complex for taxpayers to handle on their own. Furthermore, CPAs are responsible for more than tax filing, planning, and appeals. CPAs must be ready to produce financial reports, audit revenue expenditures, ensure compliance with regulatory bodies like the Securities and Exchange Commission, and investigate potential fraud within a business through forensic accounting. With a shortage of live CPAs and IRS employees, taxpayers will need to increasingly rely upon accounting software, which may miss niche credits that the taxpayer qualifies for. Rural taxpayers may thus need to embrace a new type of self-reliance when it comes to financial literacy. 

Left to burn: how federal cuts are abandoning rural America's wildfire defenses

My memory of leaving Sonoma County for San Francisco includes a period of about four years where California wildfires progressively escalated in severity, oftentimes blanketing the city in smoke. In 2017, that included ducking inside to avoid breathing in the ashes of the town where I went to high school. It culminated in 2020 with the North Complex Fire causing the orange, alien sky that enveloped San Francisco. That fire was caused by a freak "lightning siege" attributable to climate change.  

My friend took this photo outside her apartment in September, 2020.
(c) Rose Barry, 2020

The Palisades Fire early last year should have emphasized the apocalyptic urgency of addressing wildfire dangers in California and beyond. But in the name of limiting "waste and abuse" the Trump administration ignored this urgency and instead proceeded to cut federal funding to fight fires in rural America. 

The Cuts 

Like the rest of the Trump administration's 2025 efforts, these cuts are as chaotic as they are dramatic, attacking wildfire prevention and response from multiple angles. 

First, the administration cut 10% of workers at the Forest Service. The Forest Service manages Federal land, and many of their responsibilities include fire prevention and firefighting. Fewer workers means fewer people clearing the brush and fewer people trained to fight fires. This puts California in a precarious position, with the Federal government managing 57% of forests in the state. Nevada is arguably in even worse shape, with 86% of their land being federally managed. 

Critics of the policy include members of the previous Trump administration. Former Forest Service chief Vickie Christiansen posits that the policies amount to "$40 million saved now for $4 billion in wildfire expense" later. Ryan Zinke, Trump's former Secretary of the Interior, says that the cuts shift the question of hiring from "'are we paying them enough” (to) “are we even going to have the bodies?'"

Firefighters from Stockton, CA putting out a fire off Hidden Valley Road. 
Source: Creative Commons, 2013.

The administration has also merged disparate firefighting groups from the Department of Agriculture and the Department of the Interior into a single U.S. Wildlife Fire Service. While there have been proposals to this effect in the past, they were previously rejected due to a 2008 Congressional report finding this consolidation had significant drawbacks. The consolidation shifts the focus away from fire prevention and towards suppression. The Forest Service ideally fights fire through its land management duties, and separating the two functions increases the risk of catastrophic fires that cannot be adequately suppressed. 

Despite some of the most high stakes firefighting occurring in rural spaces (especially in California), rural firefighters are often volunteers. As a previous post on this blog puts it, "volunteer firefighting is a rural issue." California has 200 volunteer fire departments, with many rural spaces completely lacking professional firefighters. Communities often fund these departments partially through local fundraisers. As people leave these communities, staffing these departments becomes even more difficult. Willow Creek in Humboldt County finds their department shrinking as calls increase.  Cuts to the Forest Service means these towns already lacking in resources have even less ability to serve their community even as the fire season grows ever larger. 

Volunteer Fire Station in Occidental, CA. 
(c) Lisa R. Pruitt 2025.

 States and localities have also suffered from the suspension of FEMA Building Resilient Infrastructure and Communities (BRIC) grants in 2025, with a lawsuit forcing the resumption of grants only last year. A massive backlog has resulted, with two years worth of applicants applying for one year of grant funding. This affects infrastructure for fire prevention as well as other disasters. 

This backlog disproportionately affects rural towns. Larger municipalities frequently have full-time grant-writers, where small towns often rely on a thin secretarial support staff, if that. These towns have no ability to fund their own improvements, with necessary infrastructure often costing several times the town's budget. 

The Response 

California moved relatively swiftly to counter the Forest Service cuts, deploying $72 million in Cal FIRE grants to "rake the forest" and fast track critical fire prevention projects. While certainly helpful, the State can only work with the 3% of forest land it manages directly and must work with private landowners who own the other 40% of the land. With a majority of the land in California under Federal management, this effort is limited. 

Utah also increased their wildfire funding by $150 million and joined the Great Plains Interstate Fire Compact. The compact enables coordination and resource sharing with other western states to fight wildfires and prevent wildfires. While this likely won't make up for the gap left by the federal government, this more coordinated local effort is cause for optimism. 

The Department of the Interior also announced a $20 million grant to equip "small, remote emergency response agencies with practical, deployable tools," i.e. modern water tanker trucks. While not unwelcome, this targeted funding does not make up for the larger structural damage done by the Trump administration. 

Notably, none of these responses make efforts to alleviate the specific burdens on rural communities. They simply attempt to fill in the gaps left by the federal government's retreat, failing to address the prior inequities. 

Conclusion  

On our current trajectory I find it difficult to be optimistic about anything involving climate change. As a Californian, there are few things that seem more immediately pressing than addressing the increasing severity of wildfires. The current administration's efforts harm everyone by failing to address these systemic issues, and rural communities will bear the brunt of the impact. 

The SAVE Act and rural America

Point Arena, California 
© Lisa R. Pruitt 2025

The Safeguard American Voter Eligibility Act (“SAVE Act”) has returned to Congress and sits before the Senate after passing the House.This bill would amend the National Voter Registration Act of 1993 by requiring every eligible voter to provide proof of citizenship when registering to vote or updating a registration.

The bill would require individuals to appear in person at an election and present approved documentation even for routine updates. These updates can include address changes, name changes, or party affiliation adjustments. Each federal election cycle, approximately 80 million people either register to vote for the first time or update their voter registration information. This bill would impose new logistical hurdles on all of them. Acceptable documentation would include a valid U.S. passport, a certified birth certificate paired with a photo ID, or a naturalization certificate. If a person’s legal name does not match their birth certificate, they must also provide additional legal documents to prove the change.

Supporters of the bill, including many Republican lawmakers, argue that stricter verification requirements will prevent non-citizen voting. Arguing that Joe Biden’s “reckless open-border policies” necessitate this bill because without it we can’t be sure that Americans are the only ones voting in federal elections.

What does the White House have to say about the SAVE Act? The official White House website refers to it as a “common sense, bipartisan bill,” emphasizing that all it “simply” requires is a valid ID to register to vote in a federal election, proof of citizenship, and no mail-in ballots. The website then goes on to list other countries that enforce stricter voter identification laws.

The SAVE Act is not new. Last year it passed the House but failed to advance in the Senate due to nationwide public opposition. It was reintroduced this January. Critics, previously and this time, argue that the SAVE Act solves nothing. Numerous studies and audits have shown that non-citizen voting occurs at extremely low rates. In fact, many view this bill as a way for Republicans to hammer Trump’s narrative of widespread election fraud.

Additionally, the act will determinately impact rural America, which particularly relies on mail-in and online methods for voter registration. Rural Americans already face long travel distances and fewer government service offices. A Center for American Progress analysis found that in some cases rural Americans would need to drive hours to an election office in order to meet the requirements of the act. The maps below highlight two examples. In two rural counties, Catron County, New Mexico, and Harney County, Oregon, residents must travel four hours or more round trip to reach their local election office. In states like Alaska, the burden will be even more pronounced. Alaska’s Senator Lisa Murkowski is one of the only Republicans to oppose the bill, arguing that it will disenfranchise thousands of Alaskans and their ability to vote as a large majority of Alaskan voter registration is done online. 

Credit: Center for American Progress, 2025

Furthermore, while the act imposes no direct fee to vote it requires Americans to provide documentation that can only be obtained by paying a fee. Obtaining documentation that requires payment will discourage low-income rural residents from even participating. Under this act, rural voters will face longer travel time, higher costs, and fewer alternatives. These barriers will not just inconvenience voters but will prevent participation in the voting process.

Energy poverty burdens rural America, especially as the climate warms

Mt. Sherman, Arkansas 

Credit: Lisa R. Pruitt, 2009

Rural areas produce much of the energy that our nation relies on. Sixty percent of coal plants are located in rural areas, and 83% of wind, solar and geothermal energy is produced in rural regions. Even so, families living in poverty in rural areas are more likely to experience energy poverty. Energy poverty is the inability to pay utility bills to heat or cool a home. A report by the Island Institute explained that the median energy burden (percent of income spent on energy bills) is 33% higher for rural households than the national median. 

Inability to pay for utilities can increase exposure to heat or cold, leading to various health risks such as respiratory issues, heart problems, allergies, and kidney disorders. Climate change has exacerbated exposure risks due to the greater frequency of extreme weather conditions.

Rural areas face these energy inequities because of rising energy costs and a lack of investment. Across the country, residential electricity costs have increased 30% since 2021 and residential gas costs have increased 40% since 2019. The geographic isolation of many rural areas makes it more expensive to deliver energy and provide energy efficiency upgrades. 

Investor-owned utilities in the early twentieth century didn't want to provide the same service in rural areas as in urban areas because the lower population densities in rural areas made profits too low to justify construction and investment. In 1935, the Rural Electrification Agency (REA) was created. The REA utilized a "rural cooperative model" which allowed for publicly owned and controlled electricity. While this cooperative model has some benefits, rural cooperatives often lack capacity and resources to invest in more comprehensive energy efficiency programs. 

Additionally, rural areas are more likely to have older homes with worse insulation. In addition to houses being older, 20% of rural households live in manufactured homes (commonly called mobile homes), which are significantly less energy efficient and more costly to repair than traditional housing. 

AC Unit on Mobile Home

Credit: Creative Commons

How do we currently address energy poverty?

The Low Income Home Energy Assistance Program (LIHEAP) is a federally funded program that provides assistance to low-income households who face a high energy burden. Assistance can range from one-time financial assistance to free energy efficiency upgrades. A study done by the American Council for an Energy-Efficient Economy (ACEEE) found that weatherizing a home for families living at or below 200% of the federal poverty line can save an average singe family household $283. These savings are even greater for those living in manufactured homes per year and manufactured homes, at $458 per year.

Katrina Metzler from National Energy and Utility Affordability Coalition explained that rural areas have a harder time accessing LIHEAP benefits because the resources are not centralized as they are in urban areas. A 2024 survey found that only 17% of households that qualify for LIHEAP assistance utilize the program. 

LIHEAP's funding formula has historically provided more funding to cold-weather states. But climate change has caused a shift in the historical energy burden being faced by rural communities. Extreme heat is now the primary cause of weather-related deaths, with 2,302 heat-related deaths in 2023. This is a 44% increase from 2021. With rising temperature, regions such as the South and Southwest have greater cooling needs, while the heating needs in regions such as the North and Northwest have become less extreme. 

LIHEAP is still using a funding formula from the 1980s to determine how funding is distributed to states. With the changing climate, it may be time to shift the funding formula to better aid states struggling with extreme heat. 

Credit: ACEEE

What are states doing?

Nine states have implemented percentage-of-income payment plans (PIPPs). This type of program caps energy bills at a specified percentage of household income for low-income customers. Fourteen states provide low-income households energy at a discounted rate to keep costs low.

Additionally, 10 states offer arrearage management plans, which forgive a portion of debt for each timely payment of a new bill. This helps to defeat the energy bill debt cycle that many households in energy poverty face. One missed payment can turn into growing debt that threatens disconnection from service, forcing households to pursue risky options such as emergency aid or high-cost loans. 

The Rocky Mountain Institute modeled the cost of a universal PIPP, capping bills at 4% of annual income. They determined it would cost only $9.3 billion to fund this program, 0.14% of federal spending in 2024.

In 2024, Congress appropriated $4.125 billion in LIHEAP funding. Last April, the Trump administration sought to completely cut funding for LIHEAP, but full funding was eventually included in the appropriations package passed in February of this year.

LIHEAP is an essential program to ensure that rural households have some assistance with the crushing costs of utilities. Implementation of PIPPs, ideally at the federal level, could drastically reduce the burdens of energy costs on low-income rural families and prevent them from having to choose between buying food or having air conditioning during severe heat. 

The burden of the "American Dream" on rural communities

Photo Credit - Chelsea Peng 2025 "The end of the American Dream and why it’s OK"

On March 14, the House Committee on Small Business held a hearing called “Empowering Rural America Through Investment in Innovation.” Subcommittee Chairman Jake Ellzey, a Republican representing Texas's 6th Congressional District (a mix of Dallas-Fort Worth suburbs and rural counties like Navarro and Cherokee), told the room that “as the demand for AI accelerates, America’s digital infrastructure is rapidly expanding into rural communities.” He promised that for every data center job created, seven more would follow in the surrounding community.

I have spent this semester writing about technology arriving in rural America. The promise is always the same: innovation, jobs, progress. The pattern is also the same: the benefits flow out, and the costs remain.

Three posts, one pattern

In my first post, I wrote about a $25 billion AI data center planned for Tonopah, Arizona, population a few hundred. Backed by a billionaire venture capitalist and a Trump mega-donor, the project would consume as much electricity as a million homes and drain aquifers that residents depend on for drinking water. The tech consumers served by the facility live in cities. The residents of Tonopah got noise, light pollution, and a fight they lacked the political power to win.

In my second post, I stepped back from tech to look at the framing. I had caught myself thinking that rural investment came at urban expense. That zero-sum instinct turned out to be the wrong lens. The federal government spends $850 billion a year on defense and asked $1.8 billion for the Legal Services Corporation. The scarcity pitting rural against urban is a policy choice, not a fact of nature. Rural and urban working people have lost ground to the same forces and share the same interest in functional public services.

In my third post, I wrote about robotic strawberry harvesters arriving in Salinas Valley. Immigration enforcement had squeezed the farm labor supply. The federal government’s response was to lower guest worker wages, and then automation filled the gap. The robots cost $300,000 each, priced for corporate farms. Small growers and the farmworker communities who built Salinas for generations got nothing.

Each story has different characters and geography. But the structure is identical: federal policy creates or worsens a rural problem, and capital arrives promising solutions. The benefits accrue to investors/urban consumers and the people who already live there absorb the costs.

Photo Credit - Will Robinson 2020 "Is the American dream dead?"

The packaging

This pattern persists because it is wrapped in a story that Americans have been told their whole lives: that progress rewards hard work, that innovation lifts all boats, that the people who struggle simply need to adapt. This is the "American Dream," and I have come to believe it is one of the deepest sources of political paralysis in this country.

I said something like this in class a few weeks ago. I told Professor Pruitt and my fellow students that the American Dream is this country’s “original sin.” She pushed back, fairly, and pointed out that there are things about this country that are more original and more sinful. She’s right. Slavery, land theft, and genocide are the material foundations. But the American Dream is the legitimating story that makes those foundations look earned. It converts structural advantage into personal merit and structural disadvantage into personal failure.

I know this because I lived it. I grew up male, Mormon, white, healthy, and financially comfortable. My family believed fiercely in individual agency. I followed the rules and concluded that people whose lives were less "successful" than mine were in that position because of their own bad choices. It took college and a lot of unlearning to see that my “good choices” were only available because the structure was built for me.

The same logic operates at the community level. When a rural hospital closes after Medicaid cuts, residents blame the hospital, not the lawmakers who voted for the bill. When a farmer in Colorado threatens to mechanize rather than pay overtime, the framing is that labor protections killed the farm, not that the farm’s business model depended on paying workers less than the legal standard in every other industry. The American Dream teaches people to punch down and look away from the hand above them.

What would it look like to say no?

There are signs of resistance. At least 25 data center projects were cancelled across the United States in 2025 after community opposition, four times the number in 2024. Rural school voucher programs have been blocked by rural Republicans who understand that their public schools are the backbone of their communities. Bernie Sanders and Alexandria Ocasio-Cortez drew 10,000 people to Greeley, Colorado, a conservative town in Weld County, on a message of class solidarity across the rural-urban divide.

None of these are sufficient. But they share a feature that the American Dream framework lacks: they start from the premise that rural communities have the right to decide what happens to their land, their labor, and their resources. That premise is incompatible with a system that treats rural space as a site of extraction and rural people as obstacles to progress.

Congressman Ellzey’s hearing (referenced at the beginning of this post) promised rural America seven jobs for every data center. Nobody on the panel asked how many jobs, aquifers, and night skies those same communities would lose. Until that question gets equal time, the American Dream will keep doing what it has always done: blaming the most vulnerable among us for their poverty and lack of resources, while lionizing the most powerful people in this country as they get increasingly wealthy. 

SNAP under fire

Credit: USDA, May 2010
The Supplemental Nutrition Assistance Program (“SNAP”) has played a pivotal role as one of the most effective tools for combating food insecurity at a federal level. Food insecurity and food desserts often go hand in hand, and this blog has previously discussed their impacts. The current administration has proposed major changes to SNAP under the Make America Health Again (“MAHA”) campaign, but what exactly is happening? And how will those changes impact rural Americans differently than urban ones? 

In July 2025, Congress passed H.R. 1 (the "One Big Beautiful Bill"), which introduced significant federal cuts to a range of social programs, including SNAP. Beginning in October 2027, the law will change SNAP’s work requirement policy, payment error rate policy, and the share of administrative costs covered by the federal government.

SNAP time-limit work requirements require participants to spend at least 80 hours per month engaged in allowable activities such as employment or job training. Previously, applied these requirements only to “able-bodied adults without dependents.” This group included people between the ages of 18 and 54 without children or a work-limiting disability, and excluded those who were pregnant, veterans, experiencing homelessness, or youth aged out of foster care. The new law expands these requirements. Now, non-disabled adults aged 55 to 64 without dependent children and non-disabled adults ages 18 to 64 whose youngest dependent is between the ages of 14 and 15 must meet the work requirement. In addition, the current law removes previous exemptions for veterans, people experiencing homelessness, and youth who aged out of foster care.

Beyond work requirements, the law also changes how states are held accountable for SNAP benefit distribution. SNAP defines the payment error rate as “the measurement of the accuracy of active case review.” In simple terms, the rate reflects the percentage of SNAP benefits that states issued incorrectly, including both overpayments and underpayments. In the past, states with high payment error rates were required to implement corrective action plans and could face financial penalties only after sustained high error rates over multiple years. Under the new law, states with payment error rates exceeding six percent will be required to absorb a portion of their SNAP benefit costs.

However, past data suggests that this threshold is set too low. In 2024, only seven states reported payment error rates below six percent. Additionally, in an effort to increase cost-sharing, the federal government has reduced the percentage of administrative costs it will cover, lowering the federal share from 50 percent to 25 percent. Administrative costs include staffing, case management, eligibility verification, IT systems, and customer service infrastructure. Cutting federal support in half places a higher burden on state budgets and makes it difficult for states to reduce payment error rates and properly enforce SNAP eligibility requirements.

Consequently, this cost-sharing structure will likely impose the greatest hardships on under-resourced states. For example, based on Ohio’s previous error rates, the state could potentially be on the hook for $318 million in SNAP benefit costs.

In addition to restructuring how SNAP operates, policymakers have also pushed to change what participants can purchase with their benefits. The MAHA movement has pushed to restrict the types of food that can be purchased with SNAP benefits. For decades, federal policy allowed SNAP benefits to be used to purchase any food item except alcohol and ready-to-eat hot foods. States wishing to impose any additional restrictions were required to obtain a waiver from the U.S. Department of Agriculture (USDA). While these federal rules remain in place several states encouraged by the current administration, have applied for waivers that would prevent SNAP benefits from being used to purchase “junk foods.” Beginning January 1, 2026, a number of states, including Utah, West Virginia, Nebraska, Iowa, and Indiana, implemented restrictions preventing SNAP participants from using their benefits to purchase soda.

Supporters of the MAHA movement frame these changes as necessary to combat a national health crisis, critics disagree. Opponents highlight the barriers that many rural communities already face when trying to access food. In some areas, residents may only have access to gas stations or small convenience markets as their primary food sources. Additional restriction on eligible food purchases could leave SNAP participants with few practical options for using their benefits. Furthermore, health policy experts note that limiting choices does not guarantee that individuals will make “healthier” decisions. Instead, these restrictions that limit food purchasing options may undermine participants’ autonomy and dignity.

Taken together, these changes represent a significant shift in the federal approach to SNAP. Expanded work requirements, increased state cost burdens, and new restrictions on eligible food purchases may share how participants access and use benefits. These changes will be felt strongly in many rural communities with limited food access. One in seven rural households rely on SNAP. For these Americans, limited job opportunities, seasonal or unstable employment, and long distances to workplaces make it significantly harder to consistently meet work requirements, especially when reliable transportation and childcare options remain scarce.

The importance of pharmacies in rural areas

Pictured is Newfane Pharmacy, a rural pharmacy in Newfane, New York my family owns

Newfane has a population of roughly 3,400

When discussing access to healthcare in rural communities, the focus often centers on hospitals and physicians’ offices but rarely on pharmacies. Yet pharmacies are critical healthcare access points: they provide not only prescription and over-the-counter medications, but also direct access to highly trained healthcare professionals. Pharmacists counsel patients on medications, diagnoses, and general health concerns while serving as trusted, familiar faces in their communities. They answer questions about immunizations, referrals to medical services, common colds, heart attack symptoms, and even pet medications. Pharmacists have a uniquely valuable position in their community-- they possess specialized medical and pharmacological knowledge while maintaining close personal relationships with their patients. 

At the same time, rural hospitals are increasingly at risk of closure due to systemic challenges such as funding reductions, high operational costs, and insurance provider reimbursement inadequacies. An article written in November, 2025 from Boston University School of Public Health stated that over 100 rural hospitals have closed in the United States over the past decade. The article also reported that 700 rural hospitals are currently at risk of closing, with 300 of them being at immediate risk of closing. Rural healthcare systems are already strained, and hospital closures further restrict access to care and shift additional pressure onto remaining providers, including pharmacies, critical access hospitals and small clinics, all of which are already few and far between. 

As hospitals close and medical services shrink, rural pharmacies absorb much of the strain. They face growing patient volumes, inadequate reimbursement from insurers—sometimes resulting in financial losses on certain prescriptions—and increasing pressure to expand services such as compounding and immunizations. An analysis by the Rural Policy Research Institute found that 80% of rural independent pharmacies recieved reimbursement less than the cost of acquiring and dispensing medications. Some states, like New York, provide additional reimbursement rates for state medical programs in rural areas to bolster healthcare assess. Additionally, unlike chain pharmacies, independent pharmacies often have the flexibility to adapt. Many provide delivery services for patients without reliable transportation and they expand clinical offerings to fill gaps left by other providers.

Despite funding challenges and cuts, there are signs of support for rural healthcare infrastructure. On December 30, 2025, the New York State Department of Health announced that the state will receive $212 million in 2026 under the federal Rural Health Transformation Program to improve health care access and delivery in New York communities. While the announcement states that "to ensure the funding directly benefits rural residents across the state... [p]rogram implementation will be supported by ongoing stakeholder engagement, including feedback from providers, tribal and faith-based organizations, local leaders and community members to target resources where they will have the greatest impact," it remains unclear if the funds will truly reach rural areas in need. Nevertheless, programs like this are essential to sustaining healthcare infrastructure and providers in rural areas.

(An model antique pharmacy in upstate New York)

Some may argue that funding rural pharmacies is secondary to hospitals due to mail-order prescriptions or outsourcing of prescription services. Access to prescriptions has increasingly shifted to mail-order pharmacy services. While mail delivery can be convenient, particularly for maintenance medications, it presents its own set of challenges. Delays, incorrect dosages, stolen packages, or temperature-sensitive drugs compromised during transit can place patients at serious risk. Additionally, mail-order services do not offer the same in-person consultation and real-time problem-solving that community pharmacists provide. Although mail services play a role in rural healthcare delivery, policy efforts should prioritize sustaining brick-and mortar pharmacies that provide direct support. 

Recent retail pharmacy closures have further intensified the strain. The closure of all Rite Aid stores and numerous CVS locations has increased patient volume at independent pharmacies. With a large proportion of rural patients relying on government-funded insurance programs, reimbursement pressures can make profitability difficult. Independent pharmacists must balance delivering high-quality healthcare with managing the financial realities of running a small business. The dual responsibility of being a pharmacist and a business owner adds stress but many remain committed because of the meaningful and tangible impact they make in their communities.

With healthcare in rural areas experiencing increased strain, policymakers should consider how to strengthen pharmacies’ roles. Perhaps independent pharmacies should have the ability to prescribe some drugs in rural areas. Perhaps federal and state governments should allocate greater support to rural healthcare infrastructure compared to urban ones? Rural pharmacies are pillars of community healthcare—the question is whether policy will evolve to recognize, and adequately support, that reality.

Rural health "slush fund" distributions announced

Fall River Mills, California
(c) Lisa R. Pruitt 2018

The Centers for Medicare and Medicaid Services announced this week the establishment of the Rural Health Transformation Program in relation to Trump's "One Big Beautiful Bill" passed in July--and the so called "rural slush fund" that was a last-minute addition to that law.  An earlier post about that late addition to the law is here, also noting that it was added in part to secure the vote of U.S. Senator Lisa Muskowski's (Alaska) support for the law.  

The Rural Health Transformation Program website touts it as 

empower[ing] states to strengthen rural communities across America by improving healthcare access, quality, and outcomes by transforming the healthcare delivery ecosystem. Through innovative system-wide change, the RHT Program invests in the rural healthcare delivery ecosystem for future generations.

Its stated goals are: 

• make rural America healthy again
• sustainable access
• workforce development
• innovative care
• tech innovation

At the end of this post, I cut and pasted from this website more information about the structure and requirements.  For now, however, I want to focus on details of the distribution.  First, all states got a share of the distribution,  and the states that fared best were Texas, Alaska, California, Oklahoma and Montana.  That said, the award amounts to the states did not vary dramatically.  The average amount awarded to each state was $200 million, with the range from $147 million (New Jersey) to $281 million (Texas).  Here's an excerpt from the CMS announcement of the awards, which went to all 50 states.  

This unprecedented federal investment will help states expand access to care in rural communities, strengthen the rural health workforce, modernize rural facilities and technology, and support innovative models that bring high-quality, dependable care closer to home.

It includes this long quote from Health and Human Services Secretary Robert F. Kennedy, Jr.:  

More than 60 million Americans living in rural areas have the right to equal access to quality care.  This historic investment puts local hospitals, clinics, and health workers in control of their communities’ healthcare. Thanks to President Trump’s leadership, rural Americans will now have affordable healthcare close to home, free from bureaucratic obstacles.

It also features this direct quote from Dr. Mehmet Oz, the CMS administrator:  

Today marks an extraordinary milestone for rural health in America. Thanks to Congress establishing this investment and President Trump for his leadership, states are stepping forward with bold, creative plans to expand rural access, strengthen their workforces, modernize care, and support the communities that keep our nation running. CMS is proud to partner with every state to turn their ideas into lasting improvements for rural families.

Roll call covered the matter, with a focus on Texas.  Some key excerpts follow: 

Twenty percent of [a state's] score [on the application for the competitive part] was determined by a state’s policy actions, including vows to pursue waivers to ban SNAP users from buying certain items like soda and candy, reinstating the presidential fitness test for schoolchildren and requiring that medical schools teach students about nutrition, among other things. States could lose money in future years through a “rescoring” process if they don’t follow through on those initiatives, Oz said.

The remaining 30 percent is based on the strength of the ideas that states proposed in their applications.

Projects highlighted by CMS on Monday include ones that aim to expand access to preventative, primary, maternal and behavioral health care. States also are pursuing “food as medicine” initiatives, models to address chronic disease prevention and programs to shore up their health care workforce.

Critics had argued the amount of funding available is nowhere near large enough to offset reductions in federal Medicaid spending made by the reconciliation law, which amounts to $911 billion over 10 years. Sen. Susan Collins, R-Maine, who voted against the bill, had pushed for at least $100 billion in rural health funding.

The $50 billion would offset only about 37 percent of the estimated loss of federal Medicaid funding in rural areas, according to KFF, a health policy research organization.

But Dr. Mehmet Ozi is quoted as saying the funding is not intended to offset the reductions:  

The purpose of this $50 billion investment in rural health care is not to pay off bills.  The purpose of this $50 billion investment is to allow us to right-size the system and to deal with the fundamental hindrances of improvement in rural health care.

This excerpt from PBS Newshour coverage hits more squarely at the politics of the matter and what the Trump administration's CMS is trying to accomplish with these awards in relation to its wider "Make America Healthy Again" agenda: 

Several Republican-led states — including Arkansas, Iowa, Louisiana, Nebraska, Oklahoma and Texas — have already adopted rules banning the purchase of foods like candy and soda with SNAP benefits.

The money that the states get will be recalculated annually, Oz said, allowing the administration to "claw back" funds if, for example, state leaders don't pass promised policies. Oz said the clawbacks are not punishments, but leverage governors can use to push policies by pointing to the potential loss of millions.

"I've already heard governors express that sentiment that this is not a threat, that this is actually an empowering element of the One Big Beautiful Bill," he said.

Carrie Cochran-McClain, chief policy officer with the National Rural Health Association, said she's heard from a number of Democratic-led states that refused to include such restrictions on SNAP benefits even though it could hurt their chance to get more money from the fund.

"It's not where their state leadership is," she said.

Next, I quote from the analysis of a rural health care consultant working out of Texas, which came across my LinkedIn feed: 

Just reviewed the state allocations from CMS’s landmark $50B Rural Health Transformation Program, and the per‑rural‑person math is fascinating. I'm a CPA and I love excel...so you know I had to create my end of year fun facts related to the CMS awards for RHTP.

If you missed the announcement, here is a link to the full article. 

For context, the average award across all states is $1,957 per rural person.
Texas received $329 per rural person — a solid, meaningful investment in our rural communities. 

N.B.   It is not clear how this consultant is defining "rural" for purposes of these calculations.  

To put that in perspective:
Rhode Island: $31,525 per rural person
Just above Texas: Ohio ($345), NC ($360), PA ($390), MI ($413)
Next tier below RI: NJ ($5,343), AK ($4,949), MA ($3,332), DE ($3,231)

Texas’s total award is $1.4 billion over five years — the largest in the country. While we weren’t guaranteed the top spot, the hard work by the Texas team at HHSC on the application positioned us to lead in rural innovation.

I was personally hoping for closer to $2.1B, but we’ll take this $1.4B and put it to work transforming the rural health landscape across Texas. Huge congratulations to the HHSC team and all our partners who made this possible.

Here’s to an innovative, data‑driven 2026 and beyond for rural Texas! 🌟

Finally, I'm pasting here the details on the program (as promised above), which is essentially the call for applications: 

Program Structure

RHT Program funding is $50 billion to be allocated to approved States over five fiscal years, with $10 billion of funding available each fiscal year, beginning in fiscal year 2026 and ending in fiscal year 2030.

• 50% to be distributed equally amongst all approved States
• 50% will be allocated by CMS based on a variety of factors including rural population, the proportion of rural health facilities in the State, the situation of certain hospitals in the State, and other factors to be specified by CMS in the NOFO

Uses of Funds

States must use RHT Program funds for three or more of the approved uses of funds:Promoting evidence-based, measurable interventions to improve prevention and chronic disease management.

• Providing payments to health care providers for the provision of health care items or services, as specified by the Administrator.
• Promoting consumer-facing, technology-driven solutions for the prevention and management of chronic diseases.
• Providing training and technical assistance for the development and adoption of technology-enabled solutions that improve care delivery in rural hospitals, including remote monitoring, robotics, artificial intelligence, and other advanced technologies.
• Recruiting and retaining clinical workforce talent to rural areas, with commitments to serve rural communities for a minimum of 5 years.
• Providing technical assistance, software, and hardware for significant information technology advances designed to improve efficiency, enhance cybersecurity capability development, and improve patient health outcomes.
• Assisting rural communities to right size their health care delivery systems by identifying needed preventative, ambulatory, pre-hospital, emergency, acute inpatient care, outpatient care, and post-acute care service lines.
• Supporting access to opioid use disorder treatment services (as defined in section 1861(jjj)(1)), other substance use disorder treatment services, and mental health services.
• Developing projects that support innovative models of care that include value-based care arrangements and alternative payment models, as appropriate.
• Additional uses designed to promote sustainable access to high quality rural health care services, as determined by the Administrator.

This KFF Health News site tracked the states' applications for these funds.  

Congress (finally) renews Secure Rural Schools Act, through 2027

Congress voted overwhelmingly yesterday to renew the Secure Rural Schools Act.  Here's an excerpt from the Los Angeles Times coverage, by Hailey Branson-Potts, which leads with a bit historical perspective on rural schools lobbying efforts for the funding over the past few years:  

In February 2023, Jaime Green, the superintendent of a tiny school district in the mountains of Northern California, flew to Washington, D.C., with an urgent appeal.

The Secure Rural Schools Act, a long-standing financial aid program for schools like his in forested counties, was about to lapse, putting thousands of districts at risk of losing significant chunks of their budgets. The law had originated 25 years ago as a temporary fix for rural counties that were losing tax revenue from reduced timber harvesting on public lands.

Green, whose Trinity Alps Unified School District serves about 650 students in the struggling logging town of Weaverville, bounded through Capitol Hill with a small group of Northern California educators, pleading with anyone who would listen: Please renew the program.

They were assured, over and over, that it had bipartisan support, wasn’t much money in the grand scheme of things and almost certainly would be renewed.

But because Congress could not agree on how to fund the program, it took nearly three years — and a lapse in funding — for the Secure Rural Schools Act to be revived, at least temporarily.

On Tuesday, the U.S. House overwhelmingly voted to extend the program through 2027 and to provide retroactive payments to districts that lost funding while it was lapsed.

The vote was 399 to 5, with all nay votes cast by Republicans. The bill, approved unanimously by the Senate in June, now awaits President Trump’s signature.

“We’ve got Republicans and Democrats holding hands, passing this freaking bill, finally,” Green said. “We stayed positive. The option to quit was, what, layoffs and kids not getting educated? We kept telling them the same story, and they kept listening.”

Green, who until that 2023 trip had never traveled east of Texas, wound up flying to Washington 14 times. He was in the House audience Tuesday as the bill was passed.

In an interview Tuesday, Republican Rep. Doug LaMalfa, who represents a vast swath of Northern California and helped lead the push for reauthorization, said Congress never should have let the program lapse in the first place.

I don't agree with LaMalfa on many issues, but on this one he is absolutely correct.  

The five congresspersons who voted against the Act were: 

• Rep. Andy Biggs (R-AZ)
• Rep. Paul Gosar (R-AZ)
• Rep. Anna Paulina Luna (R-FL)
• Rep. Thomas Massie (R-KY)
• Rep. Ralph Norman (R-SC)

Here is an Ed Source story about the passage of the law, and here's an Oregon Public Broadcasting story focused on the significance of this funding to many counties in the Pacific Northwest.  CalMatters covered it here.  An announcement by New Mexico Congressman Gabe Vasquez, who says it means $9 million for his state's rural schools, is here. 

Finally, here is a February 2023 post based on Branson-Potts' previous story about California rural school administrators lobbying in Washington, D.C., for the Secure Rural Schools Act.   The term used there for the pittance represented by this spending--at least from the perspective of all federal spending: "budget dust."  

Rural public media struggling in the face of funding cuts

We became aware this summer, when the Trump administration announced cuts to public broadcasting and the abolition of the Corporation for Public Broadcasting, that rural areas would be hit especially hard.  This is because rural stations are more reliant on federal funding.  Rural areas also tend to have fewer media outlets, which means that those supported by public dollars are less easily replaced by the private sector--including in the reporting on weather and natural disasters.    

This week, Reveal reported on the closure of a public radio station, KYUK, in the Bethel/Kuskokwim Delta region of Alaska.  Here's an excerpt: 

When a typhoon hit Alaska, public radio station KYUK was on the air, broadcasting critical information about conditions, evacuations, and search and rescue operations. An estimated 1,600 people were displaced, and many were saved in the biggest airlift operation in state history.

“The work that we do in terms of public safety communication literally does save lives,” said Sage Smiley, KYUK’s news director.

KYUK is small, scrappy, and bilingual. It broadcasts in English and Yugtun, the language of an Indigenous population that lives in villages along two massive rivers. The station airs NPR content, but also high school basketball games, local call-in talk shows, and even a show hosted by the volunteer search and rescue team, answering listeners’ questions about ice conditions and safety. The station is a lifeline for this unique region.

KYUK covers an area the size of the state of Oregon, but after Congress passed the Rescissions Act over the summer, it lost 70 percent of its operating budget. Republicans have targeted public media since its inception in the late 1960s. But this is the first time they have successfully ended the Corporation for Public Broadcasting, wiping out more than $1 billion in funding for public media.

For more on that typhoon in mid-October, see NPR's coverage here. 

New angles on rural library closure, with a story out of central Washington

Library in Kingtson, Arkansas 2013

Major media outlets have published several rural library stories --most of them about the closure of rural libraries--in the past few years.  (Read some of them here). This latest, from the New York Times, is a bit more complex than most.  Anna Griffin reports form Tieton, Washington, population 1389, in Yakima County.  The headline is "Federal Cuts, Immigration Raids, and a Slowing Economy Hit Rural Libraries."  Here's the lede: 

Cole Leinbach, a librarian in Tieton, Wash., population 1,610, watched intently as a 7-year-old girl hunkered down with a book in a corner of the town’s one-room library. Her brother, 4, had opened a board game searching for potential toys. Their mother talked quietly on her phone in Spanish.

“This is what libraries are supposed to be,” he said, “just a place a mom can go with her kids for an hour to hang out and get some kind of enriching entertainment.”

But the Tieton library, which occupies a few hundred square feet in a side room at the city hall, is closing next month, a casualty of rising costs in Yakima County, Wash., shrinking help from Washington, D.C., financing decisions made decades ago and significant demographic change.

“I’ve had people come express dismay,” said Mr. Leinbach, who at 26 has been a librarian for about a year and a half. “A library is in a lot of ways a kind of civic symbol, a demonstration of a community’s commitment to itself. So what does it mean if that goes away?”

* * * 

That is a question a growing number of communities, many of them in Republican states, will be facing soon. In March, President Trump issued an executive order dismantling the Institute of Museum and Library Services, which has provided around $270 million a year to public and academic libraries to help pay for services such as summer reading programs, broadband internet access, lending between libraries, staff training and access to national databases.

Don't miss the rest of the Tieton, Washington story here.  

Farm Bureau skirts Obamacare (ACA) requirements on health plans

The Washington Post story is here, under the headline, "More states are offering cheap health plans to farmers, with a catch."  The lede follows:  

For years, Indiana farmer Corina Brant found herself squeezed on health care. Unable to qualify for Affordable Care Act subsidies, she worked an extra job that took her away from her farm duties.

That all changed in 2021, when she bought a policy for herself and her family under the Indiana Farm Bureau. It’s one of the growing number of states that allow these agencies — which lobby on behalf of farmers — to sell policies underwritten by large insurers such as UnitedHealthcare. The laws are modeled after a decades-old Tennessee statute that allows a state farm bureau to sell health coverage to farmers.

The catch: While these policies are inexpensive, they come with major restrictions. The plans cover checkups and most medical procedures, but they aren’t required to cover applicants with preexisting conditions or maintain coverage for someone who becomes seriously ill. In that sense, they resemble the cheap short-term plans that the Trump administration has pushed as a private-market alternative to the ACA. Critics call them “junk plans,” while proponents say they expand affordable options to an underserved group.

Bipartisan effort to re-open rural California hospital

I blogged this summer about the impending closure of the Glenn County Hospital in northern California, a closure attributable to a change in interpretation of a federal regulation regarding what counts as a "critical access" hospital.  Because of that changed interpretation, the hospital lost a critical funding stream and closed in early October, as reported here.  Now, however, U.S. Senator Adam Schiff and U.S. Congressman Doug LaMalfa, both from California, have introduced legislation that would restore the funding stream, leading to the possibility of the facility again opening.  Here is some detail of how that might work:

Schiff teamed up with Republican Sen. Cindy Hyde-Smith of Mississippi to introduce legislation that would amend the Medicare Rural Hospital Flexibility Program, which helps fund critical access hospitals. Their bill would allow hospitals designated critical access as of Jan. 1, 2024 – including Glenn Medical Center – to keep that status.

 Ana Ibara reports for CalMatters on why the effort is unlikely to be successful.  Here's an excerpt:  

Each proposal would restore the hospital’s “critical access” status, a designation that brings increased Medicare reimbursement and regulatory flexibilities that help small hospitals.

* * *

Changing federal policy to restore the hospital’s critical access status, however, would not enable Glenn Medical to reopen immediately. Even if Congress approves Schiff’s or LaMalfa’s bill, the hospital is still left with another problem: reopening a closed facility requires cash, and lots of it.

“Having the critical access designation reinstated, which is my understanding of what the bill would do, that at least makes [reopening] a possibility,” said Matthew Beehler, a spokesperson for American Advanced Management, the for-profit company that owns Glenn Medical Center and several other rural hospitals in California.

But, he said, “the reality is once the employees have left, you’re starting from scratch. We need to see this be successful first and then work with electeds to help identify potential funding sources,” he said.

Beehler did not have an exact figure, but reopening Glenn Medical, he said, would cost in the tens of millions of dollars.

Catching up on rural healthcare stories

I wrote several posts about rural healthcare this summer, mostly prompted by the consideration and passage of Trump's One Big Beautiful Bill, which was widely discussed as undermining rural health care and rural hospitals.  Since then, I've neglected the issues except to address some of them in this forthcoming law review article, which focuses on the challenge of maternal mortality for rural women.  

In this post, my plan is just to provide links to the stories I've seen about rural health care since the summer, making this something of a repository of resources to study how rural health care is faring in the Trump administration's first year and likely further degradation of services as a consequence of recent Republican policies.

First off, the Trump administration is withholding support to tsunami proof this hospital.  Katia Riddle reports from Astoria, Oregon.   One interesting aspect of this story is how local Republicans who supported Trump are flummoxed--or worse--about his administration's failure to support a rural hospital that has saved many local lives.  Here's some context:   

The Trump administration has canceled billions of dollars in federal grants across multiple agencies, and one of those grants is for a program that was designed to help local governments fortify places that are vulnerable to natural disasters.

* * *  

[The hospital in Astoria], called Columbia Memorial, was built decades ago. Now that we know more about earthquakes, it's hard to imagine a worse spot to build a hospital. Not only is the whole town in a major subduction zone, the building is just a few blocks from the water, on top of dangerously unstable ground.

And here's a key quote from a former mayor of Astoria, Willis Van Dusen, a Republican who voted for Trump but now is frustrated by the recent turn of events regarding the needed hospital work: 

Van Dusen: What is more important than a hospital in a rural community like Astoria? Now, it saved my life.

Riddle: Van Dusen points to a framed photocopy of a piece of paper - the EKG reading when he had a heart attack some years ago. At one point, he flatlined.

Van Dusen: All these are (imitating electric current), and they're hitting the paddles. And I had actually died.

Riddle: It was doctors at Columbia Memorial that brought him back. Van Dusen says he and many other people in Astoria wouldn't be here without this hospital. Making sure that it can keep providing care during an earthquake and a tsunami, he says, is the opposite of waste, fraud and abuse.

Van Dusen: And just to jerk that money away from us, I can't just say it makes - it's frustrating. It makes me livid. It makes me angry.

Riddle: Van Dusen says he's not the only one in this town who's mad.

Van Dusen: I know every single Republican that I have talked to is livid over what's happening.

This is a rare instance when I've seen a Trump voter whose mind has been changed by Trump's spending priorities--and how those priorities have played out in the voter's own community.  It shows that Trump voters can be swayed when Trump's spending priorities impact them, something rarely illustrated.  

Regarding the $50 billion "rural health fund," sometimes referred to as the rural slush fund, Sarah Jane Tribble of Kaiser Health News reported about ten days ago on how states are competing for these funds.  It hardly seems like a fair fight.   Tribble provides details on how and why substantial chunks of the funds might not even wind up in rural places:  

Nationwide, states are racing to win their share of a new $50 billion rural health fund. But helping rural hospitals, as originally envisioned, is quickly becoming a quaint idea.

Rather, states should submit applications that "rebuild and reshape" how health care is delivered in rural communities, Centers for Medicare & Medicaid Services official Abe Sutton said late last month during a daylong meeting at D.C.'s Watergate Hotel. Simply changing the way government pays hospitals has been tried and has failed, Sutton told the audience of more than 40 governors' office staffers and state health agency leaders — some from as far away as Hawaii.

"This isn't a backfill of operating budgets," said Sutton, CMS' innovation director. "We've been really clear on that."

Rural hospitals and clinics nationwide face a looming financial catastrophe, with President Trump's massive tax-and-spending law expected to slash federal Medicaid spending on health care in rural areas by $137 billion over 10 years. Congressional Republicans added the one-time, five-year Rural Health Transformation Program as a last-minute sweetener to win the support of conservative holdouts who worried about the bill's financial fallout for rural hospitals.

Yet, the words used by CMS Administrator Mehmet Oz and his agency's leaders to describe the new pot of cash are generating tension between legacy hospital and clinic providers and new technology-focused companies stepping in to offer new ways to deliver health care.

It's "what I would call incumbents versus insurgents in the rural space," said Kody Kinsley, a senior policy adviser at the Institute for Policy Solutions at the Johns Hopkins School of Nursing.

I further detail possible non-rural uses of the fund in my forthcoming law review article, which relies on Tribble's reporting. 

Finally, Abigail Ruhman reported for the Texas Tribune a few weeks ago on how Texas' rural hospitals are competing for a piece of that "rural slush fund."  

As Texas develops its application for a new rural health funding program, rural hospital leaders say the priority should be financial stabilization for their facilities.

The recent sweeping tax and spending plan includes a $50 billion appropriation for the Rural Health Transformation program. States will receive funding based on applications they submit in early November.

During an hours-long public hearing Monday to discuss the program, several hospital leaders raised concerns that without direct funding, the state may experience more rural hospital closures.

Erin Clevenger, CEO of Memorial Medical Center in Port Lavaca, southeast of Victoria, said her hospital is high on the list of Texas hospitals at risk of closure.

“Every day is a battle to make sure we don’t become one of those statistics,” Clevenger said.

In the last decade, Texas has lost 14 rural hospitals. Of the 156 rural hospitals currently in the state, about 70% have lost services, and more than half are at risk of closing, according to a report from the Center for Healthcare Quality and Payment Reform.

Memorial Medical Center is in the southern part of the state, but it provides critical services that benefit people across Texas – even patients in Dallas.

“When even large urban hospitals could not take on more patients, we opened a COVID care unit and accepted their transfers, even flying patients in from Houston and Dallas,” Clevenger said.

Keep an eye out for more news about whether rural hospitals are getting the benefit of the "Big Beautiful Bill" and its rural slush fund--and whether any funds they receive are sufficient to keep them open.  It'll also be interesting to see if the anticipated closure of rural hospitals will turn rural Trump supporters against him--if those closures happen during his presidency.  

Meanwhile, the reduction and reinterpretation of other federal funding streams, along with other strains,  have been threatening--and in one instance, closing--hospitals in rural California.  Read more here (Inyo County in the eastern Sierra) and here (Imperial/Riverside County).