The carcinogenic classification of glyphosate faces new pressure

Glyphosate, the most widely used herbicide in the world, is a controversial product in agriculture due to its potential carcinogenic effects. In 2015, the International Agency on the Research for Cancer (IARC) published a monograph concluding that glyphosate is “probably carcinogenic to humans.” However, in February 2020, the U.S. Environmental Protection Agency (EPA) issued an interim registration review decision (ID) finding glyphosate poses “no risks of concern to human health when used in accordance with its current label.”

© Kristy Ardalan 2024.

On March 20, 2020, the Natural Resources Defense Council challenged the EPA’s ID in the U.S. Court of Appeals for the Ninth Circuit. In May 2021, the EPA requested—and the court granted--a partial voluntary remand without vacatur of the ecological portion. The EPA later withdrew the entire ID, and the status of glyphosate remains under reconsideration.

As of 2026, the EPA maintains that there is no evidence glyphosate causes cancer in humans; there is no indication glyphosate is an endocrine disruptor; that residue on food items are safe for consumption; and that ecological risks are low, with the exception of potential harm to bees.

Despite these conclusions, public skepticism remains high. The widely publicized Monsanto Roundup litigation—through which Monsanto has paid nearly $11 billion to tens of thousands of plaintiffs alleging cancer caused by Roundup—has intensified doubts about the EPA’s classification. Additionally, organizations such as the Environmental Sciences Europe and the World Health Organization have criticized the EPA for failing to adequately consider individuals with heightened exposure, such as farmworkers and nearby residents. The Center for Food Safety has also cited emails between an EPA scientist and a Monsanto officer that suggest “coordinated efforts to undermine the legitimacy of IARC’s… determination.”

White House Easter celebration 2023.

© Kristy Ardalan 2024.

On February 18, 2026, President Trump signed an executive order titled “Promoting the National Defense by Ensuring an Adequate Supply of Elemental Phosphorus and Glyphosate-Based Herbicides.” A related fact sheet states that the order is intended to “protect domestic production of elemental phosphorus and glyphosate-based herbicides” which are “essential to military readiness and America’s agricultural strength.” The fact sheet emphasizes that currently only one domestic company produces elemental phosphorus and glyphosate-based herbicides. It also notes that the demand in the U.S. far exceeds current output, which “gravely endangers national security and defense” including food-supply security.

A particularly controversial provision of the order grants immunity to domestic producers that comply with federal law.

The famously polluted Potomac River in Washington, D.C.

© Kristy Ardalan 2023.

Environmental groups, such as the Waterkeeper Alliance, have strongly criticized the order arguing that “it puts chemical industry profits above public health and clean water.” Granting immunity for industrial chemical producers that follow federal directives makes it harder to hold them accountable for harm to human and environmental health. As discussed in this prior blog post, critics also point to broader legislative trends—such as provisions in the recent farm bill—that may weaken environmental protections, including removing dozens of pesticides from health and environmental safety reviews, granting the USDA power to block EPA health and environmental safeguards, removing Clean Water Act protections that limit pesticide pollution, etc.

However, there are signs of legislative pushback. On February 20, 2026, Representatives Thomas Massie (KY) and Chellie Pingree (ME) introduced the bipartisan “No Immunity for Glyphosate Act” to Congress in effort to undo the February 18 executive order. Representative Pingree stated “If there was ever any doubt about whose side this Administration is on, this Executive Order makes it crystal clear: Big Chemical comes first, and the health of Americans comes last.” Representative Massie similarly argued that “If the goal is to 'Make America Healthy Again,' the federal government should not be using its authority to promote or protect the production of glyphosate.”

© Iowa Environmental Council and The Harkin Institute, Environmental Risk Factors and Iowa’s Cancer Crisis, p. 9. Data from the National Cancer Institute state cancer profiles.

The No Immunity for Glyphosate Act was introduced to Congress shortly before a disruptive report from the Iowa Environmental Council and the Harkin Institute for Public Policy and Citizen Engagement titled “Environmental Risk Factors and Iowa’s Cancer Crisis” was released on March 25, 2026. The report focuses on pesticides, PFAS, Nitrate, Radon, and other industrial contaminants in Iowa. The Executive Director of the Iowa Environmental Council stated that the report “demonstrates clear links between environmental pollution and our health and well-being.” As found in the 2020 census, the majority of Iowans live in rural areas and the rural areas are surrounded by endless fields of corn all likely sprayed with glyphosate. The graph below shows that rural residents in Iowa experience and live around the most dense pesticide application areas in the United States and the cancer rates reflect that.

A map of counties depicting high and low cancer rates

© Investigate Midwest, National Cancer Institute, and the CDC

Iowa’s cancer rate exceeds the national average by more than 10%, with a particularly elevated rates among individuals under 50. The state has the highest number of concentrated animal feeding operations (CAFOs) in the country, a number more than 2.5 times as many CAFOs than the next highest state. With emerging research linking glyphosate and other environmental contaminants to adverse health outcomes, pressure is mounting for legislative action—and soon.

Recent reports identify rural public health interventions, some with potential to mitigate Medicaid cuts

U.S. Department of Public Health Building.
Image courtesy of Boston Public Library. 

Healthcare in rural America finds itself a topic of much discussion lately, with mainstream media coverage of the crisis unfolding after Medicaid cuts by the Trump administration's 2025 budget reconciliation bill, which was signed into law July 2025. By some estimates, the new law will increase the number of uninsured people by 10 million in 2034. Other coverage concerns the fate of a $50 billion rural health slush fund that is yet to pay out in the communities who need it most and the recent slew of hospital closures in rural communities.

While the new restrictions on Medicaid eligibility and reduced federal spending will be felt across the nation, rural communities will be hit especially hard, due to the higher rates of people on Medicaid in nonmetropolitan areas. Sarah Jane Tribble, reporting for KFF Health News, writes: 

People who live in the nation’s rural expanses have more chronic diseases, die younger, and make less money. Those compounding factors have financially pummeled rural health infrastructure, triggering hospital closures and widespread discontinuation of critical health services.

Hospital closures (online tool showing a map of recent closures) exacerbate the present struggle to meet rural healthcare needs, where people are generally more vulnerable and less likely to utilize primary care services due to structural barriers like cost and provider shortages. In 2016, Dr. Julia T. Caldwell et al. published a paper in the American Journal of Public Health, which states that "[r]ural adults are less likely to be insured, less likely to use healthcare, and more likely to delay seeking care than urban residents." To put it plainly, access to acute care is bleak in much of rural America right now, and reductions in Medicaid spending and eligibility are poised to make things worse. 

Rural hospital closures, 2005-2010 (in blue) and 2010-present (in yellow).
Graphic courtesy of Sheps Center for Health Services Research, UNC. 

There is, however, another dimension of the rural health conversation that is gaining traction in public discourse – rural public health. Where the trends in healthcare are alarming, improvement in public health feels tractable. This post focuses on insights from two recent reports – this one from the Aspen Institute (Feb. 2026) and this one from California's Department of Public Health (Feb. 2026) – to highlight opportunities for high-impact rural public health intervention amid the ongoing healthcare crisis. 

Public Health: Rurality in Focus

In general, the healthcare industry aims to treat people who are sick or injured, whereas public health seeks to keep people from getting sick or injured in the first place. According to the American Public Health Association, healthcare focuses on individualized care; public health focuses on entire populations. Because a key responsibility of public health is to collect, analyze, and interpret health data to inform timely public health interventions, policies, and resource planning, it is more likely to analyze and include the axes of identity and experience that inform vulnerability. In fact, rurality has been an axis of analysis in public health research for decades. "Place," meaning where people live, work, and play, is widely understood by experts in the field as a fundamental social determinant of health.

In February 2026, the Aspen Institute and the California Department of Public Health each published reports that examine, in significant detail, the state of rural public health. The Aspen Institute Report is titled "Meeting the Health Needs of Rural America," and represents the tenth installment in the Aspen Health Strategy Group's mission to tackle a single health issue annually through year-long, in-depth study. The California Department of Public Health Report, the State's second-ever "California State of Public Health Report," ("Cal. DPH Report") carves out tens of pages devoted to risks, trends, and interventions specific to rural children, adolescents, and adults.

All-Cause Mortality Rate by Race and Ethnicity in Urban/Rural
Areas, California 2022-2024 (Cal. DPH Rep., p. 32)

This post focuses on one paper from the Aspen Institute Report titled Population Health in Rural America: Changes, Challenges, and Opportunities, authored by rural demographer Shannon M. Monnat and sociologist Tim Slack. Their paper tees up several useful policy proposals, which provide a path to remedying the so-called "rural mortality penalty" – the name for a widening disparity where rural U.S. residents experience higher age-adjusted mortality rates than urban counterparts. The authors suggest that the relative recency of the rural mortality penalty, which emerged in the data only four decades ago, "provides reason to believe it can be reversed." (Aspen Inst. Rep., p. 5). 

Systemic Risks and Opportunities 

Each report does a thorough inventory of factors driving mortality rates across the lifespan, from infants to working-age adults to the elderly. Unsurprisingly, barriers like lack of access to healthcare, transportation, healthy food, broadband internet, and other social services are central to their findings. But each goes a step further to do some accounting of recent social and economic trends driving the numbers: substance abuse and misuse; growing gaps in educational attainment; and persistent economic disinvestment that has hollowed out local institutions and workforce pipelines. Environmental risks (including climate change) and exposures also explain recent losses in resilience and increases in mortality rates. These overlapping stressors compound, reinforcing cycles of poor health outcomes that are difficult to interrupt through healthcare access alone. 

Adult Mortality Rates in Nonmetropolitan (Rural) Counties,
2000-2022 (Aspen Inst. Rep.)

Writing for the Aspen Institute, Monnat & Slack characterize "rural economic and human health" as "intertwined." The data in both studies bears this out. Lower income, wealth, and levels of educational attainment correlate strongly with shorter lifespans and fewer years lived in good health. Importantly, both reports frame these outcomes not as inevitable features of rural life, but as the product of policy choices and disinvestment patterns that can be changed. The California report, in particular, emphasizes that upstream interventions–those that target education, early childhood development, and economic stability–offer some of the highest returns for improving long-term health outcomes (Cal. DPH Report). 

The reports identify education policy reform as a major inroad for uplifting rural communities struggling with economic disinvestment and population decline. 

Education, particularly possessing a bachelor’s degree, has become an increasingly important determinant of health and longevity in the United States. Higher education confers economic, social, and lifestyle advantages that manifest as a “personal firewall” that protects health, even in the face of external and unpredictable threats, such as pandemics, recessions, and natural disasters.

(Aspen Inst. Rep., p. 76). Investments in vocational programs, community colleges, and early childhood education programs like Head Start not only improve education and employment outcomes, they also provide measurable health benefits over time. Many health outcomes and disparities in adulthood are rooted in childhood conditions such as family and community health, neighborhood safety, policies, and systems" (Cal. DPH Report, p. 58). By strengthening local economies and expanding opportunities, these interventions address root causes of poor health, rather than treating symptoms as they occur. In this way, rural public health policy begins to function as a cross-sector strategy for community resilience. 

Conclusion 

The current crisis in rural healthcare access underscores the need for action, but it also highlights the limits of a healthcare-only response. As the reports analyzed in this post make clear, improving rural public health outcomes requires sustained investment in the social and economic conditions that shape health, long before a person ever becomes a patient. Public health offers a framework for identifying upstream opportunities and making interventions where they can have the greatest impact. In the face of hospital closures and shrinking coverage, this broader approach might provide a path forward: one that treats rural health not only as a medical issue but as a function of place, policy, and long-term community investment.

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. 

A 2026 Farm Bill enters the House…

On February 13, 2026, the Farm, Food, and National Security Act of 2026, an updated version of the Farm Bill, was introduced in the House of Representatives. Shortly afterwards, on March 4th, the House Agriculture Committee voted 34-17 to advance the bill to the House floor, marking the first major legislative step in process likely to be long and contentious, given the recent extreme polarization on the U.S. Congress.

Supreme Court of the United States in 2023

It's high time for a new farm bill-- the last official version, the Agriculture Improvement Act of 2018, was authorized for 5 years, spanning from 2018 to 2023. Updates to the Farm Bill after 2023 were stalled by political gridlock. Instead of passing a new Farm Bill in 2023, Congress opted for two consecutive one-year extensions of the outdated 2018 framework.

At last, lawmakers are attempting to move forward with a new Farm Bill that will update how the federal government supports or defunds a range of programs affecting agriculture, food systems, conservation, and rural communities across America.

Farm bills have been introduced to Congress starting in 1933. The first one followed the catastrophic impact the Great Depression and the Dust Bowl had on American farmers. In response, the federal government created programs designed to stabilize farm income, conserve land, and ensure a stable food supply. You can read more about the history of the farm bill here or in this prior blog post. Indeed, many posts going back to this blog's inception in 2007 mention the Farm Bill.

Throughout the years, the Farm Bill has grown into one of the federal governments largest and most comprehensive policy packages, typically spanning hundreds or thousands of pages. Programs housed under the Farm Bill include SNAP funding, crop insurance, conservation programs, rural development programs, agricultural research, food distribution programs, and beyond. 

This Farm Bill claims to “expand investments in rural communities, bring science-backed management back to our national forests, and restore regulatory certainty in the interstate marketplace.”

Within the report, two sections specifically caught my eye—the MAHA section and the discussion surrounding California’s Proposition 12. Both sections highlight how the Farm Bill increasingly serves as a platform for broader political debates.

Somerset, El Dorado County, California

(c) Lisa R. Pruitt 2025

MAHA Section
The highlighted MAHA section references the Make America Healthy Again (MAHA) movement within the current administration led by Robert F. Kennedy. MAHA aims to address national health issues. As expressed in the one-pager released by the House Agriculture Committee on MAHA in this Farm Bill, the goals of MAHA are to “renew our lands, reforming dietary guidelines to focus on sound nutrition science, ensuring that rural America has access to quality healthcare, and making whole foods such as fruits and vegetables more affordable and accessible for everyday Americans.”

This Farm Bill codifies recent reforms to the Dietary Guidelines for Americans (DGAs) which include prioritizing whole, high-quality protein and full-fat fluid milk and hard cheeses. This Farm Bill also proposes the incorporation of these guidelines into SNAP which may impact which foods are promoted within federal nutrition assistance programs. 

Sign in Sonoma County

(c) Lisa R. Pruitt 2024

Another initiative highlighted in this one-pager is the establishment of a “local procurement program” that will in theory strengthen partnerships between local producers and the “food distribution community” in effort to ease fresh food distribution.

On paper, the idea sounds promising. Strengthening local food systems could support farmers while improving access to healthier foods. However, the proposal remains vague-- it is not clear (at least to me) who, how, or where these programs will take place.

Another major component of the MAHA section focuses on rural healthcare, an issue that has become increasingly urgent as rural hospitals close and rural healthcare systems become increasingly stressed, as I discussed in this prior blog post.

Clinic in McCloud, California

(c) Lisa R. Pruitt 2018

This bill proposes expanding programs affecting rural healthcare including the Distance Learning and Telemedicine Program, the Community Facilities Program, and the Rural Hospital Technical Assistance Program (RHTAP). RHTAP is codified within the bill with the goal of “improv[ing] the financial and operational sustainability of rural healthcare facilities, bolstering essential health services for rural residents and preventing hospital closures in their hometowns.” This program originally received funding through the Rural Development Hospital Technical Assistance Program Act of 2025, which appropriated up to $2 million per year from 2025-2029. The proposed Farm Bill extends that funding window, restating the maximum funding for the fiscal years 2027-2031. As I mentioned in this blog post, politicians use policy packages such as this to signal their support of rural farms, families, systems, etc.. Yet the monetary value proposed in each case is insignificant to the cause. Here, $2 million spread among the countless rural healthcare systems that are in serious need is negligible.

Proposition 12 Section
Another section highlighted by the House Committee on Agriculture focuses on California’s Proposition 12 (Prop 12), one of the most controversial livestock welfare laws in the United States. Passed by 63% of California voters in 2018, Prop 12 prohibits the sale of certain pork, veal, and egg products in California unless they are produced according to certain animal welfare standards. These standards focus on enclosure size compliance. 

Chickens in transportation truck in Northwest Arkansas

(c) Lisa R. Pruitt 2017

Corporations like the National Pork Producers Council (NPPC) advocate for repealing Prop 12 to allow for the sale of animal products from animals raised in smaller and confined spaces. The American Farm Bureau Federation and the National Pork Producers Council brought suit against the California Department of Food and Agriculture asserting that Prop 12 violated the Dormant Commerce Clause. The Supreme Court upheld Prop 12, yet the current administration and House Republicans have attempted to overturn the decision and influence public opinion or legislatures not to support it anymore—for example, through this one-pager. In this one-pager, the House Committee on Agriculture calls Prop 12 “arbitrary and unscientific.” They state that “retail pork prices in California have increased 18.7% compared to a 6.3% increase nationwide. They then state that “[c]ompliance costs disproportionately affect small and mid-sized producers, who face tighter margins and less access to capital.” While small or mid-sized facilities may be affected more than large ones, Prop 12 has been fully in effect since 2022. I support Prop 12 and find that since the majority of California voters supported it, the NPPC and the MAHA movement should reassess their priorities.

Ultimately, the Farm Bill has increasingly incorporated broader policy debates, but the 2026 rendition highlights how influential national debates and administrations can be on this hallmark legislation. Programs initially intended to support farmers, rural communities, and ecological conservation are now debated at length in an effort to gain an inch of power or influence. However, a new Farm Bill was desperately needed to address the everchanging landscape—especially post-COVID and entering a likely recession.

On town hobbies and country hobbies

  On my way to go shoot trap, sometime in 2024, somewhere in Colorado 

 

I spend a lot of time outdoors and in rural locales for my hobbies. I shoot a great deal of trap, and hike even more. Despite the common belief that fresh mountain air and the cool ocean breeze would be just what the doctor would prescribe, I would not say that these rural hobbies are good for my health. Between the lead exposure, my ever increasing appetite for nicotine that perks up only outdoors, and my increasingly protestant knees and hips, I would say that overall it's actually quite the opposite.

Upper Yosemite Falls, Yosemite, 2024 

Much has been written on this blog about the rates of firearm ownership and hunting in rural localities (Read more here and here respectively). Despite high rates of participation in these forms of recreation, participation in other forms of physical activity are in decline. (Physical activity is defined by another study). 

Anecdotally, I have spent some time in a hunting blind and did not move more than ten meters in a 48-hour timespan once we were established. If rural hobbies are more commonly sedentary or, at least less physically active than urban hobbies, this may partially explain the higher rural rates of certain health disorders related to sedentary lifestyles. It seems, then, that there is a rural/urban health divide when it comes to hobbies.

This hobby health divide is aggravated by the fact that some rural hobbies may even be dangerous to their participants. Lead exposure is a common issue amongst recreational shooters. Any personal injury attorney or orthopedic surgeon can give you horrific war stories about the dangers of ATV and dirtbike riding (Here's a forthcoming study from the University of California, Davis). Municipal laws that allow for the burning of wood campfires impact particulate concentrations in the air, only one degree upstream of increased rates of asthma and other respiratory illnesses (Read the EPA warning here). All three of these hobbies (still necessities for some), hunting (read more here), ATV/dirtbike riding, wood burning stoves correlate to rural areas.

I believe this disparity in health reflects tension in either the health benefits of the hobbies available to rural/urban denizens, or the accessibility of health beneficial hobbies to rural residents. Even outdoors biking or jogging requires specific accommodating infrastructure, such as bicycling or walking paths. These activities may be impossible or at least unsafe in car centric rural areas. I am unsure of any potential solutions to this divide. Any sort of increased regulation on dangerous hobbies is likely seen as paternalistic, a stance already disfavoured in rural places. Rural folks may see such infrastructure as an urban affront to rural practicality. 

One potential investment that could increase rural population health is that of encouraging youth athletic participation. This may happen at the municipal or state level via increased funding of sports fields and competitions. Suburban children participate in sports longer and earlier than rural children. Studies on public health indicate that these sports can have positive downstream effects on adulthood health. By increasing the already high rural participation in youth sports, rural populations may be induced to be healthier as they age if they keep participating in these recreational activities. 

On the way to Lake Hensley, California, 2025

Additionally, wooded areas and pools of water are still required to fish and hunt. What happens where there is no infrastructure at all for any type of recreation?  Public health studies have documented the higher rates of drug and alcohol use in rural and poorer areas. There are less studies on specifically the proliferation of drug use given a lack of recreation, but it's not hard to imagine a correlation there. Consider the old adage of, "idle hands are the devil's workshop."

I'll close with a personal anecdata point. In my mind’s eye, I am in a rural part of Manitoba. The municipality is landlocked. The altitude in the area varies not more than 20 meters. The highest point is a landfill lovingly called garbage hill hours away in the city of Winnipeg. In the winter, the average temperature is -19C and the lakes and streams freeze over. There are no oceans or mountains to escape to. I asked my friend from there what there is to do. He shrugs, and we very quickly got drunk.

    Elk on the way to Point Reyes, California, October 2025

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.  

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.

Getting to the bottom of the rural health "slush fund"

When the U.S. Senate passed Trump's "Big Beautiful Bill" a few weeks ago, considerable attention was paid to the sweetheart deal the administration had made with Alaska Senator Lisa Murkowski.  Initially skeptical and critical of the bill because of the impact it would have on rural Alaska (read more here), Murkowski eventually signed on to support the act after the Trump administration made concession to Alaska, including a $50 billion program for rural health.  

On Marketplace (American Public Media), Sarah Jane Tribble of Kaiser Health News breaks down how this so-called "slush fund" would work.  Here are some key excerpts about the so-called Rural Health Transformation Program: 

The Rural Health Transformation Program calls for federal regulators to hand states $10 billion a year for five years starting in fiscal year 2026.

But the “devil’s in the details in terms of implementing,” said Sarah Hohman, director of government affairs at the National Association of Rural Health Clinics.

“An investment of this amount and this style into rural — hopefully it goes to rural — is the type of investment that we and other advocates have been working on for a long time,” said Hohman, whose organization represents 5,600 rural health clinics.

People who live in the nation’s rural expanses have more chronic disease, die younger, and make less money. Those compounding factors have financially pummeled rural health infrastructure, triggering hospital closures and widespread discontinuation of critical health services like obstetrics and mental health care.

Nearly 1 in 4 people in rural America use Medicaid, the state and federal program for low-income and disabled people. So, as Senate Republicans heatedly debated Medicaid spending reductions, lawmakers added the $50 billion program to quell opposition. But health advocates and researchers doubt it will be enough to offset expected cuts in federal funding.

Senate Majority Leader John Thune, a Republican from South Dakota, which has one of the largest percentages of rural residents in the nation, led the push to pass the budget bill. His website touts support for strengthening access to care in rural areas. But his office declined to respond on the record to questions about the rural health program included in the bill.

The story also notes Tribble's efforts to get comments from Senator Susan Collins of Maine, another state with a significant rural population.  Senator Josh Hawley of Missouri, having voted for the "big beautiful bill" is pushing for a reversal of its cuts to Medicaid and an increase in the "rural program," which presumably refers to the $50 billion fund. 

From the think tank, libertarian sector, Tribble gives us this note of skepticism: 

Michael Cannon, director of health policy studies at the Cato Institute, a libertarian think tank headquartered in Washington, D.C., said the money was set aside because of politics and not necessarily for rural patients.

Here is a further quote from Cannon:   

As long as it’s a government slush fund where politics decides where the money goes, then there’s going to be a mismatch between where those funds go and what it is consumers need.

I can't help wonder by what factors and with what algorithm Cannon determines "mismatch." 

Here's a full report from KFF on the so-called rural health slush fund.  

"Rural" all over the news as Senate passes "Big Beautiful Bill" that will undermine rural services, especially health care

Analysis of what Trump's "Big Beautiful Bill" would do to rural health care has been in the news for several weeks, and it stayed there today as the Senate passed the Bill by a vote of 50-50, with Vice President J.D. Vance breaking the tie.  

What follows appeared on the Ezra Klein Show today, July 1, but much of it was recorded in advance in anticipation that the bill would pass.  Here, I'm just going to highlight the bits about rural health care, including as they relate to "red state" voters: 

Klein: [T]hey are very substantially cuts to the Republican Party’s voters. They’re cuts to Republican states. They’re cuts to Republican hospitals — rural hospitals in areas that vote for Republicans and are very dependent on the care that gets financed by Medicaid in order to stay open.  (emphasis added)

This is the Republicans’ old ideology coming into conflict with their new coalition.

Yglesias:  Absolutely. If you look at the share of people who are on Medicaid by state, there are seven states where more than a quarter of the population is on Medicaid.

One of them is New York, and one of them is California. But the other five are New Mexico, Louisiana, Arkansas, Kentucky and West Virginia.

And then you look at states like Mississippi and Alabama: If they would accept Medicaid expansion funding, there’s a huge, potentially eligible population share in those states.

It’s a big conflict inside the heart of Republican politics. [Details about Mitch McConnell and Kentucky] 

There’s just a conflict between the Republican Party electorate and their ideology, which has shifted in some ways but really remains focused on low taxes, on investment income, low corporate taxes and wanting to cut spending on programs for the poor.

About work requirements and how they've worked out so far, Klein and Yglesias shared this conversation:

The most conservative states don’t accept Medicaid expansion funds. They have tried to impose work requirements in Arkansas, for example.

(Read more about the Arkansas experiment here and here.) 

So we ran the experiment: Does putting work requirements on Medicaid increase employment? And the answer was no. When they did it, employment didn’t go up. People did lose coverage, but employment didn’t go up.

And Republicans didn’t reverse course after that. They didn’t say to themselves: Oh, our goal here was to get more people working, but we didn’t succeed at that. They said: You know what? This cut the rolls. It cut spending. We’re happy with that.

That’s a free market view: If you want a television, you’ve got to pay for it yourself. If you want chemotherapy, you’ve got to pay for it yourself.

On work requirements, I published this three years ago in Politico.   

Here's more from Yglesias, on perverse incentives: 

There’s this threat that hospitals will go out of business. I’m in Maine right now in a very rural area, and hospitals don’t have a ton of customers here. If they lose let’s say 10 percent or 15 percent of their customer base and have higher uncompensated care burdens — some of the facilities will just close.

Senate Republicans have discussed creating a hospital bailout fund to prevent this, but it seems crazy to me to address hospitals’ business model problems by giving them direct payments to stay in business even though they’re not treating patients, rather than just letting people get the treatment they need.  (emphasis added)

Senator Lisa Murkowski of Alaska ultimately voted for the bill, but only after she was offered big concessions for her state.  Read more about those here.  Apparently, one of those concessions was to double to $50 billion (from an initial $25 billion) the amount in a fund that would support rural hospitals.  Another related to how SNAP will be administered in Alaksa. 

Also instructive is this interview by NPR with Kaiser Health News reporter Sarah Jane Tribble, published yesterday, leading with Juana Summers questioning Tribble: 

SUMMERS: Rural America is poised to be greatly impacted by these proposed cuts. Roughly 20% of the U.S. population lives in rural areas where Medicaid covers 1 in 4 adults. Here to talk about what could be at stake for those communities is Sarah Jane Tribble. She's the chief rural correspondent for KFF Health News. ...

Sarah, just start if you can by telling us a bit about what you have been hearing from people in rural communities across this country about these proposed cuts.

TRIBBLE: Yeah, I'm not hearing good things. They're very concerned, because Medicaid rates are so high in rural America, that these cuts will be very detrimental, they'll cause more hospitals to close, they'll tax rural health clinics. I was sitting next to a CEO of a rural hospital from Colorado. He has a 25-bed critical access hospital, the only hospital between the Kansas border and Denver on the Colorado I-70 corridor. And he had been talking about the cuts and not happy about them. And then we heard about the rural transformation fund that the Senate has been working on to sort of help offset the cuts. And he leaned over and he just scoffed. He just said, that's just not going to be enough. So I think that there's a lot of concern out there in rural America.  (emphasis added) 

Here's a late June NPR story about the ripple effects the cuts are likely to have on hospitals in rural Colorado, this one focused on the San Luis Valley in the southwest part of the state.  Here is a key excerpt from the story by John Daley: 

"I'm trying to be worried — and optimistic," said Konnie Martin, CEO of San Luis Valley Health in Alamosa. It's the flagship health care facility for 50,000 people in six agricultural counties — Alamosa, Conejos, Costilla, Mineral, Rio Grande and Saguache.

The numbers out of the bill about deep Medicaid cuts were "incredibly frightening," Martin said, "because Medicaid is such a vital program to rural health care."

Martin's hospital is not alone. "I think in Colorado right now, nearly 70 percent of rural hospitals are operating in a negative margin," in the red, Martin said.

Here's a late June Washington Post story about Medicaid as a "lifeline" in West Virginia.  

Supreme Court decision on Planned Parenthood and Medicaid will undermine rural health

The U.S. Supreme Court today ruled (quoting the Associated Press) that 

States can block the country’s biggest abortion provider, Planned Parenthood, from receiving Medicaid money for health services such as contraception and cancer screenings.  

 The case rose to the Supreme Court from South Carolina.  The Associated Press explains: 

South Carolina Gov. Henry McMaster, a Republican, said Planned Parenthood should not get any taxpayer money. The budget bill backed by President Donald Trump in Congress would also cut Medicaid money for the group. That could force the closure of about 200 centers, most of them in states where abortion is legal, Planned Parenthood has said.

Several news outlets have mentioned the impact that this decision will have on rural healthcare.  NPR brings us this: 

Planned Parenthood's president and CEO, Alexis McGill Johnson, in an interview with NPR, said the decision would have widespread ramifications and would allow seventeen states to strip Planned Parenthood clinics of the ability to provide non-abortion medical services to rural and low income people.  (emphasis added)

The story further quotes Johnson:  

It's a dark time [when] a health center has to close, any time a patient is not able to get the care that they need.  That is a dark time because we can provide that care for our nation's most vulnerable. 

Black lung spreads to younger miners due to complications from silica

Kate Morgan reports from the New York Times from a trip across Appalachia to learn about black lung disease's newest manifestation, which implicates silica and is affecting younger miners.  Some key excerpts follow:

Modern miners are contracting [black lung disease] at younger ages and at rates not seen since the 1970s. For 20th-century miners, it could take decades to develop severe black lung. For men of Aundra Brock’s generation, just a few years can be enough. Nationwide, one in 10 working miners is now estimated to have black lung. In the heart of the central Appalachian coal fields, it’s one in five. Often, their disease is more severe, the progression faster. Doctors are seeing larger masses and more scarring in the lungs. Transplants, disability claims and deaths are all on the rise.

* * *  

In an old industry, the reasons are modern. Centuries of extraction have altered the landscape, making the mountains more dangerous to mine, researchers say, and the men beneath them vulnerable not just to black lung, but to another lung disease called silicosis.

* * * 

Silicosis is caused by inhaling a mineral called crystalline silica that is typically found in sand, stone and concrete. It is a building block of the Appalachians. But in the air, it is dangerous, able to create much worse scarring in the lungs than coal dust alone. Breathing the coal and silica dust together can create a kind of hybrid disease that quickly leads to progressive massive fibrosis.

Scientists and miners alike have long understood the dangers of the rock dust. “You can tell there’s silica when you see the flicker in it,” said Charles Thacker, a 69-year-old former miner from Norton, Va., who now has black lung. “It looks like bits of glass flashing in the light. It’s almost pretty. But that’s what gets in your lungs and cuts you up.”

Don't miss the rest of the story, which is chock full of human interest context.   Also, I want to mention that the ravages of silica on miners was a topic of discussion at this event at West Virginia University College of Law this spring.  (See the panel at 11:00 am).

Building blocks: how a lack of childcare infrastructure is hurting children and their parents

In mid-March, The Daily Yonder published a piece detailing social worker and filmmaker Laura Norton-Cruz’s efforts to bring awareness to the lack of childcare infrastructure in rural Alaska. Norton-Cruz is intimately familiar with the shortage of childcare, and the problems this shortage creates for rural Alaskan families. The Daily Yonder writes:

Norton-Cruz remembers finding out that she was pregnant and feeling like she’d just been “thrown to the wolves.”  “What am I going to do about child care?” she asked. “What am I going to do about breastfeeding and pumping at work? What am I going to do about paid leave?"

Over a decade after becoming a single mother, Norton-Cruz enlisted the help of filmmaker Joshua Branstetter and created At Home/In Home: Rural Alaska Childcare in Crisis, a documentary that would provoke Alaska’s state legislature.

Norton-Cruz’s documentary focuses on Kotzebue, Alaska, a rural town of 3000 residents, primarily Alaskan Native people. More than 500 children under the age of five reside in Kotzebue, yet the town does not have a single licensed childcare facility. 

Unfortunately, Kotzebue is not unique. According to a December 2024 report from the Alaska Governor’s Task Force on Child Care, 61% of Alaskans have limited or no access to licensed childcare facilities, even though over half of young children live in households where all parents are employed and need childcare.

The documentary portrays parents who are forced to leave jobs in childcare deserts, employers who cannot find employees, public officials who track the economic damage of the childcare crisis, and residents who battle the state childcare licensing system as they try to establish a home-based childcare facility.

Childcare deserts are not just present in rural Alaska. In fact, nearly two-thirds of American rural families live in a childcare desert. Childcare deserts are defined as areas where there are more than three young children for every licensed childcare slot available. 

Additionally, rural Americans spend more money and travel farther for childcare arrangements. On average, a rural family spends 12.2 percent of their income and travels 7.5 miles for childcare while urban families spend 10.8 percent of their income and travel 3.5 miles for childcare. (Read more about rural childcare here and here).

The lack of infrastructure to support women and children is a recurrent problem in rural areas, and expands beyond a lack of childcare. A 2023 CDC report found that only 31% of rural municipalities had some type of paid maternity leave in 2021 compared to 41.2% of urban areas, and 42.3% of rural municipalities provided break time and space to pump breast milk versus 55.4% of urban municipalities.

It is well documented that rural areas are also lacking in maternal care. As of 2024, 59% of rural counties qualify as maternity care deserts. As a result, rural women have consistently higher predicted probability of maternal mortalities, with 37.9 pregnancy-related deaths per 100,000 occurring in rural areas in 2020 and 31.2 deaths per 100,000 in micropolitan areas, compared to 29.9 per 100,000 in large metropolitan areas. (Read more about rural maternal health care here and here).

Alaska is a particularly challenging place to deliver health and human services due to its vast size, sparse population, extreme climate, and the unique needs of its diverse communities, including Native populations. As such, rural Alaskan populations often face even more extreme disparities in healthcare access and outcomes.

Thankfully, Norton-Cruz’s film has prompted the Alaskan governor to set up the Alaska Child Care Task Force, which has allowed Kotzebue residents to erect a home-based non-profit early learning program. Although residents admire the program’s progress, the early learning program only serves eight of the 500 children under the age of five in Kotzebue. Clearly, there is still much work to be done. 

Norton-Cruz continues to document the Task Force’s progress. She states:

We have to keep paying attention to this issue and keep the pressure on…because that’s what leads to changes in funding and changes in policy. We need to help employers, legislators, and leaders see that this is the most important part of child development and the most abandoned policy issue of our time.