Rural Communities Face Growing Health Care Access and Affordability Pressures

-Editorial

More than 66 million Americans live in rural areas, where patients and health care providers face challenges ranging from hospital finances and workforce shortages to long travel distances for medical services. Health policy experts say changes to Medicaid and Affordable Care Act coverage could add to those pressures in the coming years.

About one in five Americans lives in a rural area, and roughly 8.4% of rural residents are uninsured, according to figures presented during a recent American Community Media briefing on rural health care.

Financial problems facing rural hospitals have emerged as a particular concern. According to May 2026 data from the Center for Healthcare Quality and Payment Reform, 720 rural hospitals were considered at risk of closing, including 294 at immediate risk of closure within two to three years.

Dr. Katherine Hempstead, senior policy adviser at the Robert Wood Johnson Foundation, said those financial pressures come on top of longstanding health and economic challenges in rural communities.

“Rural areas have inherent health challenges even in advance of these profound policy changes that we’re talking about today,” Hempstead said.

Hempstead said rural communities generally have higher poverty rates, older populations and greater rates of chronic disease than urban areas. They also face shortages of health care providers and longer travel distances for medical services.

Many small rural hospitals already operate with narrow or negative financial margins, she said, while the relatively low population density makes delivering health services more expensive.

Those conditions could become more significant as changes to Medicaid and other federal health programs take effect.

The Congressional Budget Office estimates that provisions of the 2025 federal reconciliation law will reduce federal Medicaid spending by about $1.2 trillion between 2026 and 2035. CBO projects the changes will reduce Medicaid enrollment by 12.9 million people and increase the number of uninsured Americans by 7.5 million in 2034 compared with projections without the changes.

Hempstead said rural communities could be particularly affected because residents are more dependent on Medicaid and Affordable Care Act marketplace coverage and less likely to receive insurance through an employer.

“When many of these people lose their coverage, that translates into a big revenue problem for hospitals,” Hempstead said. “Of course, it’s an even bigger problem for the people that are losing coverage.”

The effects could extend to residents who retain insurance, she said. Hospitals facing financial problems may close or reduce services, affecting Medicare beneficiaries and people with employer-sponsored coverage as well as uninsured patients.

Hempstead pointed to farmers and other self-employed workers as examples of rural residents who have relied on ACA marketplace coverage. Higher premiums can have a significant effect on those households, particularly older farmers who generally face higher premiums, she said.

Hospital closures are not the only concern. Hempstead said financially struggling facilities may discontinue services such as maternity care or chemotherapy, requiring patients to travel farther for treatment.

“If people have to travel beyond a certain distance to access health care, it really becomes difficult to live in certain places,” Hempstead said.

The federal government has sought to address some rural health challenges through the Rural Health Transformation Program, which provides $50 billion to states over five years, from 2026 through 2030. The money is intended to support initiatives including workforce development, technology, infrastructure, telehealth and new approaches to delivering health care in rural communities.

Hempstead said she does not believe the program is large enough to offset other reductions in federal health spending. She also said much of the funding is intended for long-term changes to health care delivery rather than immediate operating expenses for hospitals.

“The cash flow problems of rural hospitals are immediate,” Hempstead said.

Federal officials have described the program differently, saying the funding is intended to modernize rural health systems, strengthen the health care workforce, improve infrastructure and expand access to services.

The financial pressures facing rural hospitals are already evident in Tennessee, according to Dr. Amy Gordon Bono, a primary care physician who has practiced east of Nashville for 15 years.

Bono described a patient in her early 60s who worked as a caregiver but did not have employer-sponsored health insurance. The woman had coverage through an ACA marketplace plan but eventually stopped making payments because she could no longer afford them, Bono said.

The patient subsequently went without regular medical care and medications before suffering a stroke and receiving treatment at a rural Middle Tennessee hospital, Bono said.

“This patient is in her early 60s,” Bono said. “She doesn’t have access to Medicare just yet, and she doesn’t have access to employer-sponsored health insurance.”

Tennessee is among the states that have not expanded Medicaid eligibility under the Affordable Care Act. Bono said that leaves some low-income working adults without access to Medicaid or employer-sponsored coverage.

Bono cited Center for Healthcare Quality and Payment Reform data indicating that 36% of Tennessee’s rural hospitals face serious financial problems and at least 12 are considered at immediate risk of closure.

She said financial pressures have also contributed to reductions or consolidation of specialized services, requiring some rural patients to travel greater distances for treatment.

“Distance from specialized health care means death,” Bono said, referring to patients experiencing emergencies such as serious vehicle crashes or high-risk pregnancies in remote areas.

Dr. Neale Mahoney, a professor of economics at Stanford University and George P. Shultz Fellow at the Stanford Institute for Economic Policy Research, said policymakers are considering several approaches to health care affordability and coverage, including changes involving Medicaid, ACA subsidies and patients’ out-of-pocket expenses.

Mahoney said having insurance does not necessarily protect families from significant medical expenses because deductibles and other forms of cost sharing can leave patients responsible for thousands of dollars.

“In rural communities, 92% of people have insurance coverage, but for many of these people, their insurance isn’t there when they need it,” Mahoney said.

He said policy proposals under discussion include limits on out-of-pocket expenses and various approaches to expanding public insurance options. Such proposals remain subjects of political debate and would require action by Congress or federal officials.

The issue can be particularly significant in rural communities, Mahoney said, because residents and small employers may have fewer insurance companies and health care providers from which to choose.

Hempstead also addressed health care access among immigrants living and working in rural areas. She said eligibility for Medicaid depends on factors including state policy and immigration status, while federally qualified health centers and free clinics provide another source of care for some people without insurance.

She said concerns about immigration enforcement may also discourage some people from seeking medical services or enrolling in programs for which they are eligible.