This research summary draws on insights generated by America’s Rural Future: Brookings-AEI Commission on U.S. Rural Prosperity.
Executive summary
Health care delivery in rural America is fundamental not only to the physical health of its residents, but also to the economic and social wellbeing of its communities. Rural hospitals, clinics, and related health systems provide essential care across large geographic areas, often serving as major employers, sources of local stability, and anchors of broader community life. Yet many of these systems face long-standing financial strain, persistent workforce shortages, service cutbacks, and provide uneven access to specialty and preventative care.
At the same time, rural health care infrastructure is entering a period of significant transition. These long-standing pressures are now colliding with major policy changes, new delivery methods, demographic shifts, and technological adaptations that could reshape how care is organized, financed, and accessed in rural places. This moment raises a set of difficult questions: What services rural communities should be able to access locally, how the costs and risks of maintaining that access should be distributed, and whether current reforms and innovations will strengthen rural systems without exacerbating existing weaknesses.
This symposium examined the structure of the rural health care delivery system across the United States; the trends shaping its financing, workforce, and physical infrastructure; and the innovations that may help modernize care delivery in rural communities. The conversation was designed to clarify the most significant pressures facing rural health care, identify emerging points of leverage, and surface practical insights relevant to the long-term stability and effectiveness of rural health care systems as anchors of community wellbeing and economic resilience.
Opening panelists examined the current state of rural hospitals and clinics, financing models, and the health care workforce, while underscoring the role of health systems as economic and social anchors in rural communities. Subsequent discussion focused on how the implementation of H.R. 1, the rollout of the Rural Health Transformation Program (RHTP), and other health policy changes are shifting the environment in which rural health care is delivered. The discussion then turned to exploring how telemedicine, new care models, value-based systems, and community-centered planning are being used to improve access and quality in rural settings—and what conditions are necessary for those strategies to remain viable and effective over time.
Across these discussions, participants repeatedly returned to an underlying tension: Rural communities benefit from reliable, locally responsive systems of care, but the institutions that deliver that care face compounding headwinds. Access to health care affects rural residents’ wellbeing and is a key ingredient in local economic and community development, but it is eroded by higher marginal costs, pressures from public and private insurers, workforce shortages, and rapid policy changes that are creating significant stress on the system.
A 2025 analysis from the Sheps Center found that many rural hospitals in the U.S. face some level of financial distress. Yet participants suggested that the core issue is not simply whether rural hospitals and clinics should remain in their current form: Policymakers and stakeholders need to develop shared expectations for the level and type of care that rural residents should be able to access locally, versus services that might be delivered regionally. Separate analyses underscored that workforce shortages are affected by structural considerations: the geography and cost of medical education, the origin and socioeconomic status of students, and even state policy choices on issues such as provider liability and access to contested clinical services like abortion, which influence where clinicians choose to live and practice.
Policy changes now underway will affect rural health care unevenly across states, providers, and patient populations. Participants noted that modifications to Medicaid and SNAP, the expiration of pandemic-era enhanced subsidies for the Affordable Care Act, and related fiscal pressures may produce widely different outcomes depending on states’ policy choices, budget constraints, and administrative capacities. The Rural Health Transformation Program was broadly seen as a potentially important opening for experimentation, but not as a substitute for financing gaps that continue to grow. Much will depend on whether its implementation gives states enough flexibility to tailor their approaches based on their local and regional realities. Participants also questioned whether current timelines are long enough to address workforce capacity, strengthen local systems, and assess long-term outcomes.
The final discussion made clear that innovation in rural health care is not primarily about technology. While technological innovations such as telemedicine and AI-enabled tools can extend the reach of care and improve efficiency, they are unlikely to make rural health care viable on their own without parallel changes to payment, workforce, and care delivery systems. Participants emphasized that sustainable reform depends on organizational design, payment viability, workforce integration, regulatory flexibility, and community engagement and involvement. Successful models, they suggested, are often co-designed with communities or residents themselves; at a minimum, these systems must be adapted to local conditions and supported by durable financing and governance. Taken together, these tools and broader operational reforms could help rural communities build more sustainable and locally responsive models of care.
Key insights
Participants highlighted the following as foundational elements for evaluating and improving rural health care infrastructure:
- Rural health care infrastructure is both a delivery system and an anchor of rural economic vitality. Rural health care should be seen as essential to the viability of rural areas that provide the energy, food, and fiber essential to the nation as a whole.
- Policy discussions would benefit from an emphasis on what health services rural communities should be able to access locally and under what conditions, rather than simply preserving the health care infrastructure system in its current form.
- Current and future projected rural physician shortages are a distributional problem with multiple factors: rural underrepresentation in medical education, the geography of training facilities, training and certification systems and costs, and the quality-of-life conditions that shape where physicians decide to practice.
- Relocation incentives are unlikely to solve rural health workforce gaps. Rural student recruitment and matriculation, rural-serving training infrastructure, medical school affordability, and the role of Advanced Practice Providers (APPs) will likely matter more than expanding efforts to attract non-rural physicians into rural practice.
- As rural patients increasingly bypass local facilities when seeking specialized care, policymakers should design rural health systems that meet primary health needs locally and consider delivering more complex services through regional solutions or connections to metro health systems, where delivery can benefit from scaling of services. Differentiating among emergency, acute, specialized, and primary care will be important when designing solutions, as well as recognizing the differences between small rural hospitals, which may play a multi-faceted role locally, and larger regional health systems.
- The policy environment for rural health care is shifting consequentially, with H.R. 1’s Medicaid and SNAP changes, the expiration of enhanced ACA subsidies, and the rollout of the Rural Health Transformation Program.
- With these changes, rural residents face disproportionate risk of becoming uninsured, and as they continue seeking care or move to private coverage (including Medicare Advantage), providers will have to absorb additional strain from lower reimbursement rates and stricter coverage parameters.
- The RHTP can catalyze innovation, but its effectiveness depends on implementation capacity and flexibility, and it will not offset coverage losses or ease the broader financing pressures challenging rural health care sustainability.
- Without stronger local capacity, clearer metrics, and longer time horizons, rural communities may bear the burden of reform without being positioned to shape or evaluate it effectively.
- Telehealth and AI-enabled tools are creating new possibilities for extending capacity, improving efficiency, and expanding access in places where workforce and specialty services remain limited.
- Innovations in rural health care are more likely to succeed when they are integrated into communities, guided by local priorities, and designed to strengthen rather than replace existing local systems and relationships.
- Rural health care efficiency should be measured against the needs and cost structure of the communities being served, not against urban payment and spending benchmarks.
Ongoing debates and research priorities
Symposium participants reached broad agreement on the insights above, but several tensions remain unresolved. Each debate below pairs competing arguments with the research that could help adjudicate between them.
1. Fiscal sustainability versus local access
Debate. One view holds that fiscal sustainability must take precedence and that policy should consider consolidation, service redesign, or closure where local volume cannot support comprehensive services. A competing view holds that meaningful local access is a non-negotiable obligation in rural communities and that fiscal frameworks should be designed around that commitment rather than fiscal constraints. A related divide runs between those who argue for preserving rural hospitals and comprehensive care and those who argue for redirecting investment toward alternative infrastructure such as emergency-only models, outpatient systems, Emergency Medical Services (EMS), and distributed specialty access.
Research needed. What standards or benchmarks can help define the appropriate level of local health care access for different kinds of rural communities? Under what conditions are different delivery models, including small and large rural hospitals, Critical Access Hospitals, Rural Emergency Hospitals, Rural Health Clinics, Federally Qualified Health Centers, and other alternative service and delivery models best positioned to meet community needs?
2. Evaluating rural facility performance
Debate. One position holds that cost and utilization metrics designed for urban and suburban systems are sufficient and that rural facilities should be held to the same performance standards as any other provider. A competing position holds that these metrics may understate the value of rural facilities, that community and economic impacts belong in the evaluation frame, and that small rural hospitals warrant distinct treatment because of their scale, patient mix, and role in local infrastructure.
Research needed. How can the return on investment of rural health care infrastructure be measured in terms of economic and community impacts, not only clinical or financial outputs? How do mergers, acquisitions, and system consolidation affect both care quality and the financial stability of rural hospitals and other facilities?
3. Public programs versus private payers as drivers of rural strain
Debate. One view attributes much of the growing financial pressure on rural providers to imminent Medicaid policy changes. A competing view argues that private payer behavior, particularly Medicare Advantage coverage restrictions and reimbursement practices, is at least an equally significant driver, and that the current policy conversation gives attention to public-program reforms while underweighting the role of private insurers. Complicating the situation are differing views on the types of financing models that are most sustainable for rural providers, given current demographics and escalating costs.
Research needed. Which payment models best serve rural providers, and how does that vary across differences in delivery? What reforms to public and private payment structures would most directly stabilize rural finances?
4. Rural workforce pipelines versus relocation incentives
Debate. One argument holds that relocation incentives are the fastest and most scalable tool for addressing rural workforce shortages, given the time required to build training pipelines. A competing argument holds that relocation incentives produce short-tenure placements and that sustained workforce gains require investment in rural representation in medical education, rural-origin recruitment, and affordable training pathways, which current policy underfunds.
Research needed. What policies could meaningfully increase applications from rural students to medical schools and expand physician training in rural communities at scale? What models could support growth across the broader rural health workforce beyond physicians?
5. H.R. 1 implementation choices
Debate. One view holds that H.R. 1 imposes fiscal and administrative burdens severe enough that state strategy should focus primarily on minimizing disruption to existing rural patients and providers. A competing view holds that H.R. 1 implementation also opens genuine opportunities for structural reform, and that states that focus only on damage control will miss the chance to reshape rural delivery on better terms.
Research needed. How are different state implementation decisions affecting patients and providers, and which state-level decisions merit consideration by others to replicate?
6. The scope and limits of the RHTP
Debate. One view holds that the RHTP can seed durable transformation even within a five-year window, if paired with flexibility, technical assistance, and loosened practice boundaries that unlock provider-led innovation. A competing view holds that the workforce and system-building goals of the RHTP extend well beyond five years, that the program’s current funding is insufficient (especially amid H.R. 1 changes to Medicaid and SNAP) to catalyze lasting improvements to rural health care, and that stronger public design is required to balance innovation against access obligations and provider viability.
Research needed. What evaluation framework is appropriate for the RHTP, and how should success be measured given the diversity of state strategies, the limited time horizon, and the difficulty of capturing infrastructure and workforce gains on a short timetable? How can the causal impacts of the RHTP and concurrent Medicare and Medicaid reforms be separately identified? What payment and regulatory reforms are most likely to keep rural innovations locally anchored after pilot or catalyst funding ends?
7. Place-specific access versus national infrastructure
Debate. One framing treats rural health care challenges as place-specific access problems to be solved by community through targeted interventions. Variations at the local level, including differences in local economies, demographics, geographic features, and overlaps with Tribal sovereignty, seem to reinforce this place specificity. An alternate framing treats them as a national infrastructure issue tied to labor force participation, economic resilience, and the communities that sustain key sectors of the national economy, which implies sector-specific federal or state investments, rather than locally tailored interventions.
Research needed. Which innovative rural delivery models are genuinely scalable, and which depend on place-specific institutions, workforce conditions, or governance arrangements that make replication difficult? How should policymakers incorporate tribal systems into rural health reform frameworks, especially in states where tribal delivery serves as the effective public health infrastructure for entire regions?
Related Content
Relevant resources
Aspen Health Strategy Group. “Meeting the Health Needs of Rural America.” Aspen Institute, February 10, 2026. https://healthmedicineandsociety.org/wp-content/uploads/2026/02/Meeting-the-Health-Needs-of-Rural-America-FINAL-2.pdf
Cecil G. Sheps Center for Health Services Research. “Rural Hospital Closures.” University of North Carolina at Chapel Hill. https://www.shepscenter.unc.edu/programs-projects/rural-health/rural-hospital-closures/.
Center for Healthcare Quality and Payment Reform. “Problems and Solutions for Rural Hospitals.” Saving Rural Hospitals. https://ruralhospitals.chqpr.org/Overview.html
Chatterjee, Paula, Eliza Macneal, and Rachel M. Werner. “Rural Health Transformation Program Allocations and Rural Health Needs in the US.” JAMA, March 5, 2026. https://jamanetwork.com/journals/jama/fullarticle/2845968
Graboyes, Robert F., and Darcy Bryan. “Virtual Health in a Post–COVID World: Optimizing Regulation, Reimbursement, and Regularity.” Mercatus Research Paper, March 2022. SSRN, posted August 9, 2022. https://papers.ssrn.com/sol3/papers.cfm?abstract_id=4052777.
Hulver, Scott, Zachary Levinson, Jamie Godwin, and Tricia Neuman. “10 Things to Know About Rural Hospitals.” KFF, April 16, 2025. https://www.kff.org/health-costs/10-things-to-know-about-rural-hospitals/
McGinnis, Tricia, and Rob Houston. “Launching Rural Health Transformation Plans: Lessons from Other Large-Scale State Initiatives.” Center for Health Care Strategies, February 2026. https://www.chcs.org/resource/launching-rural-health-transformation-plans-lessons-from-other-large-scale-state-initiatives/
Patterson, Davis G., et al. “Growing a Rural Family Physician Workforce: The Contributions of Rural Background and Rural Place of Residency Training.” Health Services Research, February 2024. https://onlinelibrary.wiley.com/doi/10.1111/1475-6773.14168
Pope, Chris. “Assuring Essential Rural Hospital Care.” Manhattan Institute, July 17, 2025. https://manhattan.institute/article/assuring-essential-rural-hospital-care.
Scanlon, Dennis, et al. “The Pennsylvania Rural Health Model: Hospitals’ Early Experiences With Global Payment for Rural Communities.” Journal of Healthcare Management, May 1, 2022. https://pubmed.ncbi.nlm.nih.gov/35261348/
Sigaud, Liam. “Provider Taxes Do Not Save Rural Hospitals.” Paragon Health Institute, March 6, 2026. https://paragoninstitute.org/paragon-prognosis/provider-taxes-do-not-save-rural-hospitals/.
Walensky, Rochelle P., and Nicole C. McCann. “Challenges to the Future of a Robust Physician Workforce in the United States.” New England Journal of Medicine, January 16, 2025. https://www.nejm.org/doi/full/10.1056/NEJMsr2412784
Authors
Compiled by
America’s Rural Future: Brookings-AEI Commission on U.S. Rural Prosperity is a bipartisan endeavor to enable rural prosperity by strengthening economic opportunity, resilience, and quality of life across rural America. Learn more.
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Acknowledgements and disclosures
The Brookings Institution is a nonprofit organization devoted to independent research and policy solutions. Its mission is to conduct high-quality, independent research and based on that research, to provide innovative, practical recommendations for policymakers and the public.
The Brookings-AEI Commission on U.S. Rural Prosperity and associated work is supported by the Robert Wood Johnson Foundation, Ascendium Education Group, CoBank, and The SCAN Foundation.
The conclusions and recommendations from the commission are solely those of its author(s), and do not reflect the views or policies of Brookings or AEI, their management teams, other scholars, or the funders acknowledged above.
The Brookings Institution is committed to quality, independence, and impact.
We are supported by a diverse array of funders. In line with our values and policies, each Brookings publication represents the sole views of its author(s).
Commentary
Rural health care infrastructure: Trends and considerations for the future
Research summary of America’s Rural Future symposium | March 12, 2026
May 26, 2026