Bringing Healthcare to the People
Rural communities face unique challenges, such as geographic isolation, limited healthcare infrastructure, workforce shortages, and diminished access to health insurance options. These challenges drive increasing health disparities, often spanning across multiple generations. Could community health fairs and mobile health clinics finally level the playing field, addressing regional health disparities, often disproportionately impacting 13 states, 423 counties, and 8 independent Virginia cities in what we commonly call the Appalachian region (AL, GA, KY, MD, MS, NC, NY, OH, PA, SC, TN, VA, WV)?
Rural communities face unique challenges, such as geographic isolation, limited healthcare infrastructure, workforce shortages, and diminished access to health insurance options. These challenges drive increasing health disparities, often spanning across multiple generations. Could community health fairs and mobile health clinics finally level the playing field, addressing regional health disparities, often disproportionately impacting 13 states, 423 counties, and 8 independent Virginia cities in what we commonly call the Appalachian region (AL, GA, KY, MD, MS, NC, NY, OH, PA, SC, TN, VA, WV)?
Deep within the mountains of Appalachia, nestled among the coal fields of southwestern Virginia, stand two grey buildings.
From its beginnings in the early 1980s, when Sister Bernadette Kenny began offering free medical care from the back of her donated Volkswagen Beetle (Health Wagon, 2024b), The Health Wagon—along with the Owens & Hill Dental Health Clinic—provides low- and no-cost medical services to those unable to people who are uninsured or enrolled in Medicaid (Figure 1).
And several times a year, they go on the road to host two-day health fairs across the central Appalachian regions of southeastern Kentucky, southwestern Virginia, and northeastern Tennessee.
Photo Source: Health Wagon, 2024a; Photo Credit: Earl Cash
Whether at fairgrounds, 4-H camps, local health departments, or grocery store parking lots, people travel hundreds of miles to access perhaps the only healthcare services they will see in a year. From dermatologists to endocrinologists, from cancer screenings to tooth extractions, these health fairs serve as an invaluable resource in a region of the United States that can often feel like the Land That Time Forgot (Burroughs, 1918).
When many Americans think about accessing healthcare, they think of going to their general practitioner, urgent care, or their nearest hospital. But, for roughly 1 out of 7 Americans (14.2%), rural healthcare can look very different (Farrigan, 2024): roads can be washed out; floods can isolate entire communities; cell phone service can be non-existent; the only hospital in 60 miles might have been one of the nearly 200 rural hospital that have fully or partially closed since 2005 (Bennett et al., 2026).
But, necessity is the mother of invention.
Even in a time of technological marvels, rural Americans—especially those living in Appalachia and in areas with high concentrations of Native Americans—often face significant barriers to accessing healthcare services. We call these conditions the Social Determinants of Health (SDOH).
The SDOH are the conditions where people live, learn, work, and socialize that can influence health disparities and health outcomes (Vrtikapa et al., 2025; Figures 2-7). For example, in regions where coal mining has or continues to serve as the primary industry, driver of economics, or source of energy, communities are often geographically isolated (Bleizeffer & Adams, 2020) with school systems that produce where students achieve worse educational outcomes (Boettner, 2011), and collapsing economies (Trisko, 2024).
Photo Source: Appalachian Learning Initiative, 2022
When we look at rural America and begin to examine the conditions for each SDOH, it’s little wonder that out-of-the-box thinking was required to begin addressing these barriers to access and improving health outcomes.
And while home calls by physicians may largely be a thing of the past, rural providers have taken that idea, created mobile health units, and grown the movement to being one of the most effective rural health interventions on the planet.
Beyond the Health Wagon, other organizations, such as Remote Area Medical (RAM®), exist to provide mobile medical services. From February 6th through February 8th of 2026, RAM set up a pop-up healthcare clinic in Knoxville, TN, where some patients drove 200 miles, one way, and slept in their vehicles in parking lots just to attend a free clinic to access dental services due to a lack of insurance coverage (Pelley et al., 2026).
These types of health fairs and mobile clinic services are becoming a vital tool, as enrollment in healthcare coverage programs—both public and private—begins to see record declines. KFF recently projected that enrollment in Affordable Care Act (ACA) Marketplace plans may decrease by 21.5%, from 22.3 million enrollees in 2025 to 17.5 million in 2026 (McGough, 2026). This decline in enrollment is likely to occur as a result of rising insurance premiums, deductibles, and out-of-pocket maximums.
Further exacerbating the need for these services, KFF also projects that an additional 5.3 million could become uninsured by 2034 as a result of newly tightened work requirements exacted upon America’s most vulnerable patients by the One Big Beautiful Bill Act (KFF, 2026). While there are mandatory exemptions that allow certain individuals, such as those who are medically frail, participating in a substance use disorder (SUD) program, or parents/guardians/caretakers of dependent children under the age of 13 or disabled persons, there are no mandatory exemptions for people who reside in counties with high unemployment rates (KFF, 2026).
But this increase in demand for services comes with a severe cost for mobile medical care providers, many of which already operate on a first-come, first-served basis (Pelley et al., 2026). So, someday…maybe someday soon…even those who rely on mobile services may just go untreated, altogether.
How very Victorian of us.
The dedication of these organizations and the people who serve their communities to ensuring that people are able to access vital healthcare services regardless of their ability to pay is nothing short of what the American Spirit should be.
For more information about Remote Area Medical, please visit:
For a list of their upcoming pop-up or telehealth clinic dates, please visit:
https://www.ramusa.org/schedule/
For more information about The Health Wagon, please visit:
For a list of their upcoming mobile clinic and health fair dates, please visit:
The Rural Health Transformation Program Might Be A Too Little, Too Late
The Republican Party, in 2025’s One Big Beautiful Bill Act (BBB), signed into law an estimated $900+ billion in cuts to federal Medicaid spending over the next decade while simultaneously creating a paltry $50 billion new fund that they insist will “transform” rural health in the United States (Knight, 2025). If it sounds too good to be true, then it probably isn’t.
The “Rural Health Transformation Program” (RHTP) is, at its heart, an underfunded boondoggle that is purposefully designed to provide the illusion that the Trump Administration is investing in meaningful healthcare reforms—a sentiment they clearly failed to express when they slashed funding for the “socialist” programs that actually serve their constituents.
A “boondoggle,” for those unfamiliar with Great Depression-era slang, is a project that is a waste of both time and money while having the side benefit of occasionally being accompanied by graft. This term describes the dishonest or illegal acquisition of gain (usually money).
So, why is the RHTP a boondoggle? Let us count the ways:
The first and most obvious way in which the RHTP is a boondoggle is basic math: the funding hole that will be blown into Medicaid spending in rural areas is estimated to be approximately $137 billion—nearly thrice the grand total of the $50 billion RHTP expenditure (Saunders, Burns, & Levinson, 2025).
This funding discrepancy raises a fundamental question that supporters of the RHTP have openly refused to answer: “How are rural areas and states supposed to make up the $87 billion in lost funding?”
The answer to that question has been a reverberating, “Do what, now?”
The real answer is that nobody has any clue—not rural health experts (Watt & Mulvany, 2025), nor federal nor state elected or appointed officials.
While this one-time investment (meaning that it isn’t a consistent federal program that can be repeatedly tapped for future improvements) is a grand, underfunded gesture, there are real-world implications that the BBB Medicaid cuts will have that simply will never be offset by the RHTP. Providers will lose money, staffing levels will be reduced, corners will be cut, many lower-income patients—approximately 11.8 million of them—will lose healthcare coverage (Mukkamala, 2025), out-of-pocket costs will explode (Coffey & Hahn, 2025), and people will die as a result of these cuts.
But these outcomes, based on historical evidence and careful analyses rather than just using “MAGA Vibes,” have been largely ignored by the controlling party except, of course, to contend that the only people who will lose access to healthcare are the indolent moochers and “Welfare Queens” who have been “defrauding” a system they believe shouldn’t exist.
The reality is that nobody knows, because of the unspoken hope that someone competent steps in to undo this slow-moving disaster.
The second way the RHTP is a boondoggle is its demand for states to provide last-minute, detailed plans to solve a problem largely created by the for-profit healthcare model.
The RHTP consists of one-time $50 billion in funding that will be allocated “evenly” over federal fiscal years (running October 1st – September 30th of the next year), 2026 through 2030 at $10 billion per year. Half of this annual $10b will be distributed according to a statutory formula (which the Centers for Medicare & Medicaid Services [CMS] has not yet announced); the other half will be awarded to states that apply and are approved to receive funds (Watt & Mulvany, 2025).
This approval must occur by December 31st, 2025.
The applications are not due by December 31st, 2025; they must be approved or denied by CMS by that date.
In order to successfully apply, states must submit a detailed rural health transformation plan—a plan they have had basically three months to develop—that lays out how they will:
Improve access to hospitals and other providers for rural residents
Improve health outcomes for rural residents
Initiate, foster, and strengthen local and regional strategic partnerships between rural hospitals and other health care providers to promote measurable quality improvement, increase financial stability, maximize economies of scale, and share best practices in care delivery (Watts & Mulvany, 2025)
Enhance “economic opportunity for and supply of health care clinicians” through advanced recruiting and training
Prioritize new technologies to improve access to high-quality healthcare services in rural areas, and
Identify “specific causes” driving the accelerating rate of rural hospital closures, conversions, or service reductions.
Essentially, Congressional Republicans decided that the BEST way to improve rural health in the United States is to come up with a last-minute plan to solve problems that have been ongoing and worsening every year in this new millennium.
And to do so for $50 billion.
Can it be done?
The short answer is, “No.”
The longer answer is, “We’ll see what we can slap together. But…still, no.”
If all 50 states submit applications for this funding, there is no guarantee that all 50 will be awarded the funds. As this regime has demonstrated across numerous federal programs, funding is neither guaranteed nor will it be legally disbursed in accordance with federal law (Katz, 2025), and the Trump Administration has made no apologies for refusing to send Congressionally appropriated funds to states that Trump didn’t win in 2024.
According to the BBB, CMS has blanket authority to approve or reject applications. What happens to the leftover funding if states get rejected?
“Do what, now?”
The third way the RHTP is a boondoggle is that, under the statute that created it, the allocation and use of funds are not required to be made publicly available.
CMS is not required to disclose how it approves or denies applications, how much has been awarded, or how those funds have been allocated. Similarly, states are not required to disclose this information to the public, either.
That said, the statute does require that states use the funds for at least three of the following purposes:
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 CMS 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, 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 are designed to promote sustainable access to high-quality rural health care services, as determined by the CMS Administrator (Levinson & Neuman, 2025).
Each of these goals is admirable. All of them need to be accomplished in every state. So…why on earth would you create a program to address them that is critically underfunded, application-based, and makes states choose which ones they think they can accomplish?
Because this program was not created to fix the problem.
Realistically, not every state has the same priorities, and, more accurately, not every state has a good track record of utilizing and managing federal resources responsibly or legally.
Remember when Mississippi’s Republican governor, Phil Bryant, and his criminal administration defrauded Temporary Assistance for Needy Families (TANF) and The Emergency Food Assistance Program (TEFAP) to the tune of $77 million to build volleyball courts, rehab facilities in California, and other purposes for Mississippi’s well-connected Republican elites (McLeod, 2023)?
All of that occurred from 2016 to 2019, under the previous Trump Administration.
Additional scandals occur when states, such as West Virginia, leave federally disbursed funds in interest-bearing accounts for as long as possible to pad their general funds, and wait to distribute funds to the intended contractors at the last minute, forcing programs to implement a year’s worth of work in three to six months.
While the BBB stipulates that no more than 10% of funds may be used for administrative costs, there’s nothing that says those funds can’t be used to generate interest revenues for the states while people are dying.
What fun would that be?
Finally, the fourth way that the RHTP is a boondoggle is that it disregards literal reality.
Part of why the rural health infrastructure in the U.S. has been so quickly deteriorating is that the provision of healthcare in the U.S. is fundamentally tied to profits.
Why are rural hospitals closing so quickly?
Because hospitals realistically cannot be profitable when faced with a population that is, on average, older, sicker, more disabled, and less likely to seek health appointments or screenings until there’s an absolute emergency (U.S. Government Accountability Office, 2023; Coughlin et al, 2019).
Roughly 20% of the U.S. population is “rural,” and with rare exception, those people have seen many modern innovations and conveniences pass them by because of geographic and distance-related barriers. And, as we’ve spent nearly a century learning, profit-driven industries don’t play by Field of Dreams rules. If they build it, people WON’T come.
As a result, rural areas have been scrambling for federal funding crumbs since the 1970s. At the same time, their roads disintegrated, factories and mines shuttered, local economies crumbled, and the consequences of both labor-intensive jobs and the “miracle” chemicals developed in the mid-20th century ended up causing long-term damage to the human nervous system, lungs, and other critical organs.
Combine this with a healthcare system that is driven by a profit motive, and you end up with a long-neglected population of individuals with fewer physical and financial resources, higher rates of health conditions that are expensive to treat, and a paucity of places to go for treatment.
Those problems aren’t going to be solved between 2026 and 2030. They are going to worse as the population continues to age, healthcare becomes less affordable, people are kicked off of Medicaid, and they have nowhere to go because new facilities can’t be built and staffed overnight.
While many who work in rural health recognize that this is one of the first federal programs in the modern era to be specifically focused on improving both the rural health infrastructure and rural health outcomes, they are quick to say, “Thank you!” to this Administration’s faces, but are warning people working in rural health—especially those living in Blue states—to prepare for the worst. Unfortunately, Red states will be woefully unprepared for the impending disaster.
Perhaps the most insulting thing about the RHTP is that it fundamentally misses the point of why rural health outcomes tend to be worse than those observed in urban settings: people who live in urban areas are more likely to have access to…well… “things.”
People who live in urban areas are more likely to have access to transportation (either private or public), more likely to have access to functional transportation infrastructure (roads and bridges that don’t get washed out or become impassable due to weather-related issues), more likely to have high-speed Internet that is capable of utilizing healthcare-related technology, and are more likely to have a greater number of facilities and providers available to them.
The RHTP can't solve any of those issues, including the last one, because building healthcare facilities and staffing them isn’t a one-time deal. It’s ongoing. Facilities need to be upgraded. Staff need to be obtained and retained, and frankly, not a lot of healthcare workers are excited to upend their lives to go from a place where they have access to “things” (including entertainment, food, and other activities and commodities) to move to a place where they require a 4-wheel drive vehicle to get out of their homes only to traverse a barely functional road in terrible weather conditions.
At best, the RHTP is a cruel joke being played on rural Americans. For most people, the concept of a billion dollars doesn’t really compute. It’s a hard number to fathom unless you regularly deal with numbers that large. So, they’ll see and say, “$50 billion! That’s a lot of money,” without realizing that $50 billion is a drop in the ocean compared to what is needed just to bring rural facilities up to standard. One time. And then, when the states inevitably fail or enjoy limited success in utilizing any funds they were awarded, Congressional Republicans will turn around and angrily ask how those states misused or misspent those funds but didn’t see any results.
In practice, the RHTP will be unable to overcome the massive losses inflicted upon American citizens and their states in the BBB. Rural health disparities will continue to increase as people lose access to healthcare coverage through Medicaid, and the costs of commercial insurance will increase to the point where it will be less expensive to just be uninsured and dodge collection agencies until you’re dead. The costs of uncompensated care are likely to skyrocket, forcing even more rural healthcare facilities to shutter their doors, while the people who caused this crisis will escape scot-free to enjoy their pensions and healthcare for life.
There’s danger ahead. This is your warning.