Ensure Health Care Access for All
Background
For years, people living in rural communities have been more likely to be uninsured,[1] to face barriers to routine and lifesaving health care, and to die from pregnancy-related complications[2] than their nonrural counterparts, due to lack of insurance coverage, affordability,[3] poor access to doctors and hospitals, and workforce shortages. The 2022 U.S. Supreme Court Dobbs decision overturning the protections established in Roe v. Wade has exacerbated these disparities. Actions by the Trump Administration are expected to do the same.
Access to reproductive healthcare has been severely restricted in many states following Dobbs, requiring people to travel out of state for in-person care or face the risk of criminalization for their pregnancy outcomes. A 2024 study of state-level policy also found that differences in Medicaid coverage have left millions of women either uninsured or with gaps in their health care coverage, with many of the most impacted being rural women.[4]
Although about 20 percent of Americans live in rural areas, barely one-tenth of physicians practice there.[5] In 2022, nearly 60 percent of rural counties had no hospital-based obstetrics unit,[6] and the federal government projects a shortage of over 20,000 primary care physicians in rural areas by 2025.[7] These numbers are only expected to rise as the Dobbs decision continues to impact maternity care and women’s health care more broadly. Rural hospitals, clinics, and doctors offices have also been subject to tightening economic forces. Many have closed or been bought up in recent years, including by private equity firms, which since the 2000s have been aggressively purchasing hospitals, nursing homes, and physician practices and “rolling up” healthcare acquisitions into conglomerates. They drastically cut staff and equipment to reduce costs and then flip them to make enormous profit, leading to chronic understaffing, patient deaths, layoffs, and facility closures. According to a report by the American Economic Liberties Project (AELP), private equity acquisition of healthcare facilities leads to rising costs, a 24 percent decline in hospital assets within two years, and an 11 percent increase in patient mortality due to reduced staffing and regulatory failures.[8] Fortunately, the issue of private equity in healthcare is receiving bipartisan attention. The U.S. Senate Budget Committee released a report in January 2025 on Profits Over Patients: The Harmful Effects of Private Equity on the U.S. Health Care System.[9] 35 state legislatures have passed laws attempting to address the issue.[10] Lack of health insurance is another barrier for people in rural communities seeking healthcare. In 10 percent of counties across the country – mostly rural counties – residents can only choose from one insurer.[12] Ineligibility and fear of immigration enforcement are added challenges for rural Indigenous and Latino people and noncitizens trying to access health care.[13] On the positive side, states that have taken advantage of the option to extend Medicaid coverage to adults living below 138 percent of the federal poverty level saw some of the largest health insurance coverage gains among rural adults – threefold faster than rural adults in non-expansion states.[14] 47 states and the District of Columbia have enacted legislation to extend postpartum Medicaid coverage to address the maternal mortality crisis, which disproportionately affects Black, Indigenous, and rural people.[15] Medicaid and other public programs, like the Children’s Health Insurance Program (CHIP), cover a larger share of people in rural areas than in nonrural areas. These programs play a critical role in keeping people and families healthy while buffering rural communities against hospital closures and provider shortages. They also help the economy, as they cover small business owners and solo entrepreneurs as well. These programs can be expanded to cover even more rural residents, including noncitizens. Finally, the value of telehealth became clear to everyone during the COVID-19 pandemic; for many rural communities, telehealth is critical even without a pandemic. Although telehealth services are now covered through Medicaid in all 50 states and the District of Columbia, the way that states define telehealth services may continue to leave rural communities behind.[16] It is also important to be aware of privacy protections for digital health data. These can be explored in the SIX report, User Error: Reproductive Health, Rights, and Justice. [1] U.S. Census Bureau, and Jennifer Cheeseman Day. “Rates of Uninsured Fall in Rural Counties, Remain Higher than Urban Counties.” Census.gov, 8 Oct. 2021, https://www.census.gov/library/stories/2019/04/health-insurance-rural-america.html. [2] National Advisory Committee on Rural Health and Human Services. U.S. Department of Health and Human Services, 2020, Maternal and Obstetric Care Challenges in Rural America Policy Brief and Recommendations to the Secretary, https://www.hrsa.gov/sites/default/files/hrsa/advisory-committees/rural/2020-maternal-obstetric-care-challenges.pdf . [3] Tolbert, Jennifer and Kendal Orgera. “Key Facts about the Uninsured Population.” KFF, 12 Nov. 2020, https://www.kff.org/uninsured/issue-brief/key-facts-about-the-uninsured-population/. [4] Sara R. Collins, et al. “2024 State Scorecard on Women’s Health and Reproductive Care.” The Commonwealth Fund, 18 July 2024, www.commonwealthfund.org/publications/scorecard/2024/jul/2024-state-scorecard-womens-health-and-reproductive-care. [5] Gudbranson, Emily, Aaron Glickman, and Ezekiel J. Emanuel. “Reassessing the data on whether a physician shortage exists.” Jama 317, no. 19 (2017): 1945-1946. https://jamanetwork.com/journals/jama/article-abstract/2613209 [6] “Loss of Hospital-Based Obstetric Services in Rural Counties in the United States, 2010-2022 – the University of Minnesota Rural Health Research Center.” The University of Minnesota Rural Health Research Center, 8 July 2024, rhrc.umn.edu/publication/loss-of-hospital-based-obstetric-services-in-rural-counties-in-the-united-states-2010-2022. [7] “Physician Workforce: Locations and Types of Graduate Training Were Largely Unchanged, and Federal Efforts May Not Be Sufficient to Meet Needs.” U.S. GAO, 21 Sept. 2017, www.gao.gov/products/gao-17-411. [8] American Economic Liberties Project. America’s Health Care Consolidation Crisis: A Ledger of Harms and Framework for Advancing Economic Liberty for All. Pages 4, 6, and 10 2024, www.economicliberties.us/wp-content/uploads/2024/10/10-24-AELP-healthcare-ledger.pdf. [9] United States Senate Committee on the Budget. Profits Over Patients: How the Pharmaceutical Industry Game-plays the System to Price-gouge Americans. Majority Staff Report, 2024, https://www.grassley.senate.gov/imo/media/doc/profits_over_patients_budget_staff_report.pdf. [10] Jaromin, Sarah. “The Evolving Landscape of State Health Care Transaction Laws.” National Conference of State Legislatures, 19 Aug. 2024, https://www.ncsl.org/health/the-evolving-landscape-of-state-health-care-transaction-laws. [11] National Women’s Law Center. “Private Equity and Child Care – National Women’s Law Center.” National Women’s Law Center, 22 July 2024, nwlc.org/resource/private-equity-and-child-care. [12] McDermott, Daniel and Cynthia Cox. “Insurer Participation on the ACA Marketplaces, 2014-2021.” KFF, 23 Feb. 2021, https://www.kff.org/private-insurance/issue-brief/insurer-participation-on-the-aca-marketplaces-2014-2021/. [13] Bernstein, Hamutal, et al. “One in Seven Adults in Immigrant Families Reported Avoiding Public Benefit Programs in 2018.” Urban Institute, 5 Feb. 2020, https://www.urban.org/research/publication/one-seven-adults-immigrant-families-reported-avoiding-public-benefit-programs-2018. [14] Hoadley, Jack, et al. “Health Insurance Coverage in Small Towns and Rural America: The Role of Medicaid Expansion.” Center For Children and Families, 25 Sept. 2018, https://ccf.georgetown.edu/2018/09/25/health-insurance-coverage-in-small-towns-and-rural-america-the-role-of-medicaid-expansion/. [15] “Medicaid Postpartum Coverage Extension Tracker | KFF.” KFF, 6 Jan. 2025, www.kff.org/medicaid/issue-brief/medicaid-postpartum-coverage-extension-tracker. [16] Center for Connected Health Policy. “State Telehealth Laws & Reimbursement Policies Report.” CCHP, 26 Oct. 2021, https://www.cchpca.org/resources/state-telehealth-laws-and-reimbursement-policies-report-fall-2021/.
Policy Priorities
- Federal: Pass the Save Rural Hospitals Act, a bill that would preserve access to rural health care by ensuring fairness in Medicare hospital payments, creating opportunities for rural critical care facilities and investing in rural health care services.
- Federal: Expand, implement, and create rural reforms of Medicaid for poor and working-class families. Expanding Medicaid and increasing Medicare reimbursement rates have been identified by many rural health care advocates as the best way to deliver increased quality of care in rural communities. Additionally, reforms that give easier access to rural people should also be prioritized, such as making family, elder, and disability care reimbursable.
- Federal: Reduce cost and improve access to prescription drugs for rural people. This includes passing the Lower Drug Costs Now Act and reforming rural-specific programs like 340B to improve rural access, which is urgent.
- State: Expand and invest in Medicaid and CHIP, including opting in to cover lawfully present immigrant children and pregnant people and extending postpartum Medicaid coverage.
- State: Create a public health insurance option and/or expand who can participate in the state Medicaid program through a buy-in option.
- State: Extend coverage for telehealth service and also increase accessibility options to include audio-only telehealth services and translation services.
- State: Create prescription drug review boards to promote prescription drug affordability, and set allowable rates for certain high-cost drugs identified by the board.
- State: Expand mental health and addiction services for rural communities.
- State: Expand scope of practice for advanced practice clinicians, including nurses and physician assistants, to build out the pool of reproductive health care providers in rural areas.
- State: Expand access to contraception through constitutional protections and require coverage of year long supplies of birth control to reduce access barriers.
- State: Remove restrictions on reproductive health services, which compound the difficulty of accessing time-sensitive care in rural areas with fewer health care providers and force people to travel long distances – often out of state – for care.
- State: Enable telehealth provision of reproductive health care services and protect pregnant people from criminalization.
- State: Support maternal, reproductive, and perinatal care providers, including birth centers, midwives, and doulas to address high rates of maternal mortality and morbidity.
- State: Codify emergency medical care to ensure pregnant people receive care under EMTALA protections, regardless of a hospital’s religious affiliation or religious refusal laws.
State Examples
Expand insurance coverage
- Medicaid expansion: To date, 41 states (including D.C.) have expanded Medicaid,[17] while lawmakers in the remaining states continue to consider expansion in a variety of ways (see link for examples).
- Coverage for immigrants: Lawmakers in some states have extended coverage to certain immigrants regardless of immigration status. In California, children (2015 CA SB 75), young adults (2019 CA SB 104), and adults age 50 and over (2021 CA AB 133) are eligible for Medicaid regardless of immigration status, while an Oregon bill (2021 OR HB 3352) expanded eligibility to all people regardless of immigration status. Lawmakers in Illinois expanded eligibility to undocumented seniors age 65 and over in the state’s budget (IL FY 2021), while Vermont legislators extended coverage to undocumented children and pregnant people (2021 VT H 430).
- Public option: Lawmakers in Colorado (2021 CO HB 1232), Nevada (2021 NV SB 420), Oregon (2021 OR HB 2010), and Washington (2019 WA SB 5526) have approved legislation to create some version of a public health insurance option, while legislators in Hawaii (2019 HI SB 330) and New Jersey (2021 NJ S 3798) have enacted bills to allow more residents to participate in the state Medicaid program through a buy-in option.
- Coverage for telehealth: Many states limit insurance reimbursement to video telehealth visits, which may be a barrier for rural communities with limited internet access, while interpreter services are not reimbursable through Medicaid in some states. Lawmakers in Arizona (2021 AZ HB 2454), Delaware (2021 DE HB 160), and Rhode Island (2021 RI H 6032) enacted legislation to allow for coverage of audio-only telehealth services. A bill introduced in Massachusetts (2021 MA S 678) aimed to require Medicaid reimbursement and private health insurance coverage of telehealth interpreter services for patients with limited English proficiency and those who are deaf or hard of hearing.
Prescription drugs
- Oregon (2019 OR HB 2696) considered legislation to create a prescription drug affordability review board.
- Massachusetts (2024 MA S 3012) passed a law that caps prescription drug costs and creates a licensing commission and accountability for prescription benefit managers.
Mental health care
- Lawmakers in California (2020 CA SB 855), Illinois (2021 IL HB 2595), and Oregon (2021 OR HB 3046) have passed legislation to expand the mental health or substance use disorders that health insurers must provide coverage for. In Colorado (2019 CO HB 1168), lawmakers passed a law creating a reinsurance program to encourage increased insurer participation in rural areas by offsetting high-cost insurance claims at a higher level in rural counties.
- Legislation enacted in Kansas (2021 KS HB 2208) provides for the certification of community mental health centers as community behavioral health clinics and establishes a Medicaid-based payment system to fund these clinics. New Mexico (2021 NM SB 398) legislators introduced a bill to establish a mobile rural health units program to provide health services and substance use disorder recovery services in some rural counties.
Reproductive health care protections
- Tennessee (2024 TN SB 1919) passed a bill requiring insurance companies to cover 12-month supplies of birth control. Legislation introduced in Alabama (2025 AL SB 19) and Arizona (2024 AZ HB 2678) would codify the right to contraception.
- As one example of codifying state abortion protections following the Dobbs decision, Arizona (2024 AZ HB 2677) lawmakers repealed a criminal ban on abortion established in 1864.
- New Mexico (2023 NM SB 13) shields providers and patients from civil or criminal liability for certain reproductive and gender-affirming health care services.
- Lawmakers in Connecticut (2024 CT HB 5424) introduced a bill that would shield providers at religiously-affiliated hospitals from punishment for providing health care services including abortions and gender-affirming care. Legislation enacted in Illinois (2024 IL HB 581) creates state-level EMTALA protections for emergency abortion care.
- Virginia (2024 VA SB 118) requires insurers, corporations, and HMOs to provide coverage for at least eight visits from a state-certified doula during pregnancy, labor and delivery, and postpartum. A bill introduced in Georgia (2023-2024 GA SB 81) would establish a State Board of Community Midwifery to expand licensure to include community midwives.
Rural health care incentives
- Minnesota lawmakers enacted legislation (2021 MN SF 37/HF 33) that expanded eligibility for the state’s Health Professional Education Loan Forgiveness Program to include alcohol and drug counselors who agree to practice in designated rural areas or underserved urban communities.
- Legislation in New York (2021 NY AB 5220/SB 2664) would create a student loan forgiveness program for nurses working in rural psychiatric hospitals/units, addiction treatment centers, behavioral clinics, or county mental health programs.
- A bill introduced in New Mexico (2022 NM HB 17) would provide a $3,000 income tax credit to mental health professionals who work in a “rural health care underserved area.”
Healthcare ownership and consolidation
- Connecticut (CT 2025 HB 6146) has introduced a bill to regulate medical debt and pharmacy benefits management practices, limit prior authorization, and study the impact of vertical integration on health care. The state is also considering a bill to prohibit private equity firms from acquiring or owning health care facilities (2025 CT HB 6570).
- Indiana (IN 2025 HB 1666) is considering bipartisan legislation to strengthen oversight of ownership interests of healthcare facilities and allow the attorney general to block private-equity acquisitions that will adversely affect state healthcare consumers.
- Vermont (VT 2025 HB 71) is considering a bill to enhance the merger review process for health care-related transactions, giving the attorney general greater latitude to reject mergers that would adversely affect healthcare costs or access. New Mexico (NM 2025 SB 14) is considering similar legislation.
- Massachusetts (MA 2024 HB 5159) signed “An Act Enhancing the Market Review Process” into law, increasing transparency and oversight of the state’s healthcare providers, including an expansion of the information reporting requirements for private equity entities and making it easier for attorneys general to pursue legal claims against private equity investors under the False Claims Act.
- Oregon (OR 2025 SB 951) is considering a bipartisan bill to strengthen the state’s ban on corporate practice of medicine—the current bill contains loopholes that the new bill would close. Loopholes and issues addressed by the bill include allowing private equity firms to buy management services organizations that serve physician-owned practices and physician non-compete agreements.
[17] KFF. “Status of State Medicaid Expansion Decisions: Interactive Map.” KFF, 8 May 2024, https://www.kff.org/affordable-care-act/issue-brief/status-of-state-medicaid-expansion-decisions-interactive-map/
Toolkits
Inspired? Ready to dig in on these issues with your rural neighbors? Our practical communications toolkits will help you connect with new communities through common values. The toolkits provide examples on narrative framing, press release templates, sample talking points, and more.
Click here for the communications toolkit on Providing Healthcare for All.