Improving health care access in rural communities in the United States

In the United States, people living in rural communities experience significant health disparities compared to people living in urban settings. Between 14% and 19% of the population in the country lives in a rural area. 1 People living in rural communities experience higher rates of morbidity and mortality due to multiple health care barriers. Challenges can include higher poverty rates, lower levels of education, lack of transportation, and general lack of access to health care services. 1 People living in rural communities have an age-adjusted death rate that is 20% higher than people who live in urban settings. 2 Health disparities include higher rates of chronic conditions such as obesity, diabetes, cancer, heart disease, and mental health. 1 In addition, outbreaks of infectious diseases including HIV and hepatitis C virus (HCV) can occur and be a significant public health issue. It is clear that more needs to be done to address health care access in rural communities. On September 15, 2025, the Centers for Medicare and Medicaid Services (CMS) released a funding opportunity for states for the Rural Health Transformation Program for a total of 50 billion. The program was established to offset projected loses of over 100 billion for rural community health care funding as a result of federal Medicaid cuts. 3 The funding will include 25 billion distributed equally across all states based on approved applications, with the remaining 25 million distributed based on need and other factors. States that adopt certain federal policies will potentially receive more funding than other states. Funding is permitted to be used in the prevention and management of chronic diseases, provider payments (not to exceed 15% of spending), technology and IT, training and technical assistance, workforce development, behavioral health, and other innovative models of care. Funding cannot be used on capital expenditures or infrastructure, or specifically for fostering collaboration between organizations or clinics. The Rural Health Transformation Program represents a significant opportunity to improve access to care for rural communities in the United States. Addressing health care access in rural communities is complex. People in rural communities tend to have higher rates of health conditions that place them at risk of chronic diseases (i. e. , obesity, tobacco use, etc. ). There is a general scarcity of primary care services in rural communities in the United States with significantly more primary care providers in urban areas compared to rural communities. 4 Many rural communities are designated as Health Professional Shortage Areas (HPSAs). Lack of transportation to access health care can be a challenge. In addition, a significant number of people living in rural communities may be un- or underinsured. Other determinants of health such as low health literacy and lower socioeconomic status influence ability to access and navigate the health care system. A variety of solutions have been proposed and attempted to improve health outcomes in rural communities. The American Medical Association (AMA) recommends several approaches to improving the health of people living in rural communities which include: (1) Adjusting the Medicare payment system for inflation (Medicare physician payment has fallen 29% since 2001) ; (2) Expanding the physician workforce including incentives to work in rural communities; (3) Reducing administrative burden; (4) Removing telehealth restrictions; and (5) Outreach and education efforts. 5 Efforts to train and incentivize medical providers to work in rural communities have been implemented in many areas. The most common type of incentive program is loan repayment programs which aim to recruit providers by offering loan repayment in exchange for working in a shortage area. 6 Other efforts have implemented programs to attract international medical graduates to HPSAs through J-1 visa waivers and scholarship programs for recruiting medical providers to rural and other underserved areas. In addition to workforce development, other recommendations have highlighted the need for community-driven approaches that engage people living in rural communities and to build trust. 7 Collaborations and partnerships across sectors during the implementation process are key. 8 Given the diversity of rural settings, approaches must be tailored to the local community. Trusted local partners such as health departments, community-based organizations (CBOs), town administrators, faith-based organizations, and schools have been successfully engaged to address various public health issues. 9 In addition, other nonhealth organizations that are often present in local communities have been successfully engaged (i. e. , Young Men's Christian Association (YMCAs), banks, etc. ). 10 As the Rural Health Transformation Program is rolled out across the country, states will need a framework for improving health care access in these communities. A potential framework includes concepts based on best practices from implementation science8 as well as using a “Stepped Care Approach. ”11 Stepped care is an evidenced-based model of health care delivery where effective, yet least resource intensive approach, is delivered first, only “stepping up” to more intensive services if required. This approach has been successfully used across fields of medicine and behavioral health to improve access to care. 11 In rural communities, this approach makes sense to optimize limited resources. A Stepped Care Approach would address several common barriers to engaging rural communities and include the following: (1) Building and advancing partnerships with CBOs in rural areas; (2) Using community health workers at CBOs in rural areas to engage people for basic health care (i. e. , preventative health screenings, referrals and linkages to care, transportation, etc. ) ; (3) Facilitating virtual or in-person visits as needed with primary care providers; (4) Facilitating virtual or in-person visits as needed with specialists. The first step of this approach would be to identify stakeholders in rural communities that can serve as an “anchor” organization to undertake health-related activities. These could be existing CBOs focused on health, nonhealth organizations which are interested in promoting health, health departments, or other local or state agencies or government. The second step would be for organizations to hire and train community health workers. Community health workers would engage people from the community, administer common health screenings (i. e. , for chronic disease, mental health, substance use, and infectious diseases), and facilitate access to health care. Community health workers are an evidence-based approach to engaging rural communities. 12 Those with identified health conditions would be linked to primary care providers as needed. Organizations would partner with an existing clinic in the state including federally qualified health centers (FQHCs), private clinic systems, academic medical systems, or other primary care clinics. Ideally, the partner primary care clinic would already serve the rural community. Over time, efforts to build out infrastructure and workforce capacity at these clinics could help support health care access in these rural communities. Clinical visits could be in-person or virtual. Community health workers from local organizations would help facilitate transportation to in-person visits or arrange appropriate technology for virtual visits. For patients that are determined to need a specialist (i. e. , HIV, HCV, other), the community health worker would facilitate engagement with those medical providers as needed in consultation with primary care providers. In summary, a Stepped Care Approach using community health workers followed by primary care providers and specialists offers a potential approach to improving health-related outcomes in rural communities. The proposed model would optimize resources while improving access to health care in rural areas in the United States. The author reports no conflicts of interest.