On July 4, 2025, the federal budget reconciliation bill, H.R.1, was signed into law, enacting major structural reforms to Medicaid, the Children’s Health Insurance Program, and the Affordable Care Act Marketplaces. These changes, including a $911 billion reduction in federal Medicaid spending over the next 10 years, significantly reshape the operational and financial landscape of the health coverage system, with far-reaching implications for program enrollment, expenditures, and administration, immediately and in the years ahead.
H.R.1 includes $50 billion for a Rural Health Transformation Program (RHTP). These resources include tracking of state activity related to RHTP.
The Rural Health Transformation Program (RHTP) offers states a unique opportunity to invest federal resources in strategies that address not only medical care, but also the social drivers that shape health outcomes in rural communities. One highly effective intervention that has emerged across multiple state applications is “Food Is Medicine” (FIM). This expert perspective highlights select state initiatives and activities that propose leveraging the RHTP to advance FIM and other food and nutrition interventions.
The Rural Health Transformation Program (RHTP) provides an opportunity for states to leverage federal funding to support investments to improve maternal health outcomes and reduce disparities. To address these challenges, states are proposing efforts to expand and train the perinatal workforce, deploy technology-enabled obstetric services, improve access and care coordination, and enhance prevention and early intervention across the perinatal continuum. This expert perspective highlights select state initiatives and activities that propose leveraging the RHTP to advance maternal health.
This expert perspective describes states’ initial steps to implement Rural Health Transformation Program (RHTP) activities, including an interactive map which examines which state agencies are designated to lead RHTP implementation and identifies whether states have established dedicated public-facing websites to promote transparency and accountability as implementation progresses. Agency designations in the map reflect an interpretation of publicly available materials.
As of December 12, 43 states have shared either their full Rural Health Transformation Program (RHTP) application or a summary of their proposal. States aligned their submissions with the five RHTP strategic goals outlined by CMS: (1) Make Rural America Healthy Again, (2) Sustainable Access, (3) Workforce Development, (4) Innovative Care, and (5) Technology Innovation. While there are similarities in the applications, there are also notable differences in the specific initiatives and activities proposed across states. This expert perspective explores select themes from the publicly-available applications and summaries.
On November 5, 2025, the Centers for Medicare and Medicaid Services (CMS) announced that all 50 states have submitted applications for the Rural Health Transformation Program (RHTP). Created by Congress to address concerns stemming from the deep funding cuts in H.R.1, the RHTP will distribute $10 billion annually from 2026 through 2030; 50% of those payments will be distributed equally across states with an approved Rural Health Transformation Plan, while the remaining half will be distributed to states at the discretion of CMS, according to factors detailed in the funding announcement. This expert perspective identifies states that have formally announced their submission and/or publicly released their application materials, and includes links to the publicly-available material.
With rural healthcare in distress and looming cuts from H.R.1, there has been intense state interest in the $50 billion Rural Health Transformation Program, and states are working quickly to create the Rural Health Transformation Plans that are a requirement of the application for funding. To inform their plans, most states have solicited public input via surveys and requests for information and taken other actions, such as hosting community listening sessions. Several states have already begun reporting themes from their efforts to engage stakeholders, including Alaska, California, Georgia, North Dakota, and Washington. This expert perspective summarizes the key themes that have emerged across these five states during their stakeholder processes, as identified by the states.
On July 4, 2025, President Trump signed budget reconciliation legislation (H.R.1) into law. It made sweeping changes to healthcare programs, cut Medicaid spending by $911 billion over 10 years, and will lead to significant coverage losses. To address rural health concerns stemming from these cuts, H.R.1 includes $50 billion for a Rural Health Transformation Program (RHTP). This expert perspective highlights state action to create a transformation plan and prepare to apply for the RHTP, including issuing Requests for Information and other efforts to educate the public and gather stakeholder input.
On September 15, the Centers for Medicare & Medicaid Services released a Notice of Funding Opportunity (NOFO) for states to apply for funds under the $50 billion Rural Health Transformation Program, established by H.R.1. This analysis summarizes the NOFO including the allowable uses of funding, application components, and the distribution and scoring methodology.
The federal budget reconciliation legislation, H.R.1, includes $50 billion for a Rural Health Transformation Program, which offers an opportunity for state health leaders to double down on efforts to improve access and transform systems of care for rural communities—but doing so will require both vision and innovation. This expert perspective details key considerations for states as they design their transformation plans to apply for the fund.
This Excel tool provides an integrated view of implementation dates for Medicaid, the Children’s Health Insurance Program, Marketplace, and Medicare provisions in the budget reconciliation law, H.R.1. Because of interdependencies with the budget reconciliation provisions, policies in the Marketplace Integrity and Affordability final rule of June 25, 2025, are also included in this timeline. This tool is intended to support states in (1) planning for timely implementation of reconciliation-driven health policy changes, and (2) effectively communicating potential impacts to communities and key stakeholders.
On Thursday, July 24, State Health and Value Strategies hosted a webinar on the budget reconciliation legislation (H.R.1) and the sweeping changes to Medicaid that it will make to state Medicaid program expenditures, enrollment, and operations now (with many provisions having already taken effect upon enactment) and in the years to come. It concentrates cuts to the Affordable Care Act’s Medicaid expansion population, limits use of provider taxes and state directed payments, constraining the ways states can raise revenue to finance their share of Medicaid program costs, and adds major restrictions on access to affordable health coverage for noncitizens.