New Medicaid work rules go into effect no later than Jan. 1, 2027. Federal guidance outlines exemptions.

CMS announced exemption guidance for Medicaid's 
new work requirements.

As the "One Big Beautiful Bill" continues to remake American safety net programs, guidance from the Centers for Medicare & Medicaid Services, released earlier this week, outlines "how states should carry out the work rules, including who would be exempt," reports Berkeley Lovelace Jr. of NBC News.

While the federal government will require states to roll out the new Medicaid work rules no later than Jan. 1, 2027, until now, states didn't know who could be considered for exemptions. Lovelace explains, "Pregnant women, parents of young children, veterans with disabilities and several other groups will be exempt from Medicaid’s new work requirements," according to CMS rules. "States will have discretion to determine which medical conditions qualify for exemptions."

The work rules do not require recipients to work full-time; instead, most adult Medicaid recipients must "work, attend school or volunteer for at least 80 hours a month to keep their coverage," Lovelace reports.

CMS will also allow exemptions for individuals who are considered too "medically frail" to work. The guidance also allows exemptions for people with "conditions that significantly limit their ability to work, such as cancer or substance use disorder," NBC reports. "The guidance doesn’t include an exemption for people who are homeless."

Before this week's announcement, Medicaid supporters worried that enrollees would lose their coverage while trying to prove their eligibility for an exemption; however, the guidance allows for that possibility. Lovelace reports, "During the first year, people will be allowed to attest — on their Medicaid applications or renewal forms — that they qualify for one of the exemptions rather than provide documentation."

The main thrust behind the work rules is to get more Americans to work. The National Bureau of Economic Research, a nonpartisan research group, found that Americans are working fewer hours than they did in previous decades, NBC reports. "The officials argued that government benefits reduce incentives to seek employment."

A small infusion clinic in rural Texas helps cancer patients not have to drive hundreds of miles a week for care

New Jersey and Rhode Island do not have rural hospitals and are excluded from the analysis.

(Map by Deidre McPhillips, CNN, from Chartis data)

Rural cancer patients often drive hundreds of miles for treatments only bigger cities can offer, but a smaller hospital that chose to add an infusion clinic in a rural area shows that cancer care can move closer to home, reports Caleb Hellerman of CNN News.

Childress Regional Medical Center, which serves roughly 30,000 people in a 5-county region of North Texas, did the opposite of what many smaller hospitals have been doing. They added services instead of shrinking them. Hellerman writes, "Childress [began with] opening a small infusion center in 2013 and steadily expanding its capabilities in order to serve patients."

When it comes to diagnosis, treatment and survival rates, rural cancer patients are already at a disadvantage. Hellerman reports, "Rural cancer patients tend to be diagnosed later and have worse outcomes. . . . Rural patients are also less likely to receive treatment that meets the standard of care."

Although the Childress infusion clinic started small, the need for it quickly became apparent, and its provider count grew to meet the needs of rural patients. Hellerman explains, "The infusion center started with two chairs but has since grown to encompass 10 spots for patients, three full-time pharmacists and three full-time oncology nurses."

Residents in the region are luckier than many of their rural peers. The medical consulting group Chartis "found that 448 rural hospitals – nearly a quarter of the nation’s total – stopped offering chemotherapy services between 2014 and 2024," Hellerman writes. Out of all the states, Texas lost the most.

Beyond the transportation issues, rural cancer patients will continue to face a dwindling number of oncologists willing to practice in rural regions. Some of that shortage is attributed to younger specialists preferring to live and work in more urban areas. But, according to Hellerman, the high cost of cutting-edge cancer drugs is also preventing younger oncologists from considering rural-leaning positions. 

"Oncologists and hospital administrators say pressures are likely to worsen over the next few years as provisions of the 'Big Beautiful Bill' kick in," Hellerman reports. Most of those cuts are slated to come from reducing the number of Americans who receive Medicaid.

Rural hospitals will be hurt the most from Minnesota Medicaid cuts

Government action, such as cuts to Medicaid in Minnesota, has an “outsized impact” on rural residents, Sarah Melotte reports for the Daily Yonder.

The Trump administration recently announced its intent to withhold $259 million from Minnesota’s Medicaid reimbursements due to fraud concerns. CMS Administrator Mehmet Oz said Medicaid funds in Minnesota were going to "bogus" centers for autistic children and a behavioral health organization that had bills showing doctors working 24 hours a day for more than 450 days.

Percentage of hospital revenue coming from low-income health insurance programs. (Map by Sarah Melotte, Daily Yonder, data from the Center for Healthcare Quality and Payment Reform, Click to enlarge)

Rural hospitals are disproportionately affected by these cuts. Melotte explains that rural hospitals are more likely to operate with negative profit margins than urban hospitals, and 39 of Minnesota’s 98 rural hospitals have negative operating margins. This means the rate of uncompensated care will increase even more in these rural hospitals.

Some of these hospitals are able to stay open using non-operating revenue, such as taxes or philanthropy, but this isn’t the case for all of them, reports Melotte. More than 100 rural hospitals throughout the U.S. have had to close in the last decade, causing rural residents to have to travel farther to access the care that they need.

One nonprofit in Minnesota that houses people with disabilities reported to Minnesota Public Radio that “any cuts to Medicaid funding will directly result in reduced services.”

Medicaid now accounts for around 19% of discharges in rural hospitals nationwide, Melotte writes. “In communities where hospitals operate on thin margins, even small cuts in federal spending can destabilize entire systems of care.”

A rural hospital in California closes after federal officials strip 'critical access' designation it has held since 2000

Glenn Medical Center in Willows, California 
(Glenn Medical Center photo)

After more than 70 years of serving its rural community in Willows, California, Glenn Medical Center closed its doors following the loss of its "critical access" designation, which had allowed the hospital to receive higher federal reimbursements that helped it remain open.

To qualify as a "critical access" hospital, a medical center needs to be at least 35 miles from the next closest hospital. Glenn Medical Center was 32 miles from "the nearest neighboring hospital under a route mapped by federal officials," reports Jessica Garrison of the L.A. Times. "Though that distance hasn’t changed, the federal government has now decided to enforce its rules." The hospital was awarded its critical access status in 2000.

The loss of Glenn Medical Center leaves the surrounding farming community without emergency care, "eliminates 150 jobs and puts rural residents at risk of preventable deaths," Garrison writes.

Rural hospitals across the state are already at risk of closure. Peggy Wheeler, vice president of policy of the California Hospital Association, told Garrison, "It’s like the beginning of a tidal wave. I’m concerned we will lose several rural hospitals, and then the whole system may be at risk.”

Before Glenn Medical Center's designation was stripped, Glenn County officials and hospital administrators worked for months to persuade federal officials to grant an exception.

Now that the hospital is closed, many community members fear what will happen to older residents in need of immediate care, injured farm workers or victims of car accidents along nearby Interstate 5. Glenn County Supervisor Monica Rossman told Garrison, "People are going to die."

Report: Rural primary care physician shortages will persist for at least another 12 years

Graph by Celli Horstman and Arnav Shah, State of Rural Primary Care in the United States, Commonwealth Fund

Rural residents will continue to grapple with a shortage of primary care doctors for at least another 12 years, according to a report issued last week by the nonprofit Commonwealth Fund.

Using federal health workforce data, researchers concluded that "rural areas will continue to have only about two-thirds of the primary care physicians they need," reports Nada Hassanein for the Wisconsin Examiner. Report authors noted that the persistent shortage of primary care doctors leaves million of rural residents "with fewer options for routine and preventive care."

The report's release came just days after the window closed for hospitals to apply for a share of the $50 billion federal Rural Health Transformation Program administered by the Centers for Medicare & Medicaid Services. Hassanein writes, "Some states want to use the federal money to expand their rural residency programs, as physicians who complete their residencies in rural areas are more likely to practice in one."

Nearly all of the more than 40 million rural Americans live in areas with primary care physician shortages, according to the report. "Forty-five percent of rural counties had five or fewer primary care doctors in 2023," Hassanein adds. "Roughly 200 rural counties lacked one altogether."

The report found that doctor shortages in rural areas vary by region. Hassanein writes, "States in the South had 3,411 patients per physician, whereas states in the Northeast had 1,979 residents per physician."

Although rural areas will continue to lack enough primary care physicians, some of the gap will be filled by rural nurse practitioners. Hassanein adds, "Nurse practitioners are the fastest-growing type of clinician in the U.S., regardless of geography, the report authors wrote."

Rural hospitals tap into high schools to meet ongoing staffing challenges

Ballad Health is one of several rural-serving 
hospitals training high school students.

Ballad Health is a rural hospital system in Tennessee that, like many rural hospitals, spends millions of dollars a year paying traveling nurses to cover staffing shortages. To address its recruitment woes, Ballad is working with area high schools to train its next generation of medical care workers, reports Te-Ping Chen of The Wall Street Journal. 

Ballad's high school training academy includes students from "five northeast Tennessee school districts," Chen writes, "The first batch of 200 students will graduate in 2029, with their licensed practical nurse credentials and be eligible to work right away at Ballad, earning $23 an hour." 

Building and implementing a medical training academy for high school students is time-intensive and expensive, so Ballad Health partnered with Bloomberg Philanthropies, which "last year announced it was pumping $250 million into 10 programs in states including Tennessee, Texas and North Carolina to create a high school-to-healthcare pipeline," Chen explains. 

Ballad isn't alone in its staffing struggles, and as the baby boomer generation ages, demand for medical care staffing is expected to grow. Chen reports, "Human resources advisory firm Mercer projects a deficit of 100,000 healthcare workers by 2028."

Since 2006, Baystate Health system, which serves rural populations in western Massachusetts, has invested in a "high-school career program for jobs such as respiratory therapist and sterile processing technician," Chen adds. "Many participants have gone on to pursue additional training, and more than 900 have ended up working for Baystate in the past decade."

New Hampshire's North Country uses collaboration and training to address labor and delivery unit closures

Eleven L&D  units have closed in New Hampshire
since 2002. (NHPR map, from N.H. Peri. Collab. data)

Health care stakeholders, planners and employees in New Hampshire are working to repair and "fill gaps in a maternity care system that’s been eroding for years," reports Paul Cuno-Booth of New Hampshire Public Radio. Part of their efforts are taking shape through the North Country Maternity Network, which is a "collaboration between hospitals, health workers, social service nonprofits and others," with supportive management through Dartmouth Health.

The network added additional training and drills for its doctors and staff, so they are prepared for stressful deliveries. Cuno-Booth writes, "More than a quarter of patients now live a half hour or more from the nearest birthing hospital – making it harder to access routine prenatal care and raising the risk of an unplanned birth at home or on the way to the hospital."

Ali Willard, a high-risk obstetrics nurse and care coordinator with Dartmouth Health, told Cuno-Booth, “If you were having a heart attack, would you want to have to drive three hours to receive medical care? No. And that's not a standard anywhere in our country to have to drive that far for that type of emergency. But obstetric emergencies are just as critical to somebody's life. But some women have to drive that far.”

The network's collaboration is also working to "give EMTs and ER doctors in the region more training on how to respond to obstetric emergencies, in case something happens far from the nearest birthing hospital," Cuno-Booth adds.

Natalie Valliere, who runs a labor and delivery unit in Coos County, is working with a team to address the many challenges North Country maternity services face. "[She] says there’s no single answer," Cuno-Booth reports. "But in a region where people and resources are spread out over a vast rural area. . . collaboration will be key."

As people "work to strengthen maternity care in the North Country, [many] say that mission is about more than supporting parents and newborns," Cuno-Booth writes. "It’s about whether communities here can survive and thrive." If a woman can't safely have children in a region, will a family want to move there?

Rural areas struggling to provide local Emergency Medical Services use creative solutions to fill the void

Southern Henry Ambulance Service’s new hub is a barn in
Knightstown. (Photo by Grayson Joslin, Indiana Capital Chronicle)

The safety net local Emergency Medical Services provides to rural communities has been faltering, leaving some areas without an EMS team to respond to urgent calls. The shortage has some areas creating their own EMS solutions.

Residents of Knightstown, Indiana, have lived without an ambulance service since January 2023, when the regional ambulance service closed due to financial losses and a lack of volunteers. "The town, situated in the southern portion of Henry County, is 25 minutes away from the county seat, New Castle, which has their own EMS services and hospital," reports Grayson Joslin of the Indiana Capital Chronicle. "But sometimes the New Castle EMS may have other calls to answer, so it could be anywhere from 45 minutes to an hour for EMS to get to Knightstown."

Knightstown resident and EMT volunteer Kevin Richey decided to explore how Knightstown might develop its own EMS service. Joslin writes, "Richey asked around the Knightstown community to see if there would be support to create a new nonprofit from scratch for providing EMS resources. . . . Southern Henry Ambulance Service was approved as a 501(c)3 nonprofit in early 2023, and started a fundraising effort across Knightstown and on GoFundMe to get the service off of the ground."

Just east of Henry County lies Fayetteville County, Indiana, where over half of the population lives in a rural area. The county has its own ambulance service, but still struggles to meet its call volume. "The county lost its only hospital in 2019," Joslin explains. "This has put an additional strain on its existing EMS operations. Runs that used to take two to three minutes to make now take about 30 to 35 minutes."

Increasing local taxes proved to be a solution to some of Fayetteville's staffing problems. "In 2024, both the Connersville City Council and the Fayette County Council approved a 0.25% public safety tax on income to go toward providing more funds to the county’s various public safety services," Joslin reports. "Fayette County EMS chief Clint Hardin said the funding from the tax allowed him to give his employees a $5,000 raise."

While tax increases are often unpopular, they can finance local needs that most residents support. Hardin told Joslin, "What people kinda lose sight of is property taxes is the only tax that we pay that is 99% local. That funds police, fire, EMS, your streets, your parks, your libraries, your schools. You get to see the benefit of your tax dollars.”

Many rural residents drive almost an hour to get to a hospital for surgery, study finds

Rural Medicare patients 'typically drive 55 minutes
to a hospital.' (Adobe Stock photo)

When rural folks need surgery, long-distance drives come with the territory. "Forty-four percent of rural Medicare patients must drive an hour or more for surgery, a recent analysis finds," reports Erin Blakemore of The Washington Post. "The study shows that patients in rural areas typically drive 55 minutes to a hospital — far longer than their counterparts in more populous areas."

While rural Americans have historically struggled to have medical care access that's equal to urban residents, their plight has worsened since 2011. Blakemore explains, "The number of rural Medicare beneficiaries who traveled more than 60 minutes for their procedure rose from 36.8% in 2010 to 44.1% in 2020. . . . Among non-rural Medicare beneficiaries, travel times were lower, with a median of 20 minutes’ travel in 2010 vs. 23 minutes in 2020."

Rural hospital closures could be contributing to the problem, and "high-risk operations are increasingly centralized, the researchers note, which may have contributed to the rise in travel minutes for rural patients who must go farther for such procedures," Blakemore adds. "In a related study from the Annals of Surgery, researchers found that 98.7 million Americans — nearly 1 in 3 — lacked access to 'timely, high-quality, affordable surgical care' in 2020."

The U.S. is expected to face a nationwide surgeon shortage over the next decade, making the lack of local surgical care for rural residents an area of "growing concern," write Brittany A. Long and Michael J. Sweeney for The National Library of Medicine. "When considering the existing barriers to surgical healthcare in rural communities, there is a sense of urgency to identify innovative approaches that will promote a sustainable surgeon workforce."