Workforce & Access

CMS is using the $50B Rural Health Transformation Program as a lever for state-directed delivery redesign, but the combination of federal spending controls and clawback risk is steering many states toward lower-risk structural moves—especially shrinking inpatient capacity, consolidating services, and shifting rural hospitals toward outpatient, emergency, and networked care models rather than broad experimentation. For VBC stakeholders, the strategic signal is that rural access policy is being tied more tightly to measurable transformation and cost discipline: rural hospitals are forming alliances and clinically integrated networks to gain scale for population health, contracting, and shared infrastructure, while states and providers push CMS for clearer implementation rules and more flexibility under the Rural Health Transformation Fund amid concerns that “transformation” funding could accelerate service contraction in fragile markets rather than stabilize full-service hospitals.