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Federal, State, and Stakeholder Perspectives on the Rural Health Transformation Fund Perspectives on the Rural Health Transformation Fund Catherine Jones Explore federal, state, and stakeholder perspectives on the Rural Health Transformation Fund, shared at a discussion hosted by ASTHO and Cornerstore Government Affairs teams. In early July, ahead of final votes on the One Big Beautiful Bill Act (full text H.R.1), Senate Majority Leader John Thune (R-SD), joined by Senators Susan Collins (R-ME) and Lisa Murkowski (R-AK), secured a $50 billion funding line for a new Rural Health Transformation Program (RHTP). This five-year mandatory fund is designed with two primary goals: To stabilize vulnerable rural hospitals, health centers, clinics, and their workforces. To improve access, affordability, modernization, and health outcomes for rural residents, who on average experience higher rates of chronic disease, shorter lifespans, and lower earning power compared to urban populations. To help states better understand how to apply and utilize RHTP dollars, ASTHO partnered with Cornerstone Government Affairs to host a discussion on Sept. 4 featuring two expert panels. Participants included representatives from Centers for Medicare & Medicaid Services (CMS) and HRSA, congressional staff, state health departments, and experts from the National Rural Health Association and National Association of Medicaid Directors. Lively discussions provided valuable insights into the application process, how states might deploy funds to build and sustain rural health programs, and the realities of delivering care on the ground. Panel One: Federal Perspectives Application Tips The first order of business was to provide potential applicants with essential information they need to apply. CMS is working quickly to release the Notice of Funding Opportunity in early September. Applications will be due in November, with funding decisions finalized by Dec. 31. This is a one-time application for the five-year mandatory fund, with dollars allocated evenly across FY26 to FY30 ($10 billion per year). Importantly, the RHTP fund is separate from — and unaffected by — FY26 Labor Health and Human Services, and Education discretionary appropriations outlined by the Senate and House, and any continuing resolutions. The $50 billion program will be divided into two parts. $25 billion will be distributed evenly among states that apply and have successful applications. The remaining $25 billion will be allocated at CMS’s discretion based on factors such as a state’s rural population, the number of rural health care facilities, and state policies and policy commitments. States will not be required to provide matching funds. In anticipation of the application deadline, many state health departments have been mobilizing over the past weeks. Health officials are convening task forces, launching working groups and public hearings, and issuing Requests for Information and surveys to shape projects and spending plans. These efforts are focused on aligning with CMS’s strategic goals, including making rural America healthy again, providing sustainable access to care, workforce development, innovative care delivery, and technology modernization. Program Insights Panelists also highlighted how RHTP differs from existing rural health programs. The Federal Office of Rural Health Policy, for example, funds initiatives focused on quality improvement, hospital technical assistance programs for operational challenges, and targeted pilot programs to test the feasibility of ideas related to community needs. By contrast, RHTP will provide states with a large, flexible infusion of funds to augment existing and novel rural health care efforts. States will also be permitted to use RHTP dollars for one-time investments (e.g., electronic health record systems, diagnostic equipment, and network-building initiatives). Panelists emphasized the importance of tailoring approaches to state and community needs, noting that Tribal communities face especially severe challenges, requiring intentional engagement. The first session concluded with a focus on Alaska, where 73.7% of hospitals are in rural areas — a key driver of Senator Murkowski’s strong advocacy for the fund. Her legislative director noted the state’s persistent struggles with connectivity, limited primary care access, workforce shortages, and low patient volume. Previous funding formulas, which relied heavily on hospital bed counts or numbers of health care facilities, often disadvantaged Alaska and similar states. RHTP, structured as a cooperative agreement, gives states both predictability and flexibility: dollars they can count on, combined with broad authority to design solutions in partnership with CMS protocols and assistance. CMS has existing protocols for grant management, and Congress will likely ask for clear reporting requirements as they monitor the successful implementation of the fund. Panel Two: State and Stakeholder Perspectives Rural Health Challenges To align visions with on-the-ground realities, health department leaders from Pennsylvania and Mississippi described their extensive efforts underway to gather input and identify priorities that are both sustainable and impactful, underscoring the importance of community engagement in shaping state strategies. Panelists noted that states are working through a broad list of rural health challenges, including: Maternal and child health. Behavioral health. Substance use disorder. Emergency medical services. Transportation barriers. Aging populations. Specialist shortages. Data modernization (including cybersecurity, AI, broadband, training, and administrative support). Telehealth. Workforce shortages. Hospital, clinic and federally qualified health care center closures. Payment models (public and private). Improving health information exchanges and electronic heath records were also mentioned as universal goals. RHTP is designed with flexibility to tackle these issues and to craft solutions (some of them can be shelf-ready, such as technology or prevention kits) to respond to the diverse needs of rural communities. Aligning Programs Panelists were asked how they are working with partners to achieve alignment for their programs. All concurred that strategic planning is essential, with an emphasis on local partnerships and regional collaborations. It was stressed that rural health care should ideally be delivered as close to the community level as possible, supported by a robust ecosystem. Speakers agreed that the financial health of rural areas is inseparable from the health of their hospitals and clinics. It was underscored that local residents are deeply invested in their communities and want to see them thrive. Transforming rural health care systems will require large-scale collaborations at a local level, which are built on trust, a shared vision, and a clear understanding of the long-term goals. The challenges of chronic disease, which occurs and leads to death at significantly higher rates in rural areas, surfaced. Panelists agreed that tackling this issue requires major investments in ancillary professions — such as nutritionists, physical therapists, and community health workers — alongside a renewed emphasis on primary care services and alleviating the acute shortage of primary care physicians. According to the American Medical Association, roughly 65% of rural areas face a shortage of primary care providers, and only 4%-5% of incoming medical students now come from rural backgrounds. Some solutions noted by the panelists were extending medical student rotations in rural settings from a few weeks to 12 or more, coupled with financial and professional incentives. Encouragingly, research shows that students from rural areas are far more likely to return home as practicing physicians. Final Words Panelists overwhelmingly agreed that RHTP represents an unprecedented opportunity for states — though, notably, not for U.S. territories or Washington, D.C. — to expand access, raise the quality of rural health care, and ultimately improve both quality of life and life expectancy for their rural residents. The $50 billion fund is not only a lifeline but also a testing ground, and if implemented successfully, it could serve as a model to pave the way for future federal investments of this magnitude in rural health. For more information on RHTP, please email MAHARural@cms.hhs.gov. Participants Part One: Federal Senator Lisa Murkowski and Angela Ramponi, MPH, Legislative Director Emily Chen, MBA, Senior Advisor, Office of the Administrator, Centers for Medicare and Medicaid Services, U.S. Department of Health and Human Services Tom Morris, MPA, Associate Administrator for Rural Health Policy, Health Resources and Services Administration, U.S. Department of Health and Human Services Moderated by Carlos Jackson, Principal, Cornerstone Government Affairs Part Two: State and Stakeholder Daniel Edney, MD, FACP, FASAM, State Health Officer, Mississippi State Department of Health Debra Bogen, MD, FAAP, Secretary of Health, Pennsylvania Department of Health Zil Joyce Dixon Romero, State Government Affairs Manager, National Rural Health Association Lindsey Browning, Deputy Executive Director of Programs, National Association of Medicaid Directors Moderated by Susan Kansagra, MD, MBA, Chief Medical Officer, ASTHO article yes

Ripple Effect: What USPSTF Recommendations Mean for State and Territorial Health Law What USPSTF Recommendations Mean for State and Territorial Health Law Andy Baker-White This Health Policy Update highlights how U.S. states and territories are using policy to codify important public health recommendations. The United States Preventive Services Task Force (USPSTF) is a volunteer panel of national experts that issues evidence-based letter-grade recommendations on clinical preventive services. Under the Affordable Care Act, services with an A or B grade must be covered by most private health insurance plans without cost-sharing, with similar requirements for Medicaid enrollees and Medicare beneficiaries. An estimate by the Department of Health and Human Services concluded that in 2020, these services reached approximately 264 million Americans. States and territories implement these recommendations through statutes and rules. ASTHO identified over 200 state and territorial laws referencing the USPSTF, including in insurance statutes, Medicaid rules, disease-specific laws, and state employee health plan requirements. Over the past year, the stability of USPSTF recommendations has come into question. The U.S. Supreme Court's June 2025 ruling in Kennedy v. Braidwood confirmed the HHS Secretary’s authority to block USPSTF recommendations and remove task force members. News reports in July 2025 indicated that HHS Secretary Kennedy intended to remove all USPSTF members, and in May 2026 fired the chair and vice-chair of the task force. Questions are being raised about whether USPSTF recommendations will be rescinded or downgraded and, if so, what the impact would be on states and territories. In addition, if the USPSTF fails to convene in the future, it cannot review newer data on preventive services, meaning existing recommendations could become outdated and USPSTF can’t make recommendations for new services. To meet these challenges, states and territories are taking steps to ensure the continued scientific basis for preventive health services within their own law. Dynamic References to USPSTF Recommendations States and territories often use dynamic references to USPSTF recommendations in regulating health plan coverage of preventive services. This allows the jurisdiction to automatically require coverage for the most current USPSTF recommendations. Laws in West Virginia (state employee health plans), Oregon (regulated health plans), Hawaii (health director standing orders), and Alaska (adult Medicaid enrollees) use this approach. While dynamic references allow jurisdictions to stay up to date with the recommendations, if the task force withdraws any guidance, then those preventive services would no longer require no-cost coverage without additional action from those jurisdictions. Some jurisdictions address this by specifying that certain USPSTF guidance changes will not apply. For example, Guam’s law requires continued no-cost coverage for colorectal cancer screenings and authorizes the health director to adjust diabetes screening recommendations if USPSTF recommendations cease. Illinois specifies that the 2009 USPSTF recommendations for breast cancer screening and mammography are not to be considered current because national medical bodies created differing recommendations for screening. Another way jurisdictions avoid the unpredictability of using dynamic references is locking in the date of the USPSTF recommendations that are used for coverage requirements. For example, Massachusetts requires its state employee health plan to cover USPSTF A and B recommendations that were in effect by July 1, 2023. Using a version of USPSTF recommendations from a specific date maintains a base level of coverage regardless of future changes, though adopting new recommendations or removing outdated recommendations would require separate action. During this year’s legislative sessions, several states enacted or proposed legislation to remove dynamic USPSTF references. For example, Maryland passed legislation (HB 637 and SB 385) to lock in the USPSTF A and B recommendations that were in effect on December 31, 2024. Washington enacted HB 2242 requiring coverage of USPSTF A and B recommendations in effect on June 30, 2025, as well as recommendations adopted by the state insurance commissioner. A bill passed in Delaware, HB 338, would require the use of the USPSTF recommendations from January 1, 2025. Overall, however, neither dynamic nor fixed references to USPSTF recommendations address how jurisdictions can keep up with new scientific data and advances in preventive services in the absence of ongoing USPSTF review and recommendations. To fill this need, some states have enacted legislation that creates processes for reviewing data and establishing recommendations. For example, the new Maryland law mentioned above also authorizes the state’s health secretary to adopt preventive service recommendations that have not been recommended by or that differ from USPSTF. The new process requires notice and a 30-day comment period, an analysis by the Maryland Health Care Commission, and citations to the authoritative medical body upon which the recommendation is based. Disease-Specific Statutes: USPSTF Grades as Care Standards and Thresholds Many states also use USPSTF grades as thresholds for specific preventive services, establishing the standard of care, or issuing standing orders. For example, Arkansas law defines "follow-up colonoscopy" by reference to a colorectal screening assigned an A or B grade by the USPSTF, while Nevada’s law directs primary care providers to use criteria set out in USPSTF recommendations to screen adult women for BRCA mutations. In Hawaii, the state health director is authorized to issue public health standing orders for current USPSTF A and B recommended services, and in Idaho the law uses USPSTF guidance for applying ocular antibiotic prophylaxis to newborns as the standard for medical practice in the state. Some states are considering legislation to distance preventive service coverage requirements from USPSTF recommendations. For example, while New Jersey's current law requires no-cost coverage for colorectal cancer screenings in accordance with the method and frequency recommended by the USPSTF, introduced legislation (A4916 and S4254) would remove the reference to USPSTF recommendations and instead authorize one screening per year for persons aged 33 or older. More broadly, Hawaii considered legislation (HB 1898 and SB 3133) that would have authorized the state’s health department to “make recommendations relating to clinical preventive service recommendations of the [USPSTF] Force that have been assigned a grade of A or B as of July 1, 2025” and require no-cost coverage for the department’s recommendations. However, this legislation did not pass. State Employee Benefit Plans USPSTF recommendations may also be used to establish preventive health services covered by state employee health plans. A West Virginia statute requires the state’s employee health plans to cover mammograms consistent with "current guidelines from the United States Preventive Services Task Force," while the health plan document further states that preventive services are "subject to change as USPSTF…recommendations are updated.” In Ohio, a regulation requires state employee health benefits include all USPSTF-recommended tobacco cessation services and authorizes the state health director to update covered services if USPSTF guidance changes. Missouri law requires full coverage of USPSTF graded A and B recommended prescription and prescribed over-the-counter drugs for state plan members. The Path Forward USPSTF recommendations have helped millions of Americans receive critical health services at no cost, and states and territories have built practices, programs, and standards on that foundation. From adopting fixed-date references to establishing state-level recommendation authority to creating new state review bodies, legislative activity this year reflects a broad effort to address ripple effects from potential future changes to or lack of USPSTF guidance. Health officials may be asked to assess their jurisdiction’s laws and their use of USPSTF recommendations, and coordinate with insurance commissioners, Medicaid directors, and employee benefits administrators to confirm consistent agency interpretation and identify where action is needed. ASTHO will continue to monitor these policies as they develop. article yes

Opportunities for Public Health Agencies to Advance Sustainable Financing of Community Health Worker Programs Advancing Sustainable Financing of Community Health Workers Explore how health officials can play key roles as funders, administrators, and policy designers to advance sustainable financing of community health workers. Many states face upcoming funding gaps for community health worker (CHW) positions, with COVID-19 related grant funding streams expiring. Concurrently, many states are rapidly beginning to cover CHW services under Medicaid. In addition, Medicare launched a new reimbursement opportunity for CHWs in January 2024. These factors create an opportunity for state and territorial health agencies to develop or contribute to equitable reimbursement and robust implementation. This report details how health officials can play key roles as funders, administrators, and policy design champions to ultimately advance sustainable financing of CHW services. Get the Report (PDF) website yes

This report, based on findings from ASTHO’s 2022 Environmental Scan, dives into how Health in All Policies strategies can promote health equity.

Breastfeeding is considered the gold standard in postnatal care for both birthing persons and infants. Yet racial disparities in breastfeeding initiation and duration rates continue to persist. Effective intervention strategies require a multi-level approach that includes comprehensive legal, policy, and programmatic efforts.

ASTHO partnered with the International Association for Indigenous Aging to produce this series of communication materials to address the connection between brain health and heart health.

This ASTHOBrief addresses the importance of developing robust, culturally competent risk-appropriate care systems for American Indian and Alaska Native communities.

An issue brief by ASTHO and the Duke University Margolis Center for Health Policy that highlights considerations for state health officials as they look to maximize the benefits of COVID-19 therapeutics.

This brief focuses on how telehealth expansion during the COVID-19 pandemic has increased access to care for pregnant and postpartum women, and made maternal and child health care services like doulas and midwives more accessible.

One in three individuals who contract COVID-19 will experience lasting mental health impacts, according to a recent study. This startling discovery underscores the reality facing our nation: the challenges of this last year—the public health and economic ramifications of COVID-19, coupled with the longstanding racial and ethnic inequities that it highlighted—will be felt for years, if not decades, to come.

During the early months of the COVID-19 pandemic, the federal government enacted the Coronavirus Aid, Relief, and Economic Security (CARES) Act, temporarily expanding the use of telehealth technologies by removing various requirements and waiving certain restrictions. Many states also expanded telehealth access through changes to state Medicaid laws. These temporary policy changes created an uptick of telehealth use that improved access to care for millions of Americans—but questions remain about which policy changes will stick around beyond the pandemic. Currently, states are making decisions about what temporary policies to permanently implement and which policies to end without disrupting the delivery of care and further exacerbating health disparities.

Learn how the Alaska Division of Public Health worked to meet national public health accreditation standards and improve its processes.

Tobacco Control Programs Use Business Process Mapping to Strengthen Workforce tobacco control programs, preventable disease, tobacco industry, diverse workforce, grants management, mapping workshops, technological support, united states, tobacco product, young people, comprehensive tobacco control programs, public health, tobacco company, department of health, cigarettes and smokeless tobacco, smokeless tobacco products, health care system, youth and young adults, smoking cessation, reduced smoking, tobacco related disparities, astho, association of state and territorial health officials Amy Ciarlo Since the beginning of the COVID-19 pandemic, public health agencies have experienced significant turnover across leadership and staff throughout various programs, including tobacco control. Between 2021 and 2023, nearly 30% of all state and territorial program managers were experiencing turnover (e.g., in some cases, vacancies lasted months) or were new to this role, having less than two years of experience. This decline in workforce reduces capacity to address tobacco use—the nation’s number one cause of preventable disease, disability, and death. Tobacco control program staff require a level of knowledge that can take time to build, including: Historical context of tobacco industry marketing influence. Policy, systems, and environmental change strategies. Emerging products and changing regulations. The complexity that goes into helping people who use tobacco to quit. Finding qualified applicants that will stay in these roles long term has been challenging across jurisdictions. In response to this need, the Tobacco Control Network, in collaboration with CDC’s Office on Smoking and Health, convened a nine-month learning community with three state tobacco control programs (Alaska, Arizona, and New Jersey) to address hiring and onboarding challenges, which concluded in March 2024. Subject matter experts Health Management Associates (HMA) supported by educating participants on business process improvement (BPI) methods, facilitating business process mapping workshops, and consulting on the development of individual state implementation plans to address key challenges identified during the mapping processes. A similar model with specific OD2A grant recipients focused on procurement, contracting, and helping address spend-down of funding. Business Process Mapping and Implementation Planning Each state participated in a two-day, in-person BPI workshop to outline all steps, from filling a vacancy to completing the onboarding of new hires. This was a lengthy exercise, as agencies often have many elaborate processes in place, due to an organizational requirement, an expectation held by leadership, or a past purpose that is no longer relevant. Understanding why the process happens and visualizing the steps in sequential order helped teams identify “waste” or areas for improvement, including overwork (e.g., too many meetings), waiting (e.g., on an approval, for a training to become available), extra processing (e.g., duplicating efforts), and unused talent (e.g., insufficient training and alignment of skillsets). States then drafted implementation plans to address key issues, outlining steps with detailed timelines and tasks assigned to individuals to increase accountability. Each state team finalized their plans as part of the learning community, with some activities in progress or already completed. However, all three varied in their processes, their approaches to solutions, and the activities outlined in their implementation plans: One state’s BPI workshop focused on grantees at the county-level and streamlining onboarding, as counties lacked consistency in their hiring and onboarding approach. Their implementation plan focuses on a team of state health agency staff and local partners establishing a guidance document that assists new local staff in their first three months. Another state’s BPI workshop centered on addressing challenges in building a diverse workforce, with goals to establish a standardized practice for job postings and reduce re-posting of vacancies. The mapping process allowed collaboration across multiple departments and with health agency leadership. During the final state BPI workshop, the team identified excess meetings as a pain point and are reworking them to reduce redundancy and streamline the onboarding process. The implementation plan also prioritizes making training materials more engaging and better understanding training needs among new program staff. Lessons Learned The state teams gathered to share key takeaways from the learning community, as reported by HMA, informing recommendations for other programs looking to address hiring and onboarding challenges. Successes Participation led to team building and a mutual understanding of the process. Participants trusted one another to share with transparency. The mapping activities remained agnostic by highlighting inefficiencies in the process and not the people. Individuals with new perspectives had the opportunity to comment on system improvements. Teams recognized the numerous demands on team members and grantees, how much duplication existed across processes, and the number of approvals or layers in the hiring procedures. Teams created clearly identified roadmaps to improve hiring and onboarding staff. The learning community brought together partners across the state to address challenges that impacted their work but were not part of their everyday tasks. Challenges Staff representatives from HR or Grants Management were not present during the mapping workshops, causing gaps in information during these sessions. Power dynamics created difficulty for all participants to contribute equally. There was a lack of consideration for equity and challenges from new hire perspectives. More structured technical assistance and check-ins following the development of implementation maps were needed to support follow-through. Some participants had a sense of ownership or attachment to the established process and were protective of maintaining the status quo. Recommendations Ensure all participants understand the vision by providing an example of similar work in advance as reference material. Prior to the mapping activities, conduct a series of key informant interviews to ensure the right people are in the room, gain an understanding and awareness of organizational and interpersonal dynamics that may impact the process, and identify opportunities to establish bidirectional communications between state and local staff. Plan for ongoing technical assistance follow-up to ensure understanding of the initiative and support implementation. Ensure logistics can accommodate the process, such as proper room size and technological support. In Conclusion Given the challenges identified in this pilot learning community, states would likely benefit from change management prior to beginning BPI activities. Having intentional conversations up front can prevent these common challenges, as outlined previously. Overall, all state participants agreed that the learning community was valuable to their work, increased their organization’s knowledge and capacity, strengthened their relationships within their agency, and they intend to continue working on their improvement plans. One state team shared, “A major success from this mapping workshop was understanding the significance of engaging and listening to colleagues from diverse departments. The workshop facilitated a clearer understanding of civil service and HR operations, emphasizing the hurdles faced by hiring managers.” While business process mapping and implementation plan development can be laborious, the results are well worth the effort. website yes

This brief highlights four top takeaways from the experience of six public health agencies working to establish and strengthen their own performance management systems.

ASTHO, in collaboration with CDC, provided full-time disability and preparedness specialists to 17 jurisdictions to better meet the needs of people with disabilities. In this brief, specialists share their thoughts on why people living with disabilities may be hesitant to get the COVID-19 vaccine and some approaches public health officials can take to address vaccine hesitancy in people living with disabilities.

Though now an illegal practice, government contracts, policies, and practices have generally excluded women, and Black, Indigenous, and people of color. Still, practices and existing structures continue the inequitable distribution of all contracts. Governmental and non-governmental grants and funding should benefit the communities they serve while being proportionate to the communities' demographics. This is where inclusive contracting comes in.

This Health Policy Update is an overview of state legislative activity to increase financial stability for families during the COVID-19 pandemic which may help to prevent adverse childhood experiences.

The 2020 holiday season is coinciding with a nationwide surge of COVID-19 cases. With great concern that holiday travel to see loved ones may exacerbate community spread of the virus, many states are increasing public health measures before the winter holiday season. As of November 16, 2020, 13 states and D.C. had a quarantine requirement for out-of-state travelers. The U.S. territories also have instituted travel restrictions to limit the spread of COVID-19.

In this episode, two maternal healthcare veterans share approaches for bringing providers into the process, as well as how state health officials can promote risk appropriate care strategies and address challenges in achieving equitable risk appropriate care.

In honor of ASTHO’s 80th anniversary, a leadership panel—including CEO Michael Fraser, President Anne Zink, Past President Nirav Shah, and Idaho Commissioner of Health Elke Shaw-Tulloch—discusses the unique role ASTHO plays in the public health landscape.