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Every year, ASTHO performs an annual environmental scan to identify these policy and programmatic priorities. The most recent scan occurred from June 2019 to May 2020. Through ongoing collection of data from a variety of sources—including state and territorial health improvement plans and strategic plans, documentation of discussion topics from ASTHO’s weekly calls with state and territorial health officials, requests for technical assistance, and subject matter expert input on trends and issues emerging in the field. These priorities will be ASTHO’s “2021 resolutions” as we enter a new year.

As we celebrate National Rural Health Day this year, we are reminded of how important telehealth can be for public health and healthcare. Telehealth can minimize challenges faced by rural patients and communities—such as transportation, provider shortages, etc.—manage volume, increase the quality of healthcare, and lower overall costs by reducing readmissions and avoidable emergency department visits. However, the COVID-19 pandemic has shown that access to reliable broadband is still a challenge and is a key social determinant of health for rural Americans.

This ASTHOBrief addresses the financial challenges facing pregnant people in rural areas.

ASTHO Members Convene to Share Perspectives on Rural Health Transformation Program ARLINGTON, VA — On September 4, ASTHO members and leadership convened for a panel discussion on the Rural Health Transformation Program. The panel focused on the $50 billion investment in rural health care as part of the One Big Beautiful Bill Act. "Our vision for the rural health fund is to address issues we heard about from many rural health care providers and their community members. This includes maternal health, access to behavioral health services, emergency medical services, transportation, and workforce," said ASTHO Past-President and Secretary of Health for the Pennsylvania Department of Health Debra Bogen, MD. "It is essential that we strengthen the primary care workforce in rural parts of our state. Understaffed primary care results in overuse of emergency departments and missed opportunities for prevention. Working with many partners, we want this funding to be foundational for innovation in rural Pennsylvania." "The majority of Mississippians live in rural areas, so this grant is a big deal for us," said ASTHO member and State Health Officer for the Mississippi State Department of Public Health Daniel Edney, MD. "Some of the issues we are focused on include a statewide health information exchange, distribution of hospital beds, chronic diseases, investing in remote patient monitoring, leveraging telehealth, and emergency medical services. In terms of outcomes, we need to see the life expectancy of Mississippians go up. If all Mississippians benefit from this grant, poverty will go down and our whole ship will rise higher." In addition to Drs. Bogen and Edney, leaders from the National Rural Health Association, National Association of Medicaid Directors, and U.S. Department of Health and Human Services participated.  Learn more from a recent ASTHO blog: Understanding and Applying for the Rural Health Transformation Program. ASTHO Press Release Boilerplate website yes

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

How New Laws Support Telehealth and Access to Health Care How New Laws Support Telehealth and Access to Health Care Ashley Cram Learn how federal and state policies are improving access to health care by supporting telehealth. Telehealth strengthens the health system by reducing barriers to access to health care and extending services to underserved communities. Federal and state policies — many born out of the COVID-19 pandemic — have increased the use of telehealth by patients and providers. This includes expanded reimbursement to allow more providers to deliver telehealth services in more locations and through more modalities. This Health Policy Update summarizes recent federal and state laws and policies that impact telehealth delivery and access to care. Federal Laws and Policies Rural Health Transformation Program Enacted as part of the One Big Beautiful Bill Act in July 2025, the Rural Health Transformation Program appropriates $10 billion per fiscal year for the Centers for Medicare & Medicaid Services (CMS) to award to eligible states looking to improve rural health care. CMS encouraged state applicants to focus on select strategies, including investment in technology platforms that enhance care delivery. This includes tools and resources that support telehealth overall and remote patient monitoring (RPM), which is a way for providers to monitor and support patients through the use of devices that support data collection and transmission. Applicants that participate in interstate licensure compacts are also incentivized throughout the five-year program period by being awarded additional points for participation, which may lead to states pursuing compact legislation in the coming years. Medicare Telehealth Flexibilities Set to Expire During the COVID-19 pandemic, CMS issued numerous flexibilities that authorized broader telehealth use to expand access to care. Flexibilities included expansion of certain audio-only services, geographic areas and patient locations, and additional provider types eligible to deliver telehealth services. Current policy authorizes these pandemic-related telehealth flexibilities through January 30, 2026. Without permanent extension of these flexibilities, Medicare coverage for telehealth services beyond January 30, 2026, telehealth will again be limited to patients living in rural areas and to certain services, providers, and facilities. Physician Fee Schedule Changes CMS establishes the annual Medicare Physician Fee Schedule (PFS), which sets payment policy for health care services provided by physicians and other professionals to Medicare beneficiaries. The 2026 PFS includes new codes for RPM that allow providers to tailor monitoring frequency and engagement levels to meet patient needs. These codes, and the expansion of RPM, allow providers to effectively monitor health indicators such as weight, blood pressure, blood glucose, and respiratory flow rates, to manage health issues. By regularly monitoring a patient’s health status, a provider can reduce the risk of adverse health outcomes and emergency department visits. Additionally, the PFS streamlined the process for adding eligible telehealth services for reimbursement by removing distinction between permanent and provisional services and focusing review on whether services can be delivered via telehealth. State Legislation Impacting Telehealth Delivery States are also developing policy solutions to enable broader access to telehealth services, including expansion of audio-only and RPM services. Audio-only telehealth services are the use of communications technology, without a visual component, to deliver synchronous health care services. This modality can ensure continuity of and access to care for patients who live in areas with limited broadband and/or those who lack access to a video-enabled device. In 2025, at least four states enacted laws related to audio-only telehealth services. This includes at least three states that extended coverage that would have otherwise expired. In Hawaii, SB 1281 extended the expiration of the state’s coverage of certain audio-only behavioral health services through 2027, while Minnesota (HF 2) took a similar approach to audio-only telehealth services, including certain behavioral health and substance use disorder services, through July 1, 2027. Similarly, Maryland (SB 372/HB 869) removed the sunset date for coverage of audio-only telehealth services. And more broadly, Missouri (SB 79) clarified the state’s telehealth definition to include audio-only technologies. RPM uses digital devices to monitor a patient’s health by collecting and sharing health information with providers. RPM is particularly effective for management of chronic conditions, allowing providers to engage in shared decision making with patients and prevent adverse health outcomes through more regular monitoring. In recent years, several states enacted legislation to expand access to RPM including two bills in Louisiana. Enacted in 2024, HB 896 established the Louisiana RPM program for Medicaid patients with chronic conditions and a history of high-cost services, with the goal of improved care coordination and reduced costs. Then in 2025, SB 70 expanded these criteria to include pregnant and postpartum women and infants following discharge from the NICU. In Maryland, HB 553 specifies that the Medicaid program must cover the equipment and provider oversight of blood pressure monitoring for eligible recipients, including pregnant and postpartum individuals and those with chronic health conditions. Lastly, Virginia enacted SB 843 which directs the state Medicaid agency to develop a plan and cost estimate for expanding Medicaid eligibility for RPM for patients with chronic conditions. State and territorial health agencies can encourage public health programs to incorporate telehealth and propose policy solutions that enable broader utilization of telehealth modalities across the entire jurisdiction. States that are interested in expanding access to telehealth can visit ASTHO’s Telehealth Project Initiation and Scoping Assessment to conduct a review and identify opportunities to expand access to telehealth, particularly related to policy, infrastructure, and funding. UD3OA22890-13-00 article yes

On Oct. 4, 2023, ASTHO responded to a Request for Information from the U.S. House of Representatives' Ways and Means Committee on the subject of improving access to healthcare and rural and underserved areas, including the island jurisdictions.

The Keys to Driving Generational Health, Well-Being, and Justice 30:13 Tune in to this podcast episode to hear a discussion about the vital conditions for health and well-being framework to reach full potential. PH Conversations Series - The Keys to Driving Generational Health, Well-Being, and Justice Somava Saha and Andrew Martin from Well-Being and Equity in the World (WE in the World) discuss the vital conditions for health and well-being framework or what we all need to collectively thrive and reach our full health and wellness potential. Through their conversation, they offer reflections and stories around how public health and community collaborations across the country organize around the vital conditions, prioritizing belonging and building civic muscle, to drive health, well-being, and justice across generations. Show Notes Guests Somava Saha, MD, MS, President and CEO, WE in the World Andrew Martin, MS, MHCDS, Director of Networks and Partnerships, WE in the World Resources Organizing Around Vital Conditions Moves The Social Determinants Agenda Into Wider Action | Health Affairs Thriving Together Springboard Vital Conditions | WIN NETWORK Pathways to Population Health Equity PHC Podcast Transcript - The Keys to Driving Generational Health, Well-Being, and Justice website yes

Learn how to leverage public health assets in Medicaid managed care, with helpful background, life cycle details, and information on key obligations.

Improving Community Access to Care Through Health Disparities Grant Learn how states have addressed COVID-related health disparities and improved health equity in their jurisdictions in these case studies. In 2021, as part of the COVID-19 pandemic response, CDC distributed critical funding to state, territorial, and freely associated state health departments through the OT21-2103 COVID Health Disparities grant to promote health equity initiatives. ASTHO, in partnership with the National Association of Community Health Workers and the National Organization of State Offices of Rural Health, created state stories highlighting how some health departments have deployed this funding to advance health equity in their jurisdictions. The following state stories demonstrate how Utah, Virginia, and Texas worked to strengthen public health initiatives in rural communities, empower community health workers, and build stronger bridges between communities and health care. website yes

Investing in Indiana’s Public Health Infrastructure Through Community-Driven Policy Change public health infrastructure, community driven policy, indiana state health commissioner, public health system, indiana department of health, outpatient facilities, technical assistance, data and information integration, emergency preparedness, child and adolescent health, legislative action, state and local elected officials, health problems, health care, health system, health departments, federal agencies, essential public health services, centers for disease control, state and local levels, health outcomes, health organization, covid-19 pandemic, health infrastructure, promoting health, public health organizations, states public health, federal funding, astho, association of state and territorial health officials Maggie Davis, Keith Coleman Indiana enacts historic public health funding through community engagement and legislative support. In April 2023, Indiana passed bill SB 4, which was a historic investment in the state's public health funding and restructuring its public health system. This case study shares how the Governor's Public Health Commission and the Indiana Department of Health approached community listening sessions, formulated recommendations, and successfully built legislative support to reform the public health system in the state. Get the Report (PDF) website yes

With many of the state and territorial legislatures reconvening over the next few weeks, we can look forward to new (and not-so-new) legislation start to crop up that will impact public health. To help navigate the new legislative sessions, ASTHO’s "2021 Legislative Prospectus" series highlights eight priority policy areas jurisdictions will address during this year. Each prospectus in the series provides a brief overview of the issue, the issue’s impact on health, and recent legislative trends aimed at addressing the issue. This year, ASTHO developed prospectuses on COVID-19, e-cigarettes, HIV, influenza, maternal mortality and morbidity, neonatal abstinence syndrome (NAS), polyfluoroalkyl substances (PFAS), and rural health.

More than 100 rural hospitals have closed since 2010, and an additional 25% are at high risk of closure, and COVID-19 has magnified the existing stressors on rural healthcare. As a result, states are using a variety of measures to address and prevent more rural hospital closures.

Responsible for planting, growing, harvesting, processing, and preparing the food we eat, agricultural workers are essential workers during the COVID-19 response to keep the U.S. food supply chain operating efficiently. But farmworkers are particularly vulnerable to COVID-19 due to lack of physical distancing, lack of access to health insurance and sick leave, and poor access to clean water for handwashing throughout the work day.

The ASTHO State Health Policy team provides brief updates on 5 of the ten state health policy issues to watch in 2022: mental and behavioral health, rural health, e-cigarettes and flavored tobacco products, HIV and PFAS.

Vaccines are one of the greatest public health achievements of the last century, as well as some of the most powerful and cost-effective tools to prevent disease, disparities, disability, and death among children and adults. The COVID-19 pandemic and the unprecedented development and distribution of the vaccines against the novel coronavirus have generated much focus on state laws related to vaccinations. As state and territorial legislatures prepare to convene in the coming weeks, we can already identify several topics within vaccine law that policymakers across the country will consider.

The disparities experienced during the COVID pandemic have brought a national focus to health equity in our nation. The attention and resources currently being provided to help address health inequities provide an opportunity that I have never experienced in my public health career. There are still challenges, but we have an opportunity to build momentum for the first time in decades if we can focus on implementing evidence-based strategies, demonstrating change and documenting our progress.

When rural hospitals close, it increases the distance people must travel for essential healthcare services. The COVID-19 pandemic has highlighted and magnified the factors leading to rural hospital closures across the country. Many healthcare facilities suspended elective procedures to conserve critically needed personal protective equipment and reduce the risk of exposure to COVID-19 by patients and hospital staff. For many rural hospitals, however, the suspension of elective procedures with the reduced the use of non-urgent services by apprehensive patients meant a loss of revenue and the furloughed healthcare staff. Since the onset of the COVID-19 pandemic, approximately half of all rural hospitals are experiencing negative operating margins due to reduced outpatient revenue. The rate increases in states that have not expanded Medicaid. Unfortunately, these kinds of challenges are not new to rural hospitals.

People with chronic diseases have suffered the most during the pandemic both in rates of COVID-19 mortality and morbidity, and the health disparities that exist in those with chronic disease and poor social determinants of health are stark. On today’s episode, we speak to chronic disease and health equity experts on how to address this growing divide.

On this episode, speakers will discuss the impact of COVID-19 on rural health infrastructure and workforce, and how to improve these conditions in rural communities. We hear from three leaders who work in states with high rural healthcare needs and vast provider shortages to learn how to increase access to quality healthcare in rural areas, barriers that exist, and innovative strategies for rural health workforce recruitment and retention.