In Washington's marble halls, senators and representatives speak passionately about rural healthcare. They cite statistics about hospital closures, describe constituents driving 100 miles to deliver babies, and secure promises to address these "critical" issues. The concern seems genuine, the rhetoric moving.

Then they vote.

The recent congressional approval of legislation that healthcare experts warn will accelerate rural hospital closures reveals a troubling truth: while politicians perform concern, real communities face extinction. The very representatives who champion rural healthcare in hearings turn around and vote for bills that push these hospitals closer to the edge.

While Congress was deliberating legislation that would make their survival even harder, the people of Anson, Texas were fighting to keep their hospital doors open. Their story, captured in the video below, shows what the political rhetoric obscures: real people making extraordinary sacrifices to save the institutions their communities depend on.

As someone who has managed rural hospitals for 25 years and navigated countless healthcare policy promises that fall short of operational realities, I've learned to look beyond political rhetoric to examine actual program mechanics. The recently passed legislation includes a Rural Health Transformation Program providing $50 billion over five years. However, the same legislation simultaneously reduces federal Medicaid spending by around $1 trillion from 2025 through 2034. This represents the classic Washington approach: create a crisis with one hand, then offer inadequate solutions with great fanfare using the other.

Vice President JD Vance cast the tie-breaking vote as the Senate passed the “One Big Beautiful Bill” (or substitute your own descriptor) 50-50 after a 27-hour marathon of voting. While the most extreme Scott amendment was ultimately defeated, the base bill’s devastating wealth transfer from healthcare to tax cuts for the wealthy now moves to the House, where the real fight begins.

In the pre-dawn hours of Tuesday morning, the U.S. Senate completed one of the most consequential votes in recent American history—not just for what it passed, but for what it revealed about who matters in American democracy. After 27 hours of marathon voting that forced senators to cancel July 4th vacation plans, Republicans achieved their goal of the largest wealth redistribution in recent memory: cutting more than $793 billion from Medicaid to fund tax cuts for the wealthy.

The vote came down to a 50-50 tie broken by Vice President Vance, with only three Republicans joining all Democrats in opposition: Susan Collins of Maine, Thom Tillis of North Carolina, and Rand Paul of Kentucky. The absence of the ultra-extreme Scott amendment—which would have completely eliminated Medicaid expansion funding starting in 2031—represents the only silver lining in an otherwise devastating outcome for American healthcare.

The Semafor News report reveals a dramatic escalation in the Senate's assault on Medicaid expansion that goes far beyond what we previously analyzed. While the original Senate bill created a punitive two-tier system for expansion states, Senate Majority Leader John Thune is now backing an amendment by Senator Rick Scott that would effectively end Medicaid expansion for all future enrollees starting in 2031.

This represents a seismic shift from penalizing expansion states to potentially eliminating expansion altogether. The Scott amendment would strip away the 90% federal funding match that made Medicaid expansion financially attractive to states, forcing them to cover new expansion enrollees at their regular state Medicaid matching rates—typically between 50-75%. For most states, this would make expansion financially unsustainable.

The political dynamics are revealing. Conservative senators Rick Scott, Mike Lee, Cynthia Lummis, and Ron Johnson withheld their votes on Saturday's procedural motion until securing promises for this amendment vote. Based on publicly reported financial disclosure information, these four senators who are pushing for the elimination of healthcare coverage for millions of low-income Americans have a combined net worth of $290-450 million, with Rick Scott alone accounting for an estimated $200-300 million of that total. Their strategy worked—Thune is now publicly backing what amounts to a poison pill for Medicaid expansion. The Majority Leader's endorsement transforms this from a fringe conservative demand into a serious threat with potential majority support.

The financial mathematics are substantial. Scott's amendment would save $313 billion over the budget window, but that "savings" comes directly from shifting costs to states or eliminating coverage entirely. Consider North Carolina, which just expanded Medicaid and could see hundreds of thousands of residents affected. Under current law, the federal government pays 90% of costs for expansion enrollees. Under Scott's amendment, North Carolina would pay its regular 35% state match, effectively tripling the state's costs for new expansion enrollees after 2031.

Right now, as I'm writing this, U.S. Senators are debating a bill that could determine whether your local hospital stays open. I know that sounds dramatic, but it's not hyperbole. The "One Big Beautiful Bill" that's moving through Congress includes some of the deepest cuts to hospital funding we've ever seen.

And here's the thing - this isn't about some abstract policy debate. This is about whether the hospital where you were born, where your kids might be born, where your parents go for emergency care - whether that hospital will still be there next year.

We're already seeing hospitals close at an alarming rate. In rural areas especially, about one in five hospitals are on the financial edge. Many have already cut services that communities depend on - labor and delivery units, mental health programs, even emergency departments. Once those services are gone, they almost never come back.

The problem is that hospitals lose money on every Medicaid patient they treat. The government simply doesn't reimburse the full cost of care. To make up for some of that gap, states have programs called "State Directed Payments" that help hospitals stay afloat while serving Medicaid patients. It's not perfect, but it's been a lifeline.

This Senate bill would essentially eliminate that lifeline. It caps those payments at Medicare rates, which sounds reasonable until you realize Medicare rates don't cover the actual cost of care either. Hospitals would be forced to choose: keep losing money until they close, or cut services that people need.

In the heat of congressional budget battles, advocacy campaigns face a crucial challenge: how do you make abstract policy debates feel real and urgent to everyday Americans? The Coalition to Strengthen America's Healthcare rises to meet this challenge with "These Halls," a powerful three-minute national television spot that launched as part of their essential #FacesofMedicaid campaign in mid-June 2025.

As Congress considers devastating Medicaid cuts through budget reconciliation, this seven-figure advertising push represents more than just another political ad—it's a vital effort to protect a program that serves as the backbone of American healthcare. The campaign correctly reframes how Americans think about Medicaid's indispensable role in their communities. Rather than focusing solely on the 70 million Americans who directly rely on Medicaid, the Coalition makes the compelling and accurate argument that cuts to this critical program would create a catastrophic domino effect threatening the entire healthcare infrastructure that serves everyone.

The Clock is Ticking: Senate Republican leaders are racing to pass their version of President Trump's "big, beautiful bill" with a vote potentially happening within days—giving rural America an extremely narrow window to prevent a healthcare catastrophe. With senators already expressing alarm over the devastating cuts to rural hospitals, these next few days represent the last chance to stop legislation that would accelerate hospital closures across small-town America while extending tax cuts that primarily benefit the wealthiest Americans.

Rural hospitals across the United States are bracing for potentially devastating cuts under Medicaid changes being crafted by the Senate Finance Committee, with healthcare leaders warning that the proposed legislation could lead to the closure of critical access hospitals that serve as lifelines for small communities nationwide. The Senate is expected to release its version of the reconciliation bill as early as this week, with discussions centering on deeper cuts to Medicaid funding than those passed by the House. For the nation's approximately 1,350 critical access hospitals and small rural facilities, the changes represent an existential threat to their operations, which are already strained by workforce shortages and post-pandemic financial pressures.

More than 180 rural hospitals have closed since 2005, and healthcare advocates warn that the proposed Senate changes could accelerate that trend dramatically. Rural hospitals operate on razor-thin margins, with many serving communities where Medicaid beneficiaries comprise 40 to 60 percent of their patient base. The proposed Senate changes include several provisions that would hit rural hospitals especially hard, including significant cuts to enhanced federal matching rates for Medicaid expansion states, which would eliminate billions in federal funding that helps offset the chronic underpayment rural hospitals receive for Medicaid services.

On June 5, 2025, the Nebraska High Value Network (NHVN) officially launched with 19 critical-access hospitals joining forces to strengthen healthcare delivery across rural communities. This collaborative network, organized by Cibolo Health, represents more than just a partnership—it's a strategic approach to ensuring sustainable, high-quality healthcare remains accessible in rural Nebraska.

The network's cornerstone is a clinically integrated network (CIN) that will serve nearly 300,000 patients while allowing each hospital to maintain its independence and community focus. For healthcare leaders like myself, this model offers a compelling path forward in an increasingly complex healthcare landscape.

The Congressional Budget Office's June 4, 2025 analysis of H.R. 1 (the "One Big Beautiful Bill Act") as passed by the House of Representatives provides stark confirmation of what rural health advocates feared, but the crisis may be far from over. The CBO projects that 16 million Americans would lose health insurance by 2034 under the House-passed bill, with rural communities bearing a disproportionate burden due to their heavy reliance on Medicaid and federally-funded programs. However, as the Senate now works on its version through budget reconciliation, early signals suggest senators may push for even deeper cuts, making the CBO's devastating projections a floor rather than a ceiling for potential coverage losses.

This escalating threat comes on top of the Trump Administration's FY 2026 HHS Budget, which would simultaneously eliminate critical rural health programs including Medicare Rural Hospital Flexibility Grants, State Offices of Rural Health, and the Rural Hospital Stabilization Program. Rural communities now face the unprecedented prospect of losing both federal support programs and insurance coverage that keeps rural hospitals financially viable, with the Senate potentially making an already catastrophic situation even worse.

The numbers from the House-passed bill tell a devastating story, but they represent only the beginning of potential damage. The CBO analysis reveals that 5.1 million people would lose insurance from baseline policy changes including premium tax credit expiration and new marketplace rules, while 10.9 million additional people would lose coverage from H.R. 1 provisions as passed by the House. Most alarming for rural America, 7.8 million of those losses come directly from Medicaid changes that will devastate communities already facing hospital closures and provider shortages. These numbers represent more than statistics—they represent rural families losing access to critical healthcare services in areas where alternatives simply don't exist. But as the Senate crafts its reconciliation bill, comments from senators suggest they may pursue even more aggressive cuts, potentially pushing coverage losses well beyond the CBO's already-catastrophic projections.

We stand at the threshold of a medical revolution. While the promise of personalized medicine has tantalized researchers for decades, we're finally seeing the convergence of technologies that can deliver on that promise at scale. Leading this charge is an unlikely partnership between a century-old Danish pharmaceutical company and cutting-edge quantum computing research—a collaboration that's rewriting the rules of drug discovery and patient care.

Novo Nordisk, best known for its diabetes treatments and the blockbuster obesity drug Wegovy, has quietly become one of the most innovative forces in computational medicine. Their recent breakthroughs offer a glimpse into a future where artificial intelligence doesn't just assist doctors—it fundamentally transforms how we understand, predict, and treat disease.

The Trump Administration released its fiscal year 2026 Department of Health and Human Services (HHS) Budget in Brief this week, presenting a complex picture for rural health funding. While some programs see continued support, several critical rural health initiatives face elimination under the proposed budget, creating a stark contradiction with commitments made by senators during recent confirmation hearings.

The budget includes $284 million for the Federal Office of Rural Health, with $145 million specifically allocated for the Rural Communities Opioid Response Program. This represents a significant investment in addressing the ongoing opioid crisis that has disproportionately impacted rural communities across America. However, the budget request lacks specific funding levels for most other rural health programs, leaving uncertainty around the future of many initiatives that rural communities depend on.

The proposed budget would eliminate several cornerstone rural health programs that have been vital to rural healthcare infrastructure. Medicare Rural Hospital Flexibility Grants, which have helped rural hospitals maintain critical access designation and improve quality of care, would be cut entirely. State Offices of Rural Health, essential coordination hubs that support rural health initiatives at the state level, also face elimination. The newer Rural Hospital Stabilization Program, designed to help struggling rural hospitals remain operational, would similarly be terminated. Additionally, 15 workforce programs that have traditionally helped address rural healthcare staffing shortages would be eliminated, though the fate of the Rural Residency Planning and Development Program remains unclear as it's uncertain whether this program is included among those slated for cuts.

At 2 AM in rural Montana, when a farmer suffers a heart attack and his wife frantically calls 911, the nearest hospital with cardiac care is 90 minutes away—if it's still open. This scenario is becoming increasingly common across rural America as healthcare infrastructure crumbles, and proposed Medicaid cuts threaten to accelerate the devastating trend.

The House's razor-thin 215–214 passage of the "One Big Beautiful Bill Act" has ignited a Senate reconciliation process that could strip approximately $750 billion from Medicaid over the next decade. The proposed changes include capped funding formulas and 80-hour monthly work mandates that health policy experts say would disproportionately impact rural communities where seasonal employment is common.

Rural America is already experiencing a healthcare crisis. Since 2010, more than 150 rural hospitals have closed their doors, leaving entire communities without local emergency care, obstetrics services, or specialized treatment. Each closure eliminates not just medical services but also jobs and economic stability in communities that can least afford the loss.

In rural areas, Medicaid serves as more than just another government program—it's an economic lifeline. The program covers nearly one in four non-elderly residents in these communities and serves as the primary revenue source keeping hospitals financially viable. These facilities operate on razor-thin margins where a late harvest season or unexpected flu outbreak can push them into bankruptcy.

Rural hospitals across America face a precarious financial situation, with nearly half operating in the red and hundreds vulnerable to closure. According to a comprehensive new report from the Chartis Center for Rural Health titled "Medicaid cuts would push rural hospitals—and care for rural communities—over the edge (link at bottom)," potential Medicaid cuts could devastate these vital healthcare institutions and the communities they serve.

The Chartis report, released in May 2025, provides alarming data about the current state of rural healthcare in America. An estimated 10.1 million people rely on Medicaid in rural hospital communities across the country. These individuals depend on their local hospitals for essential services, yet these same hospitals are increasingly operating on what Chartis describes as "the razor's edge" of financial sustainability.

Even without Medicaid cuts, rural healthcare's capacity is already tenuous. The Chartis analysis shows that nearly 50% of rural hospitals are operating in the red, 432 are vulnerable to closure, and many are discontinuing services just to keep their doors open. Recent budget reconciliation efforts on Capitol Hill have pushed potential Medicaid cuts into the spotlight, with the House Committee on Energy and Commerce tasked with finding $880 billion in savings over 10 years.

Many organizations unknowingly foster environments where speaking up is discouraged and conformity is enforced through fear. This phenomenon isn't isolated to a few problematic institutions—it represents a systemic challenge across the healthcare sector that undermines both organizational effectiveness and patient care.

A recent Harvard Business Review article by Hyunsun Park and Subra Tangirala titled "Why Employees Stay Silent When They See Warning Signs of a Problem" sheds light on this troubling dynamic. The researchers identify how organizations face two distinct types of threats: clear ones that trigger immediate action, and ambiguous ones that often go unaddressed. While clear threats—like a detected gas leak with alarming readings—prompt quick responses, ambiguous threats with mixed signals tend to slip through organizational cracks.

We're excited to welcome Jess Nuutinen back to our leadership series with her insightful exploration of the critical distinction between being a boss and being a leader. Following her previous contribution on shared governance, Jess now turns her analytical lens to the subtle yet profound differences that separate positional authority from true leadership. In "Boss vs. Leader: Understanding the Key Differences," she skillfully dissects how these contrasting approaches affect team dynamics, organizational culture, and long-term success. Jess's thoughtful examination of authority versus influence, task-orientation versus people-orientation, and control versus empowerment provides valuable guidance for healthcare professionals at every level. Her practical wisdom reminds us that effective leadership transcends titles and hierarchies—a timely message that complements our growing collection of leadership perspectives. As you read her compelling analysis, we invite you to reflect on your own leadership style and consider how you might incorporate more leadership qualities into your daily practice.

We're pleased to continue our leadership series with an enlightening contribution from Dan Swenson that challenges conventional notions of leadership. In "Transformative Leadership - Making a Meaningful Difference," Dan thoughtfully explores how true leadership transcends formal titles and hierarchies to focus on creating genuine impact. His perspective offers a refreshing counterpoint to authority-centric leadership models, emphasizing instead how service, compassion, and humility form the foundation of transformative leadership. Dan's insights are particularly relevant in healthcare settings, where leadership decisions directly affect patient outcomes and organizational culture. As Frontier Strategy Partners continues to showcase diverse leadership philosophies, Dan's emphasis on accessible leadership—available to everyone regardless of position—adds a valuable dimension to our ongoing conversation. His message that leadership is ultimately measured by positive impact rather than power aligns perfectly with our commitment to exploring leadership approaches that create lasting, meaningful change.

Exceptional performance is rarely achieved through isolated initiatives or the heroic efforts of individuals. Instead, sustainable excellence requires a comprehensive management system that aligns people, processes, and strategic direction. Having observed this healthcare transformation effort, I've become convinced that the "three-legged stool" approach—integrating People, Process, and Plan—offers a powerful framework for healthcare organizations seeking to elevate performance across all dimensions.

We're excited to continue our leadership series with a compelling contribution from Kevin Stranberg of Stranberg and Associates. In this insightful piece, Kevin illuminates the often-overlooked yet essential role that non-clinical leadership plays in creating exceptional healthcare experiences. Building upon the shared governance principles explored in Jess Nuutinen's previous article, Kevin expertly demonstrates how non-clinical departments form crucial pillars in a healthcare organization's cultural foundation. His holistic perspective reminds us that exceptional patient care depends on every team member—from registration to housekeeping—working in concert toward a common mission. Kevin's thoughtful analysis of empowerment, collaboration, and accountability across departmental boundaries reflects his deep understanding of healthcare systems and organizational dynamics. We're confident his wisdom will provide valuable insights for leaders throughout your organization, regardless of their clinical or non-clinical roles.

Strong leadership in non-clinical departments of the healthcare system is essential to overall success.  Although most clinical departments generally have limited direct contact with patients, their efforts are important components of the overall culture of the organization.  Time and time again when patients are asked the question “did staff work together to care for you?” they include everyone they have come in contact with during their visit – registration, housekeeping, nutrition, patient financial to name a few.  As a leader of non-clinical staff, the focus of the work needs to be clear and important to every staff.  This focus centers on many of the same priorities listed by Jessica Nuutinen in the previous leadership article on Shared Governance – Empowering Healthcare Teams Through Collaborative Leadership for clinical staff leadership.

Rural hospitals face a perfect storm of challenges: aging populations, higher rates of chronic disease, lower reimbursement rates, and thinner operating margins. The Medicaid Directed Payment Program has emerged as a critical tool to ensure these essential healthcare facilities remain viable while improving care quality. Nebraska's recent implementation offers valuable insights into how these programs can transform rural healthcare delivery.

Directed payments, established by the Centers for Medicare & Medicaid Services (CMS) in 2016, allow states to require Medicaid managed care organizations (MCOs) to pay providers according to specific rates or methods. According to MACPAC (Medicaid and CHIP Payment and Access Commission), these payment arrangements can be used to establish minimum fee schedules, require participation in value-based payment arrangements, or implement uniform payment rate increases. Unlike traditional supplemental payments, which aren't allowed in managed care, directed payments must be tied to utilization and delivery of services under the managed care contract, distributed equally to specified providers, and advance at least one goal in the state's managed care quality strategy.