3 ways the Trump administration could reinvest in rural America’s future

Rural America faces many challenges that Congress and the federal government could help alleviate under the new Trump administration.

Rural hospitals and their obstetrics wards have been closing at a rapid pace, leaving rural residents traveling farther for health care. Affordable housing is increasingly hard to find in rural communities, where pay is often lower and poverty higher than average. Land ownership is changing, leaving more communities with outsiders wielding influence over their local resources.

As experts in rural health and policy at the Center for Rural and Migrant Health at Purdue University, we work with people across the United States to build resilient rural communities.

Here are some ways we believe the Trump administration could work with Congress to boost these communities’ health and economies.

1. Rural health care access

One of the greatest challenges to rural health care is its vulnerability to shifts in policy and funding cuts because of rural areas’ high rates of Medicare and Medicaid beneficiaries.

About 25% of rural residents rely on Medicaid, a federal program that provides health insurance for low-income residents. A disproportionate share of Medicare beneficiaries – people over 65 who receive federal health coverage – also live in rural areas. At the same time, the average health of rural residents lags the nation as a whole.

Rural clinics and hospitals

Funding from those federal programs affects rural hospitals, and rural hospitals are struggling.

Nearly half of rural hospitals operate in the red today, and over 170 rural hospitals have closed since 2010. The low population density of rural areas can make it difficult for hospitals to cover operating costs when their patient volume is low. These hospital closures have left rural residents traveling an extra 20 miles (32 km) on average to receive inpatient health care services and an extra 40 miles (64 km) for specialty care services.

The government has created programs to try to help keep hospitals operating, but they all require funding that is at risk. For example:

• The Low-volume Hospital Adjustment Act, first implemented in 2005, has helped numerous rural hospitals by boosting their Medicare payments per patient, but it faces regular threats of funding cuts. It and several other programs to support Medicare-dependent hospitals are set to expire on March 31, 2025, when the next federal budget is due.

• The rural emergency hospital model, created in 2020, helps qualifying rural facilities to maintain access to essential emergency and outpatient hospital services, also by providing higher Medicare payments. Thus far, only 30 rural hospitals have transitioned to this model, in part because they would have to eliminate inpatient care services, which also limits outpatient surgery and other medical services that could require overnight care in the event of an emergency.

Services for pregnant women have also gotten harder to find in rural areas.

Between 2011 and 2021, 267 rural hospitals discontinued obstetric services, representing 25% of the United States’ rural obstetrics units. In response, the federal government has implemented various initiatives to enhance access to care, such as the Rural Hospital Stabilization Pilot Program and the Rural Maternal and Obstetric Management Strategies Program. However, these programs also require funding.

Expanding telehealth

Before the COVID-19 pandemic, telehealth – the ability to meet with your doctor over video – wasn’t widely used. It could be difficult for doctors to ensure reimbursement, and the logistics of meeting federal requirements and privacy rules could be challenging.

The pandemic changed that. Improving technology allowed telehealth to quickly expand, reducing people’s contact with sick patients, and the government issued waivers for Medicare and Medicaid to pay for telehealth treatment. That opened up new opportunities for rural patients to get health care and opportunities for providers to reach more patients.

However, the Medicare and Medicaid waivers for most telehealth services were only temporary. Only payments for mental and behavioral health teleheath services continued, and those are set to expire with the federal budget in March 2025, unless they are renewed.

One way to expand rural health care would be to make those waivers permanent.

Increasing access to telehealth could also support people struggling with opioid addiction and other substance use disorders, which have been on the rise in rural areas.

2. Affordable housing is a rural problem too

Like their urban peers, rural communities face a shortage of affordable housing.

Unemployment in rural areas today exceeds levels before the COVID-19 pandemic. Job growth and median incomes lag behind urban areas, and rural poverty rates are higher.

Rural housing prices have been exacerbated by continued population growth over the past four years, lower incomes compared with their urban peers, limited employment opportunities and few high-quality homes available for rent or sale. Rural communities often have aging homes built upon outdated or inadequate infrastructure, such as deteriorating sewer and water lines.

One proposal to help people looking for affordable rural housing is the bipartisan Neighborhood Homes Investment Act, which calls for creating a new federal tax credit to spur the development and renovation of family housing in distressed urban, suburban and rural neighborhoods.

Similarly, the Section 502 Direct Loan Program through the U.S. Department of Agriculture, which subsidizes mortgages for low-income applicants to obtain safe housing, could be expanded with additional funding to enable more people to receive subsidized mortgages.

3. Locally owned land benefits communities

Seniors age 65 and older own 40% of the agricultural land in the U.S., according to the American Farmland Trust. That means that more than 360 million acres of farmland could be transferred to new owners in the next few decades. If their heirs aren’t interested in farming, that land could be sold to large operations or real estate developers.

That affects rural communities because locally owned rural businesses tend to invest in their communities, and they are more likely to make decisions that benefit the community’s well-being.

Congress can take some steps to help communities keep more farmland locally owned.

The proposed Farm Transitions Act, for example, would establish a commission on farm transitions to study issues that affect locally owned farms and provide recommendations to help transition agricultural operations to the next generation of farmers and ranchers.

About 30% of farmers have been in business for less than 10 years, and many of them rent the land they farm. Programs such as USDA’s farm loan programs and the Beginning Farmer and Rancher Development Program help support local land purchases and could be improved to identify and eliminate barriers that communities face.

We believe that by addressing these issues, Congress and the new administration can help some of the country’s most vulnerable citizens. Efforts to build resilient and strong rural communities will benefit everyone.