By Amy Oliver, Founder, Azul Heart
LinkedIn: Amy Oliver
LinkedIn: Azul Heart
Rural health is having a moment. There is $50 billion in federal transformation funding on the table, a wave of state legislation moving through capitols with a trail of confusion, and a public comment period on Medicaid work requirements that recently closed. Layer on the webinars, panels, policy briefs, and LinkedIn posts about rural hospitals, and it is more attention than I have seen in my fifteen years in this industry. And honestly, I’ve been wondering lately whether I’m finding all of this, the articles, the podcasts, the data, because it keeps finding me, or because something shifted in how personally I’m paying attention.
It’s probably both.
I have always cared about healthcare access and equity. But recently it stopped being just a professional conviction and became something messier and more specific, the kind of care that comes from watching the system fail someone you love and not being able to do anything about the system, only about showing up.
My grandmother Gladys spent the last six weeks of her life in a nursing home in rural Pennsylvania. She had fallen at home and broken her back, and she was recovering, genuinely improving, right up until a second fall gave her a brain bleed and she entered hospice, passing a couple of weeks before her ninety-sixth birthday. I’m not assigning blame, because she was ninety-five and nearing the end of a long, incredibly full life, and the people caring for her were doing extraordinary work. What I am interested in is what I saw while I was there.
I’ve been turning these few thoughts over in my head, and it was time to put ‘pen to paper. (Or is the 2026 version ‘fingers to keyboard?’)
One. The doctor came once a week. Sit with that for a sec, because it means there were roughly 144 hours between visits where the people making decisions about my gram’s care were LPNs and aides carrying a caseload built for a fully staffed building that was never actually fully staffed. One weekend a snowstorm hit and even more people called off than usual. Over and over I watched information fail to travel from one shift to the next; medication changes that should have been in the EHR weren’t always there, and the incoming shift was sometimes working from an incomplete picture of where she was that day. It was never once because somebody was careless or cutting corners. Those people were doing work that the wages they were earning did not come close to honoring, and the turnover that creates is its own kind of crisis.
Spending that time with my gram was the absolute privilege of a lifetime, and one I do not take lightly. I was lucky I could be there, to ask questions, to advocate, to be another set of eyes. I know that is not something every family can do, and I think the system has gotten quietly comfortable counting on the families who can. According to HRSA data analyzed by the Commonwealth Fund, by 2037 rural areas are projected to meet only 68% of their demand for primary care physicians, compared with 73% nationally. More than 40 million rural Americans already live in areas with too few providers today. When I read those numbers I do not picture a workforce planning chart. I picture 144 hours, making up six full days until the doctor was back at the nursing home.
Two. Kyle Kramer, CEO of Day Kimball Health in Connecticut, told a room earlier this year that he spends considerable time on a weekly basis communicating and/or with legislators regarding the unique aspects of healthcare in rural communities. Education and message consistency is crucial to the effort to build understanding and redirecting focus. He talked about building relationships with legislators over time, showing them the actual financial books, and bringing in community voices, patients, local employers, pastors, not just hospital executives. The goal is not to win an argument. The goal is to make the case so consistently and specifically that when a legislator repeats your message back to someone else like it was their own idea, you know it landed.
That is what sustained advocacy actually looks like, and it takes showing up over and over, not just at the moment of crisis. That framing stuck with me hard. In May I went to Ohio Health IT Day at the Statehouse in Columbus with the Ohio HIMSS chapters, and it was not what I expected walking in. The legislators are regular people. A lot of them are learning this material in real time right alongside the rest of us, and they are making decisions about AI oversight and rural funding and interoperability based largely on who bothered to explain it to them clearly, or explain it to them over and over. That is an opportunity and a responsibility at the same time, and I’m not sure our industry has fully reckoned with either one.
Three. The people most at risk of losing Medicaid coverage under the new work requirements aren’t people sitting at home. A significant share of Medicaid adults are already working, frequently across multiple part-time jobs without employer benefits, which is exactly why they qualify in the first place. Many others are unpaid caregivers, primarily women, whose caregiving does not count as work under the rule. Retroactive coverage windows have narrowed and eligibility checks are more frequent, and for someone working two jobs with unreliable internet and a sick kid at home, that is not a paperwork inconvenience so much as a design that reliably produces disenrollment.
The genuinely encouraging part is that people are building for this. CMS hosted a demo event with more than two dozen vendors focused specifically on work requirement navigation, and 10 technology companies have pledged over $600 million in discounted solutions to states. That is real and it matters. The harder question is speed; these tools need to be in patients’ hands before January 2027, not in a pilot phase or a grant proposal. The window between “this technology exists” and “this technology reached the person who needed it” is where people fall through, and in rural health that window has historically been wide.
Which is exactly why the clinical voice matters here too. Dr. Anita Somani is an OB/GYN with thirty years at OhioHealth and a sitting Ohio state representative, one of very few people who has sat inside the exam room and inside the committee room on the same issues.
“HR 1 will cut $33 billion worth of Medicaid funding from the state of Ohio over the next ten years. Medicaid funding is a lifeline for many rural hospitals, and in the absence of those dollars, they will be forced to downsize, or more likely, close. Hospital closures are disastrous for rural health outcomes because they mean people will have to travel farther, spend more money, and sometimes forgo necessary care. Not only will these cuts destroy the health of our rural communities, but they will also tank the economies of the small towns where they’re located because the hospital is often the largest employer in these places.
The funding from the Rural Health Transformation Partnership is pennies compared to the cuts coming from Medicaid. Believing that those dollars will be enough to save rural communities is like believing a Band-Aid is enough to stop the bleeding from a bullet-wound. Republicans at the federal level are financing tax cuts for their billionaire friends at the expense of our healthcare and economy.”
Four. This one is harder to say without sounding like I’m ranting, so I’ll just say it plainly. Preventing illness costs less than treating it. The same bill cutting Medicaid also proposes reducing the monthly fruit and vegetable benefit for a breastfeeding mother from $52 to $13, and for a child under five from $26 to $10. WIC served 6.7 million people a month last year, including an estimated 41% of all infants born in this country, and four out of five WIC recipients are covered by Medicaid or CHIP. These are not two separate populations with two separate problems. They are the same families, and eligibility for one is frequently what unlocks the other. Households qualify at or below 185% of the federal poverty line, which for a family of three is around $49,000 a year. These are working people. Thirteen dollars a month in produce for a nursing mother… the math is just not mathing.
Sometimes the system feels impossible. But here is something concrete.
If you work in health IT, the comment period has closed, but the implementation is just beginning. States must build verification systems, connect to multiple data sources, and overhaul their Medicaid enterprise systems before January 1, 2027, and CMS estimates that will cost roughly $15 million per state (!!!). Your state legislators and Medicaid agencies need to hear from the people who actually build and run these systems, because the gap between what the rule requires and what the infrastructure can deliver is where patients will fall through. Contact your state Medicaid agency. Show up at your statehouse. If you don’t know where to start, email me: amy@azulheart.com
And if you work at a health system or a rural hospital and you are living the gap between what the policy assumes and what your systems can actually do, I would really like to hear from you. I am talking to CIOs, clinicians, and administrators for the next piece in this series, and off the record is completely fine. amy@azulheart.com