The Fund supports networks of state health policy decision makers to help identify, inspire, and inform policy leaders.
The Milbank Memorial Fund supports two state leadership programs for legislative and executive branch state government officials committed to improving population health.
The Fund identifies and shares policy ideas and analysis to advance state health leadership, strong primary care, and sustainable health care costs.
Keep up with news and updates from the Milbank Memorial Fund. And read the latest blogs from our thought leaders, including Fund President Christopher F. Koller.
The Fund publishes The Milbank Quarterly, as well as reports, issues briefs, and case studies on topics important to health policy leaders.
The Milbank Memorial Fund is is a foundation that works to improve population health and health equity.
October 24, 2025
Fact Sheet
Sofia Espinosa
Mary Louise Gilburg
Morgan McDonald
Publication
Oct 21, 2025
Oct 1, 2025
Jun 23, 2025
Back to Publications
The Milbank State Leadership Network (MSLN) hosted two virtual sessions for state-to-state discussion on opportunities and strategies related to the federal Rural Health Transformation (RHT) Program, recently launched by the Centers for Medicare & Medicaid Services (CMS). Representatives from 24 states participated in the two-day convening, which consisted of five one-hour breakout sessions focused on each of the program’s strategic funding pillars: 1) Make Rural America Healthy Again, 2) Workforce Development, 3) Sustainable Access, 4) Innovative Care, and 5) Technology Innovation. Session themes and strategies are summarized below. While state names are not listed below for confidentiality, please contact Milbank to be connected to those pursuing specific strategies.
Questions on allowable costs, scoring, and other specific issues should be posed to CMS.
Across all sessions, panelists and participants identified the following areas for priority action:
This pillar focuses on prevention, primary care, behavioral health, chronic disease management, prenatal care and expanded access to coordinated care in rural communities. States are integrating clinical services, such as primary care, behavioral, maternal, and oral health, and strengthening emergency medical services (EMS) and public health capacity to reduce preventable illness and improve community wellness. Public health has had a long history of engaging with rural communities and deploying grants and resources to meet needs identified by communities via county health councils, county health assessments, and other structures. Likewise, states have been investing in certified diabetes prevention programs, certified community behavioral health clinics, and access to/incentives for physical activity and nutritious food that they plan to expand.
States emphasized the importance of creating clear timelines in the proposals to balance early implementation with long-term transformation. Short-term projects build momentum and demonstrate readiness, while later phases focus on integration and sustainability across systems. The five-year grant structure allows states to plan in stages, with an evaluation after the first year to assess progress, document early outcomes, and inform subsequent implementation phases.
Examples:
Counties (either government entities or via ongoing county health councils that may be partnered with a fiduciary entity) emerged as key operational partners in RHTP planning and implementation. Local public health and health delivery are engaged with local government, which can serve as sub-recipients or managing entities for rural health transformation efforts.
Approaches:
Legislative and cross-agency collaboration is critical for sustainability. State agencies are involving legislators early in planning, through briefings and advisory councils, to align program goals and strengthen policy continuity. In many states, legislators must approve key budget items, so active engagement throughout the process helps build shared ownership and ensures that supportive legislation creates the policy framework needed for programs to succeed.
Examples of legislation that results in RHTP scoring advantages are below.
Although the first two policies were new to most states, they were more likely to consider them accomplishable. However, states were less willing to gamble a potential funding claw-back on legislative changes to scope of practice.
This pillar includes technology to enhance care coordination, strengthen cybersecurity, and expand digital access in rural areas. In addition to data system improvements, states aim to support telehealth, e-consults, and build digital-literacy programs to ensure residents and providers can use tools effectively. These strategies aim to reduce fragmentation and build long-term, sustainable infrastructure for connected care.
States emphasized connecting existing technology systems rather than building new platforms. Expanding e-consults and health information exchanges allows providers to collaborate more efficiently and coordinate patient care.
“We are not building new platforms; we are connecting what already exists.” — [Participant]
Technical capacity remains a major challenge. States are engaging vendors early to ensure timely implementation and translate strategic goals into effective technical solutions.
Sustainable technology strategies require collaboration among payers, workforce systems, and data-governance entities. States aim to align policies, training, and reimbursement models to sustain digital tools and ensure interoperability across rural and urban settings.
Participants discussed strategies to sustain access to care and strengthen the rural health workforce pipeline. States emphasized locally tailored workforce solutions, cross-sector partnerships, and policies that align short-term grant opportunities with long-term sustainability.
One approach to addressing workforce shortages is the regional “health hub” model that brings together regional public health centers with local health care providers and social-service partners to improve access and connect residents to care and services. This has been noted as a strategy to reduce burnout and retain current workforce and also to address patient needs efficiently.
States are balancing the need for innovation with the realities of short grant timelines and limited administrative capacity. Some states are considering requesting a short-term period that encourages local experimentation while maintaining accountability. Participants noted that metrics for workforce success, such as pipeline development and retention, are evolving and should be tied to final program goals rather than short-term outputs.
Sustaining a rural health workforce requires targeted investments in education and training. States are prioritizing both clinical training programs and workforce development.
State leaders discussed strategies for designing and implementing innovative care models. The conversation focused on building upon existing programs and aligning Medicaid and public health priorities, leveraging federal funding to advance value-based care, and ensuring that models are sustainable and responsive to rural community needs.
States discussed building off existing initiatives that advance innovative care through financing models.
States also discussed adding new service lines in regional hubs to address the root causes of illness, investing in technology to reduce reliance on limited workforce capacity (from “floor-mopping robots” to telehealth systems), and expanding mobile clinics to reach remote populations.
States participating in the AHEAD discussed aligning RHT strategies with the model by building technical assistance (TA) resources for hospitals and rural providers preparing to transition to VBP. Other TA strategies included:
This pillar focuses on helping rural providers become long-term access points for care by improving efficiency, coordination, and financial sustainability. States are aligning workforce, infrastructure, and data systems so that small and rural facilities can remain viable while meeting community needs.
States are integrating planning across Medicaid, behavioral health, and public health agencies to align priorities and prevent duplication. Community engagement and local data analysis help states determine where care should be delivered and how rural facilities can collaborate to ensure reliable access.
States are pursuing regional partnerships that allow rural hospitals and clinics to share staff, technology, and administrative systems. This approach preserves access while preventing duplication and helping smaller facilities remain sustainable within broader service networks.
Financial stability underpins sustainable access. States are supporting hospitals and health systems in improving cost management, operational efficiency, and innovation in care delivery to ensure resources are used effectively over the long term.
States highlighted enduring challenges in rural health transformation that may impact the implementation of sustainable programs including fee-for-service payment models, telehealth restrictions, transportation barriers, and limited broadband access.
In addition to these challenges, states expressed uncertainty about how applications will be scored, particularly when committing to policy changes that require legislative approval — such as expanding scope of practice or creating new licensure compacts. Given potential leadership changes and the risk of federal fund rescission, many states are considering prioritizing administrative action over legislative proposals.
States emphasized the importance of alignment and accountability across agencies to ensure the Rural Health Transformation Program achieves lasting impact. Many are forming cross-agency groups that include Medicaid, public health, technology vendors, and higher education representatives to coordinate implementation and maintain oversight during the five-year grant period. Because many program budgets require legislative approval, close coordination across branches of government is also essential to sustain funding and policy continuity.
States noted that territorialism can emerge in rural health systems where providers are competing for limited patient populations and reimbursement. Participants described building communication mechanisms and on-the-ground relationship management to foster trust and collaboration across institutions to sustain transformation.
