The 66 million people who live in the rural areas of the United States are facing the emergence of a new kind of Rust Belt, with its accompanying lack of jobs and services.
The potential cause?
The continued closure of rural hospitals – an issue some Catholic and secular experts predict will be complicated significantly by the impact of the “One Big Beautiful Bill Act,” the Trump administration’s signature budget bill.
“We are deeply concerned about what the proposed Medicaid cuts would mean for the future of our health care system,” Mercy Sister Mary Haddad, president and CEO of the Catholic Health Association, told OSV News.
“Such cuts would create a system that is more unequal and unstable, putting millions of people at risk of losing coverage and leaving safety-net hospitals under even greater financial strain. The result,” she added, “would be a widening of health disparities – especially for children, older adults, people with disabilities, and low-income families who rely most on Medicaid for care.”
Almost 30 years ago, the U.S. Catholic bishops declared in their 1993 “Framework for Comprehensive Healthcare Reform” – that “every person has a right to adequate health care. This right flows from the sanctity of human life and the dignity that belongs to all human persons who are made in the image and likeness of God.”
Since then, the country seemingly can’t find a way to balance the bishops’ imperative with legislative and market realities – with the result that, according to the health-focused Commonwealth Fund, rural Americans are among the least likely to have adequate access to care compared to their counterparts in other countries.
The National Rural Health Association – which describes itself as “the only national organization with a clear mission to advance, publicize, and solve rural health issues and challenges” – released a briefing stating the “One Big Beautiful Bill Act” “made sweeping changes to Medicaid and the ACA Marketplaces that will result in coverage losses for rural Americans.”
“Further,” the NRHA said, “the legislation may limit access to care for rural residents by putting financial strain on rural facilities who care for them. It is estimated that the combined impact of the Medicaid cuts alone in the OBBBA could decrease spending in rural areas could decrease by $155 billion over 10 years.”
The “One Big Beautiful Bill Act” eliminated $911 billion from Medicaid, while also creating a $50 billion fund – the Rural Health Transformation Program, or RHTP – to offset projected losses of rural health providers. But critics have noted the program is a temporary initiative, while reductions in federal spending are long-term.
“Fifty billion dollars over five years does not equate to $155 billion over 10 years,” Alan Morgan, president and CEO of the National Rural Health Association, said in an interview with rural news source Daily Yonder.
The RHTP is also focused – as its name implies – on transforming the rural health care system, rather than providing continued funding to keep facilities open, or making up for lost Medicaid dollars.
“These cuts don’t just erode a single program – they threaten the very foundation of our nation’s health care system,” Sister Haddad said. “Within Catholic health care alone, nearly one-quarter of hospital revenue depends on Medicaid to serve communities across the country. The consequences would be especially devastating in rural and underserved areas, where hospitals are often the only access point for essential care.”
She predicted widespread community effects, and not just for hospitals.
“Many could be forced to reduce services, delay expansion projects, or even close their doors altogether,” added Sister Haddad. “The economic ripple effects would extend far beyond hospital walls – impacting jobs, small businesses, real estate values, and even school funding.”
The U.S. Department of Agriculture Economic Research Service reports that from 2005 to 2023, 146 rural hospitals closed or stopped providing inpatient services. Of that 146, 81 shut down completely.
“One of the pressures that you also feel in a rural system is you’re generally one of the top employers within the community,” Dr. Stephanie Duggan – an emergency medicine physician and chief clinical officer of SSM Health – told OSV News.
With operations in Missouri, Illinois, Oklahoma and Wisconsin, SSM – a Catholic, nonprofit care network tracing its roots to 1872 and five German nuns – includes 23 hospitals, more than 300 physician offices, outpatient and virtual care services, and 40,000 staff.
“And so,” Duggan added, “not only are you helping people heal, but you’re providing economic stability and upward growth that may not be available without traveling a further distance.”
While Duggan said it’s difficult to predict outcomes, her concern – and that of her colleagues – is rising.
“We have a particular worry for patients in our rural communities because we believe those hospitals will be struggling not only with some of the potential decrease in reimbursement, but also with the changes in Medicaid requirements,” she explained. “It may be a double whammy for patients in that community.”
Rural health care, Duggan noted, already comes with inherently complex issues, quite apart from new ones that may arise from legislative changes.
“If you don’t have access to care within your community, you will have to travel,” she said, “which will delay care. You’ll be traveling into communities in which you’re not as familiar, and that makes it challenging.”
“I think potentially, patients will wait longer to come in, and until they can get seen,” Duggan predicted. “We know that many of the diseases we see – cancer; congestive heart failure – if caught early, you can help manage the symptoms as well as oftentimes manage, hopefully, a cure. But if instead of in Stage One you come in Stage Four for cancer, your outcomes are much different.”
Duggan has two pieces of advice for fellow Catholic health practitioners serving rural populations.
“We need to lean into our Catholic social teaching,” she said, “and respect every human being as a creation of God and Jesus, our Savior.”
“I had a really dear colleague who unfortunately passed away too young,” recalled Duggan. “I would say to her, ‘How do you not get frustrated?’ Because in the ED (Emergency Department), you get pretty beaten up some shifts; some shifts are just really tough. And she used to say, ‘Oh, it’s easy. I just look into their face, and I see Jesus.’”
That’s perhaps the “easy” part.
“I would encourage our policymakers to go out to one of their rural hospitals within their district and see what is actually happening within the community,” suggested Duggan. “Talk to some of the patients that are being served by our rural communities and understand the impact these cuts will have to actual people – and not just consider them dots on a graph.”
Sister Mary Rachel Nerbun’s medical office is slightly less traditional than Duggan’s – because it’s on wheels and also offers dental care – but she, too, serves rural populations.
As medical director of the Archdiocese of Saint Louis’ Rural Parish Mobile Clinic, an internal medicine physician, and member of the Religious Sisters of Mercy of Alma, Michigan, Sister Nerbun’s rolling clinic had 1,700 visits – including many repeat visits by patients with chronic health issues – last year.
Its clientele consists of uninsured rural residents, ages 19-65, who meet income guidelines of less than 200 percent of the federal poverty level. The majority are working poor who can’t afford insurance premiums, laborers not offered health care, or the self-employed.
“Those that fall within Medicaid, they have very little access to care out here in these rural communities,” Sister Nerbun explained. “We go into communities without a lot of health care options – and we’re giving them health care options.”
“We serve six rural communities around the Archdiocese of Saint Louis,” she said, “and hope to hit all of the rural communities at some point. But those six communities only have a handful of options for hospitals.”
Poverty, said Sister Nerbun, leaves the poor with few – and often extraordinarily difficult – choices.
“People in the Medicare population over 65 – this is probably the fastest growing population of people living in poverty,” noted Sister Nerbun. “Many of them struggle even to pay for the medications, because Medicare will cover some of their medications, but not all of them. So, they actually have to decide, ‘Am I going to pay the co-pay for the medication, or I am I going to eat this month?’”
Asked if upcoming Medicaid cuts would make an outsized impact on her ministry, Sister Nerbun said no.
“We’re going to be able to provide – that’s what we’re here for,” she declared. “We’re a safety network for those who can’t get Medicaid.”
