Advocacy Groups Press for Transparency in $50B Rural Health Transformation Program

As states prepare to submit their first progress reports on the Rural Health Transformation Program, health policy advocates are raising alarms about a lack of transparency that could undermine the $50 billion initiative's effectiveness and accountability.

The five-year program, created by Congress last summer as part of the One Big Beautiful Bill Act, was designed to offset anticipated Medicaid cuts in rural communities. With funding distributed across all 50 states, the initiative represents one of the largest federal investments in rural healthcare in decades. Yet one year into its implementation, oversight groups say critical information about where the money is going remains difficult to access.

Varying Levels of State Disclosure

The Centers for Medicare & Medicaid Services, which oversees the program, has indicated it will publish an annual report on state progress. However, the agency does not plan to proactively publish individual state reports or create a comprehensive tracker of funding recipients and award amounts, according to agency documents reviewed by KFF Health News.

This opacity has left transparency advocates concerned about the program's integrity. "Transparency is really important to help protect the integrity of the program, ensure funds are reaching the communities they're meant to serve," said Maya Sandalow, director of health policy for the Bipartisan Policy Center.

The result has been a patchwork of disclosure practices across states. Alaska, Kansas, and Oklahoma have created public dashboards listing funding recipients, award amounts, and detailed project descriptions. New Hampshire has gone further, posting complete recipient contracts online.

Other states have taken a more restrictive approach. Florida and Nebraska disclose award recipients but provide no information about how the money will be used. West Virginia holds advisory committee meetings behind closed doors, while South Dakota and Mississippi have resisted public records requests entirely.

Tight Deadlines Complicate Oversight

States face pressure to spend their allocations quickly. The program's structure includes tight federal deadlines, with the first annual reports due August 31. Some state officials say the rush to deploy funds has made comprehensive transparency efforts challenging.

"The level of details that states have publicized really varies," Sandalow noted, explaining that some states are still hiring staff to manage the program. She co-authored a recent paper outlining recommendations for strengthening the program, including enhanced transparency measures.

The Bipartisan Policy Center is not alone in its concerns. The American Hospital Association and the Federation of American Hospitals have both submitted formal comments to CMS requesting more detailed reporting on funding destinations. Without this information, they argue, it will be difficult to determine whether money is reaching the rural hospitals, providers, and communities primarily intended to benefit.

Historical Context of Program Oversight

Advocates point to previous federal relief programs as cautionary tales. The CARES Act and other pandemic-era programs were plagued by fraud and improper payments, issues that many attribute to insufficient oversight and transparency.

"Previous federal programs tend to draw attention for gaps in transparency and oversight rather than for doing it well," Sandalow said.

In March, CMS published proposed quarterly and annual reporting requirements and solicited public comments. At least three major healthcare organizations responded with letters expressing concerns about transparency gaps.

Charlene MacDonald of the Federation of American Hospitals specifically requested that CMS track "downstream subrecipients" — entities that receive funding indirectly through larger health systems or academic medical centers. Many rural health initiatives involve complex funding streams where money passes through multiple organizations before reaching frontline providers.

Looking Ahead

CMS has finalized reporting requirements that will require states to list subrecipients and vendors paid with rural health funding starting with future reports. However, states will not need to describe specific services or products these downstream recipients provide.

As the program enters its second year, some states are creating their own accountability mechanisms. Most have established advisory committees with public meetings, and several nonprofit organizations and private companies have launched independent tracking tools to monitor funding distribution.

For rural communities struggling with hospital closures, provider shortages, and limited access to addiction treatment services, the stakes are significant. The Rural Health Transformation Program was designed in part to address these gaps, but without robust transparency, measuring its impact will remain difficult.

Mississippi state Sen. Hob Bryan, who chairs his chamber's public health committee, expressed bipartisan frustration with secrecy in his state's program implementation. "If they're not up to something nefarious, why do they have to do it all in secret?" he asked.

The answer to that question may become clearer as more states release their first-year reports and CMS publishes its initial annual assessment of the program's nationwide impact.