The passing of the HR.1 bill has threatened the vitality of rural health in America. To soften the blow, the Trump administration included a $50 billion Rural Health Transformation Fund (RHTF). States are preparing their applications that are due on November 5th. There is a lot to unpack with the RHTF. My colleague Adam Searing has broken down the main components of the fund. Colleagues Elisabeth Wright Burak and Anne Dwyer wrote about how the RHTF should be used to support children and families.
While $50 billion is better than nothing for rural health communities in America, it will never be able to offset the $900+ billion in Medicaid cuts that was also a result of H.R.1. Rural hospitals have been closing their obstetrics units for decades. A study found that by 2022, eight states had more than 65% of their rural hospitals without OB units.
In 2023, 23.3% of women of childbearing age in rural communities were covered by Medicaid. In states like Louisiana and New Mexico, this number jumps to 40%. Nationally, Medicaid is the largest payor of births in the United States covering 41% of births. In rural America, Medicaid covers 47% of births. There is no doubt that Medicaid cuts will disproportionately cause harm to rural communities even in Medicaid expansion states.
Maternal health should be a priority area for state proposals for the RHTF. The March of Dimes has coined the term “maternity care deserts” to describe counties where there is a lack of hospitals that provide obstetric services, no birth centers, and no OB providers. Over 35% of counties in the U.S. can be designated as maternity care deserts and this number jumps up to 59% for rural counties. The National Academy for State Health Policy had a session during its 2025 conference on “Finding Oasis in the Desert: How States are Ensuring Access to Maternity Care in Rural and Urban Areas”. There were many ideas shared to improve maternity care shortage areas such as a state financing and payment strategy to unbundle global payments so that providers could receive payments per visit and pregnant women would be allowed to have up to 14 visits without a prior authorization from insurance. Another innovative idea that panelists discussed was a public-private partnership at MedStar Health called the Safe Babies Safe Moms program. This partnership is a clincal care model with obstetrics and midwifery care where a foundation, hospital health system, and a Federally Qualified Health Center, as well as other partners, work together to improve maternal health outcomes. NASHP also has a Maternity Care Deserts Policy Academy, a two year academy operating in eight states to provide technical assistance on addressing maternity care deserts.
Community-based doulas, lactation specialists and consultants, home-visiting programs, HealthyStart, and more have helped with improving maternal and infant health outcomes. Midwifery is an area that can really benefit from the RHTF, as described in a new paper by Health Management Associates.
In most countries, midwives outnumber OB/GYNs. In the United States, there are 4 midwives for every 1,000 births and in other high income countries, there are between 30-70 midwives for every 1,000 births. Midwives provide care for low-risk pregnancies and research has shown that midwifery care is linked to better birthing outcomes. In the U.S. there are different types of midwives – not every type is covered by insurance. Certified nurse-midwives are covered by Medicaid in all 50 states; certified professional midwives can only bill Medicaid in 18 states and Washington D.C. though they have comparable birthing skills.
In rural communities, especially, certified midwives and certified professional midwives offer states an opportunity to expand the birthing workforce for Medicaid beneficiaries. During the COVID-19 pandemic, some people sought home births and birthing centers due to fear of hospitals. Midwifery care aligns with all five strategic goals of the RHTF and provides an opportunity to redesign rural health care.
- Make Rural America Healthy Again: Improved outcomes (higher breastfeeding, lower preterm birth).
- Sustainable Access: Reliable local care in areas lacking obstetric services.
- Workforce Development: Expands skilled providers, boosts retention and licensure flexibility.
- Innovative Care: Integration into hub-and-spoke models with doulas and community health workers.
- Tech Innovation: Use of telehealth and remote monitoring to expand reach and connect to specialists.
Rural America faces a maternal and child health crisis that Medicaid cuts threaten to worsen. However, the Rural Health Transformation Fund provides a rare opportunity: states can strategically invest in midwifery workforce expansion to help create new community-based access to birthing care funded by Medicaid. Doing so can help to maintain momentum in state progress in maternal and infant health, support families, and build toward long-term resilience in rural communities.