All 50 states applied for CMS’ Rural Health Transformation (RHT) program, a $50 billion fund borne from a need to reassure members of Congress during the final debate over H.R. 1 that Medicaid cuts would not decimate their states’ rural health systems. As previous blogs have detailed, the RHT program presents a unique opportunity for states to invest in their rural health systems but it still falls short of patching the hole left by HR 1’s $990 billion cut to Medicaid and CHIP and the 15% cap on using RHT funds to help rural health providers limits states’ ability to target funds.
Given that 40.6% of children in small towns and rural areas are covered by Medicaid or CHIP and Medicaid plays a significant role covering women of childbearing age in rural areas, the RHT program is more than just an opportunity to invest in health systems– it’s an opportunity to invest in maternal and early childhood health. In the lead up to the November 5th application deadline, we explored how the RHT program can make maternal health great again. Now that the first year of funding has been awarded and the applications are public, it’s time to see how states plan (or don’t) to invest in maternal health– and monitor their follow through.
Maternal Health Investments
Many states have maternal health at the forefront of their plans for using RHT program funds. Maternal health initiatives proposed in the RHT Program applications include regional care networks, telehealth expansion, workforce development, mobile health units, maternal behavioral health, home visiting, emergency labor and delivery unit preservation, and value-based payment reform.
Regional Care & Remote Monitoring
Alabama, California, Pennsylvania, and South Dakota plan to work on regional care networks, where centralized “hub” facilities will connect smaller rural sites to specialists to help women living in rural areas to reach care in a timely manner. Each state is unique in the goals of these hubs. Alabama is using specialized equipment such as telerobotic to perform ultrasounds, under an expansion of telehealth and remote monitoring infrastructure. Alaska and Maine are two among several states planning to invest in cloud-based maternal health platforms, remote fetal monitoring devices, and tele-behavioral health services targeted at perinatal women and Tribal communities.
Workforce Development
Rural communities are facing a shortage of perinatal workforce providers. Less than half of rural counties in the U.S. have a practicing obstetrician/gynecologist (OB/GYN). There is also a growing number of hospitals closing in rural areas or the labor and delivery (L&D) units closing within a larger hospital system. This may force more pregnant women to give birth far away from home Given these current challenges, workforce development is at the forefront of RHT plans for many states. States are not only seeking to recruit and fund OB/GYNs they are seeking to provide scholarship and training opportunities to a broader group of members of the perinatal workforce team such as doulas, certified nurse midwives (CNMs), community health workers, lactation consultants, and perinatal home visitors. Illinois, Missouri, Nevada, and New Jersey all include dedicated funding for such roles, reflecting a notable shift toward broadening the full spectrum of the maternal health workforce rather than narrowly focusing on physicians. Family physicians are also being included in the perinatal workforce because they are the trained birthing physicians most rural communities.
Labor and Delivery Unit Closures
In addition to investments in workforce development, a smaller cluster of states are addressing the structural problem of L&D unit closures. Indiana is training rural hospital emergency departments for obstetric emergencies, Ohio is pursuing legislative changes to allow delivery at birth centers, and Washington is exploring innovative business models to sustain hospital funding to keep maternity units from closing entirely.
Mobile Health Units
Mobile health units represent another growing strategy, with Florida and Georgia expanding mobile clinics to deliver prenatal and postpartum care directly to rural communities. These mobile clinics operate in areas where community members frequently visit such as schools, churches, and community centers to reduce transportation barriers to care. Connecticut, Massachusetts, and West Virginia plan to boost maternal nutrition support programs to ensure individuals are eating healthy to reduce the risk or manage chronic disease.
Behavioral Health
Behavioral health, which encompasses both mental health and substance use, is a priority of many states and their project narratives for the RHT Programs. Louisiana, New Mexico, and Missouri, are integrating perinatal mental health screening, substance use disorder treatment, and psychiatric consultation into their maternal care models.
Value-Based Payment Reform
Tennessee and Colorado are moving toward value-based payment reform by embedding maternal health into new rural payment models.
Home Visiting
At least eleven states (AK, CT, IL, KY, MA, MN, MO, OH, OR, SD, TN) proposed using part of their funding to develop, expand, or strengthen maternal and child home visiting programs. States like Connecticut, Massachusetts, and Oregon made reference to specific evidence-based home visiting programs like Family Bridge, Parents as Teachers, and Family Connects. Other states took a more general approach, including language to expand evidence-based prenatal and postpartum home visiting programs, support training and upskilling, or strengthen referral pathways. Some narrative proposals simply mentioned home visiting in a string of other maternal and early childhood-related investments. Regardless of the level of specificity or proposed means to support perinatal home visiting programs, it is a significant theme in state’s narrative applications and one that will be important to monitor as implementation of the proposed initiatives moves forward. Importantly, more than half of states use Medicaid to reimburse home visits, offering a way to help support programs, at least in part, over the longer term. It is not clear whether states are proposing comprehensive evidence-based home visiting models or more distinct home health checks– but both can help minimize access barriers.
Offering (and reimbursing through Medicaid) home visiting programs for new mothers, infants, and young children is an effective policy choice for addressing the needs of perinatal and early childhood populations. New data shows decreased access to care during the prenatal period, a trend that is particularly concerning given the already struggling state of maternal health, and it is simultaneously essential that mothers and infants have comprehensive support during the postpartum period. Proposals such as Alaska’s Healthy Beginnings Initiative and Missouri’s Perinatal Home Visiting expansion would create more opportunities for new or soon-to-be mothers to be connected to or receive care in a timely manner. Home visitors also help monitor young kids’ development, getting them the interventions or diagnostics they need to thrive as they grow up. An important aspect of these programs is care coordination and integrated care services. Home visitors can provide referrals to other providers or treatments, helping young families navigate an often complex health system during a busy but critical time and encouraging positive parent-child relationships and emotional connections.
State RHT Program applications reveal genuine momentum in rural maternal and infant health, but they come at a time of strong headwinds due to federal Medicaid cuts and the momentum is not a guarantee that these programs will come to fruition. States need consensus, transparency, and infrastructure among other things to implement the plans laid out in these applications. The same H.R.1 bill that created this $50 billion fund will also cause $990 billion in Medicaid cuts over the next 10 years. Medicaid is essential for rural America, especially for pregnant women, as it pays for nearly 50% of rural births. No amount of home visiting programs, mobile clinics, and even an increase in the perinatal workforce can fully offset that risk that H.R.1 will cause to maternity care in rural America. The measure of success will not be how many states named doulas or home visiting in their applications – no single, promising change should be expected to solve the maternity crisis in this country. Instead, the measure of success should be whether rural mothers, particularly Black, Indigenous, and low-income women, are meaningfully better off.