Before H.R. 1 passed, rural America was already facing difficulties with access to maternal health care. From hospital closures, workforce shortages, low reimbursement rates, and policy changes, rural maternal healthcare systems have faced a deep crisis that threatens patient access to medical services. 109 rural hospitals have closed since 2005. Between 2024 and early 2026 alone, 96 labor and delivery units closed in hospitals across 91 counties in 35 states. More than half of the recent closures (58%) took away many counties’ only birthing facility. That leaves 70% of rural counties with no access to hospital labor and delivery services. These challenges are expected to accelerate with nearly one trillion dollars being cut from Medicaid over the next decade.
Medicaid finances nearly half of births in rural communities. Labor and delivery units carry high fixed costs so when patient volume declines, hospitals take a financial hit. In general, Medicaid reimburses hospitals less money for births than private commercial plans, but Medicaid cuts will decrease the financial vitality of many rural hospitals and clinics.
The rural maternity crisis also involves a workforce shortage. The maternal health workforce comprises several professionals, both clinical and non-clinical. Clinical professionals that support pregnant women in the delivery of their babies in rural hospital settings include OB/GYNs, family physicians, and certified nurse-midwives. Only 2.6% of U.S. OB/GYNs practice in rural areas, and 57.9% of rural counties lack an obstetric clinician entirely. To address this shortage, rural hospitals rely disproportionately on H-1B visa physicians, but a 2025 executive order raised H-1B costs to $100,000, undermining that pipeline. Family physicians and midwives help fill this gap. Nationally, about 5.6% of family physicians deliver babies, but in rural communities it is 26.8%. Likewise, about 10% of CNMs deliver babies nationally, but in rural communities, the proportion rises to 30%.
The story of rural maternity care access in the United States is one of insurance coverage as well. Nationally, about 1 in 9 women of reproductive age are uninsured, with much higher rates in rural counties. And in rural areas, women of childbearing age are more likely than their urban counterparts to rely on Medicaid and CHIP for their health insurance. The Affordable Care Act Medicaid expansion lowered uninsurance rates for these women, helping them access care before, during, and after pregnancy. This progress was bolstered by the 12-month postpartum Medicaid extension, which was adopted by 49 states and D.C.
Despite these advances, significant disparities continue to exist. One in four women of reproductive age live in rural counties without obstetric hospitals or providers. Those living in counties that do not offer obstetric care face travel times an average of three times longer to access care than those in counties that do, adversely affecting birth outcomes. Pregnancy-related mortality is 37.9 deaths per 100,000 live births compared to 23.1 in metropolitan areas. There is also a nine percent higher probability of severe maternal morbidity in rural areas. Black and Indigenous women face the highest rates of maternal mortality.
Medicaid cuts could drive loss of access to maternal health even beyond maternity unit closures. Before H.R. 1, the ACA Medicaid expansion helped rural hospitals avoid negative margins. With H.R. 1 Medicaid cuts specifically targeting expansion, non-expansion states are disincentivized to adopt expansion, and expansion states will likely be forced to drastically roll back their Medicaid programs, which will hurt rural hospitals in particular.
H.R. 1 is also predicted to worsen uncompensated care costs for rural hospitals, exacerbate the financial strain they already face, and increase uninsurance rates nationwide. As our colleague Adam Searing pointed out in a new report, rural areas are often characterized by higher unemployment rates, a higher share of people enrolled in Medicaid, and limited resources that will make H.R. 1 eligibility and renewal changes like work reporting requirements much harder to meet — and much more devastating for rural communities. Despite being exempt from work reporting requirements, pregnant and postpartum women are also at risk of being mistakenly disenrolled from Medicaid, as has already happened in Nebraska. Compounded with the decline of providers in rural areas, this loss of essential coverage will make affordable maternity care that much harder to access.
We’ve shown before that the Trump administration’s $50 billion Rural Health Transformation Fund (RHTF), distributed to states in $10 billion increments over five years, will fall short of offsetting the needs of maternal health care. It cannot compensate for the estimated $137 billion in H.R. 1 Medicaid cuts to rural areas alone. States plan to use these funds to support maternity health initiatives like community health workers. However, despite being billed as the rural hospital fund when passed by Congress, the RHTF prioritizes technology, such as robots for rural maternity care, over supporting existing systems, leaving rural hospitals in the lurch. Department of Health and Human Services investments in rural hospitals and rural provider expansions will also fail to fill the gap. Even as states continue to create new birthing care options, the full range of birthing care options is shrinking without new, sustainable funding that Medicaid provided.