By Sarah Jane Tribble, Arielle Zionts
December 2, 2025 / 5:00 AM EST / KFF Health News
Medication-delivering drones and telehealth in library branches were among the ideas states unveiled in November for spending their shares of a $50 billion federal Rural Health Transformation Program. The Trump administration, whose Health and Human Services Secretary Robert F. Kennedy Jr. has pledged “radical transparency,” said it will publish a “project summary” for winning states. But many states are withholding full applications, and some refuse to release any application materials.
Alan Morgan, chief executive of the National Rural Health Association, said rural hospital CEOs, clinic administrators and community leaders need to see state proposals, know which ideas are approved or rejected, and review budget narratives that explain how funds would be used. Members of the NRHA include struggling rural hospitals and clinics that lawmakers said the program would benefit.
Congress approved the five-year Rural Health Transformation Program in the One Big Beautiful Bill, legislation that also sharply cuts Medicaid — a major source of revenue for rural providers. The program aims to fund transformational ideas rather than simply prop up failing rural hospitals. Under the law, half of the $50 billion will be split equally among all states with approved applications; the other half will be distributed through a points-based system. Of that second half, $12.5 billion is allocated based on each state’s rurality and $12.5 billion is awarded to states that score well on initiatives aligned in part with the administration’s “Make America Healthy Again” objectives.
Kennedy has emphasized opening HHS to the public and maintaining transparency. Critics, however, say the department and some states are falling short. Lawrence Gostin, a Georgetown University public health law professor, said HHS is “acting in a way that utterly lacks transparency” and that the public deserves greater openness to hold the agency accountable.
A CMS spokesperson, Catherine Howden, said the agency will follow federal regulations governing competitive grant materials. She noted grant applications are not released to the public during the merit review process to protect evaluation integrity, applicant confidentiality and the competitive nature of the process.
Democrats and many health advocates worry about political influence in awards. Rep. Nikki Budzinski (D-Ill.) expressed concern that states led by Democrats might face retaliation and get less serious consideration than Republican-led states. Illinois’ Democratic House members sent a letter to CMS Administrator Mehmet Oz asking for “full and fair consideration” of their state’s application; Illinois officials have not released their proposal and KFF Health News has a pending public records request.
Princeton’s Heather Howard, who directs the State Health and Value Strategies program tracking releases, said many states have been surprisingly transparent, posting project summaries. Her team reviewed about two dozen summaries and found common themes: expansion of home-based and mobile services, broader use of technology, and workforce development initiatives such as scholarships, signing bonuses, and child care assistance for high-demand roles. She highlighted telerobotics in Georgia’s and Alabama’s proposals and state plans to form advisory groups focused on technology, workforce, tribal collaboration, and behavioral health.
All 50 states submitted applications by the Nov. 5 deadline, and CMS says awards will be announced by year’s end. By late November, nearly 40 states had released their project narratives — the main section describing proposed initiatives — and more than a dozen had also published budget narratives, KFF tracking showed. A small group of states — Idaho, Iowa, Kansas, Minnesota, New Mexico, North Dakota, South Carolina, and Wyoming — released entire applications.
KFF Health News filed public records requests for complete state applications; some states declined to release materials. Nebraska denied a request, calling its materials “proprietary or commercial information” that could advantage competitors. Kentucky provided its project summary but said the rest of the application was a “preliminary draft” exempt from release under state law. Hawaii’s governor’s office declined to share its proposal despite saying the governor is committed to transparency. Other states are still processing records requests.
The program comes as the July law is projected to reduce federal Medicaid spending in rural areas by about $137 billion over a decade, a cut that could squeeze rural providers’ finances and push some facilities to close. A Commonwealth Fund report found rural areas continue to lack access to primary care. Program guidelines also limit states to using only 15% of their Rural Health Transformation funds to pay providers for patient care, raising questions about whether the money can meaningfully offset Medicaid-driven losses.
Among states’ publicly available proposals, Democratic-leaning states frequently signaled willingness to adopt some administration goals but rejected others, potentially costing them points. New Mexico, for example, proposed requiring students to take the Presidential Fitness Test and physicians to take continuing education in nutrition but would not restrict Supplemental Nutrition Assistance Program purchases of soda and candy.
Common state priorities include telehealth, cybersecurity, remote patient monitoring, healthy food access, emergency services improvement, chronic disease prevention and management, and using community health workers and paramedics for home visits. Specific proposals include:
– Arkansas: A $5 million “FAITH” program (Faith-based Access, Interventions, Transportation, & Health) to enlist rural congregations for education, preventive screenings, and installing walking circuits and fitness equipment.
– Alaska: Testing unmanned aerial systems to speed pharmacy deliveries to remote communities that historically relied on dogsleds.
– Tennessee: Investing in parks, trails and farmers markets to increase access to healthy activities.
– Maryland: Launching mobile markets and installing refrigeration to preserve fresh food in rural areas with few grocery stores.
Some state and local officials worry the program will not prevent closures. Kentucky State Sen. Stephen Meredith, who represents part of western Kentucky, said the proposal he heard treats symptoms without curing the larger problems driving hospital closures. Morgan said state plans can sound appealing on paper but are hard to translate into functioning programs.
The rural health funding debate sits against broader concerns about political influence, applicant confidentiality, and the public’s right to evaluate how taxpayer dollars are proposed to be spent. As awards near, many rural providers and communities are still waiting to see full applications and detailed budgets that would clarify whether the program will deliver the transformational change Congress intended.
KFF Health News staffers Phil Galewitz, Katheryn Houghton, Tony Leys, Jazmin Orozco Rodriguez, Maia Rosenfeld, Bram Sable-Smith, and Lauren Sausser contributed to this report.
KFF Health News is a national newsroom producing in-depth journalism about health issues and is one of the core operating programs at KFF — the independent source for health policy research, polling, and journalism.
