Federal officials pledged “radical transparency” for a $50 billion Rural Health Transformation Program, but many states are keeping full applications out of public view even as project summaries appear online.
The program, created in the sweeping One Big Beautiful Bill, aims to fund transformational ideas for rural health care rather than simply shore up failing hospitals. Under the law, half of the $50 billion will be divided equally among states with approved applications; the other half will be distributed through a points-based system, including $12.5 billion tied to rurality and $12.5 billion for initiatives aligned with administration priorities.
Health and Human Services Secretary Robert F. Kennedy Jr. has repeatedly promised a more open HHS. The department has said it will publish project summaries for successful applicants, but many states have withheld entire applications or significant parts of them, and some have declined to release any materials.
Alan Morgan, CEO of the National Rural Health Association, said rural hospital leaders, clinic administrators and community stakeholders need access to full state proposals and budget narratives to understand what has been approved, what was rejected and how federal funds would be spent. “Those documents matter to the providers who are supposed to benefit,” he said.
Critics say HHS itself is falling short on transparency. Lawrence Gostin, a public health law professor at Georgetown University, said the agency is “acting in a way that utterly lacks transparency” and that the public deserves greater openness to hold officials accountable.
A Centers for Medicare & Medicaid Services spokesperson, Catherine Howden, said CMS will follow federal regulations governing competitive grant materials. She noted that applications are typically not released while they are under merit review in order to protect evaluation integrity, applicant confidentiality and the competitive nature of the process.
The program arrives against a backdrop of broader policy changes that could hurt rural providers. The same legislation that created the transformation program also sharply reduces federal Medicaid spending, a major revenue source for many rural hospitals. Analysts project the July law could reduce federal Medicaid funding to rural areas by about $137 billion over a decade — a cut that could squeeze finances and push facilities toward closure.
Program limits compound those concerns: states may use only 15% of their Rural Health Transformation funds to pay providers for patient care, raising questions about whether the dollars can meaningfully offset Medicaid-driven losses.
Applications were due Nov. 5, and CMS says awards will be announced by the end of the year. By late November, KFF tracking found nearly 40 states had released project narratives, and more than a dozen had posted budget narratives. A smaller group — Idaho, Iowa, Kansas, Minnesota, New Mexico, North Dakota, South Carolina and Wyoming — released entire applications.
Many other states posted shorter project summaries. Heather Howard of Princeton’s State Health and Value Strategies program, which has been tracking releases, said about two dozen summaries show common themes: expansion of home-based and mobile services, wider use of technology, and workforce development strategies such as scholarships, signing bonuses and child-care support for high-demand roles. Her team also noted examples of more ambitious tech proposals, including telerobotics in Georgia and Alabama and plans to form advisory groups around technology, workforce, tribal collaboration and behavioral health.
Yet several states denied public records requests for full applications. Nebraska labeled its materials “proprietary or commercial information” that could advantage competitors. Kentucky released only a project summary and said the remainder of its application was a “preliminary draft” exempt from disclosure under state law. Hawaii’s governor’s office declined to share its proposal despite public commitments to transparency. Other states are still processing records requests.
Political tensions also color the review process. Democrats and many health advocates worry awards could be influenced by partisanship. Rep. Nikki Budzinski (D-Ill.) warned that Democratic-led states might receive less favorable consideration and asked CMS Administrator Mehmet Oz for “full and fair consideration” of Illinois’ application. Illinois state officials have not released their proposal; KFF Health News has a pending public records request.
Among the ideas publicly proposed across states are medication-delivery drones and telehealth services housed in library branches. Princeton’s review and KFF’s tracking show recurring priorities such as telehealth expansion, remote patient monitoring, cybersecurity upgrades, healthier food access, emergency services improvements, chronic disease prevention and the use of community health workers and paramedics for home visits.
Examples of state proposals include:
– Arkansas: A $5 million FAITH program (Faith-based Access, Interventions, Transportation & Health) that would engage rural congregations in prevention, screenings and creating walking circuits and fitness areas.
– Alaska: Testing unmanned aerial systems to accelerate pharmacy deliveries to remote communities that historically relied on dogsleds.
– Tennessee: Investments in parks, trails and farmers markets to boost access to healthy activities and food.
– Maryland: Launching mobile markets and adding refrigeration to preserve fresh food in areas with few grocery stores.
Some local officials remain skeptical that the program will stop closures. Kentucky State Sen. Stephen Meredith said proposals he has seen address symptoms but not the deeper forces driving hospitals to close. Morgan added that state plans may read well on paper but often have difficulty translating into sustainable, operational programs.
As awards near, the debate centers on three tensions: the administration’s public pledge of openness versus routine protections around grant reviews, states’ decisions about what to disclose, and public concerns that scarce taxpayer dollars be awarded in a way that is fair and verifiable. For many rural providers and communities, the lack of full applications and detailed budgets means uncertainty about whether the promised transformation will be real or merely rhetorical.
KFF Health News reporters contributed reporting to this summary.