Traditionally, “what or who is rural?” has been a question few people have lost sleep over beyond those of us living in or working to serve rural communities. But, for the moment, lots of people care, as a food fight to capture dollars from a massive, new federal program is well underway.
The “One Big Beautiful Bill Act” or H.R. 1, signed into law on July 4, 2025, included a $50 billion investment (over five years)–the Rural Health Transformation Program (RHTP). This initiative is comparable in the level of funding for the Hill-Burton Program that assisted the initial construction or modernization of most of the country’s rural hospitals for fifty years following World War II.
The RHTP is managed by the Centers for Medicare & Medicaid (CMS) under a “hands-on” cooperative agreement with each of the 50 states, with the intent to “help State governments support rural communities across America in improving health care access, quality, and outcomes by transforming the health care delivery ecosystem.” (CMS Notice of Funding Opportunity.)
Of interest, the 2020 U.S. Census defines rural as a leftover–anything not urban. And urban is defined as “a densely settled core of census blocks with a minimum threshold of at least 5,000 people or 2,000 housing units.” The Wisconsin Office of Rural Health at WORH.org has an excellent article, “Defining Rural for Wisconsin,” showing the multiple ways state geography is sliced and diced: including by counties, census tracts and commuting areas. They appropriately do not include urban hubs as rural.
The definition(s) of what and who is rural as RHTP monies are used or distributed will be a sensitive issue over the next five years, given the stated purpose to focus on rural health and communities. Who receives RHTP monies needs to be informed by University of Wisconsin Professor Katherine Cramer’s widely read 2016 book, The Politics of Resentment, that documents the consciousness of rural Wisconsinites–a feeling of being neglected, disrespected, and economically sidelined by urban hubs.
Supporters of rural health are generally not anti-urban. Our focus is to address “the unique geographic, demographic, and cultural factors of rural health that create significant differences in health status and access to care compared to urban areas.” (The Rural Health Information Hub). We advocate for rural, not against urban. We are open to partnerships that are based on collaboration versus differences in power.
The work financed by the RHTP needs to understand and respect the lived experience of our rural communities:
Sense of Place: many residents have a place-based identity, strongly connected to their community’s context and history.
Strong Social Ties: neighbors know each other and engage in regular face-to-face interactions, creating a high level of caring for their neighbors.
Self-Reliance and Independence: living at a distance from many services often fosters values of independence and a ‘do-it-yourself’ attitude.
Traditional Values: rural communities often favor traditional beliefs, with strong ties to both family and their community.
Support or opposition for any proposed uses of RHTP will be strongly impacted by a sense of alignment with what is and who is rural; rural communities will loudly speak up against the use of RHTP dollars that don’t make it to rural communities or directly enhance rural health.
Again, from WORH.org: “With an increasingly perception-based definition of rural, it is more important than ever to be aware of how the lived experience of rural people and institutions contrast from what we might expect given our measurement schemes. It is rural people that must direct our mission as practitioners and administrators of social programs and policy.”
*(Tim Size is executive director of Rural Wisconsin Health Cooperative, Sauk City. RWHC is owned and operated by 40 rural acute, general medical-surgical hospitals, including Tomah Health. The cooperative’s emphasis on developing a collaborative network among both freestanding and system-affiliated rural hospitals distinguishes it from alternative approaches. In 1996, RWHC created a nonvoting Affiliate Membership for specialty provider-based systems.)