President Trump has signed the reconciliation legislation formerly known as the One Big Beautiful Bill Act, which includes numerous provisions that will lead to the disenrollment of tens of millions of Medicaid beneficiaries and may lead to the closure of over 300 rural hospitals, dramatically increasing the number of Americans who will lose access to health care. The Agency for Healthcare Research and Quality (AHRQ) is the key federal agency for supporting the research, dissemination, and implementation of evidence that addresses rural hospital closures and works to ensure continued access to quality care for rural communities. Unfortunately, DOGE and HHS have nearly eliminated this Agency through a series of impoundments and unauthorized reorganization efforts. With the clock ticking on rural hospitals collapsing, it is critical that Congress ensure that AHRQ has the resources, staff, and support that it needs to answer the call that rural communities are making.
How the Reconciliation Bill Changes Health Care
The reconciliation law makes numerous changes and cuts to both Medicaid and SNAP to partially offset the extension of tax cuts for the wealthy and an expansion of immigration enforcement spending. The legislation is estimated to cut these two social safety net programs by more than $1 trillion dollars over the next decade. One cut is the creation of strict new work requirements with frequent eligibility reviews for Medicaid beneficiaries. The evidence is clear that not only do these requirements not increase work, the burdensome administration of them strains state budgets and removes up to 40 percent of qualifying beneficiaries.
These cuts will all have devastating implications for both health outcomes and economic prosperity in rural communities in particular.
The Congressional Budget Office estimates that 14 million people could lose health insurance coverage by 2034, and rural communities are expected to be especially hard-hit. Individuals living in rural communities are more likely to be covered by Medicaid than their urban counterparts; in rural areas, 47 percent of children and 18 percent of adults rely on Medicaid/CHIP for their health insurance. We know from analyses of individual states who have implemented work requirements that such changes reduce federal spending for individual patients, increase the number of uninsured individuals, and fail to significantly increase rates of employment. Since almost all eligible Medicaid recipients are already working, the loss in coverage is disproportionately due to reporting errors, documentation delays, or other bureaucratic concerns rather than a failure to work or volunteer. Individuals without health insurance are more likely to delay or forgo care due to prohibitive costs which in turn is associated with worse clinical outcomes, increased total health care costs, and increased utilization of expensive emergency care.
The new law threatens the health care coverage of nearly two million rural residents, but the harm to rural communities is not limited to loss of individual coverage. Rural hospitals are already struggling to preserve essential services and keep their doors open, with most relying heavily on Medicaid reimbursements to remain viable. Even with current Medicaid reimbursement rates, which are lower than commercial insurance rates, most hospitals lose money treating Medicaid patients; further cuts would make it nearly impossible for hospitals to treat Medicaid patients, causing more hospitals to turn away Medicaid recipients for elective services, and for hospitals to eventually close when the economic losses becomes unmanageable.
Since 2010, more than 150 rural hospitals have been forced to limit essential services or close altogether, causing some to travel an hour or more for health care. In emergency situations where minutes can make the difference between life and death, such delays can have fatal consequences: compared to people living in urban centers, patients living in rural communities experience a 20 percent increase in all-cause mortality. Rural hospitals are already struggling to preserve essential services and keep their doors open, with most operating on slim-to-nonexistent margins.
The role of AHRQ
By law, AHRQ prioritizes the health of rural Americans, funding research and programs aimed at uncovering barriers to health care and improving access to quality care by addressing the unique needs of rural communities. The Agency publishes an annual report that highlights health care quality and gaps in care, including that of rural communities, which can inform funding priorities, policy, and practice. AHRQ-funded initiatives focus on developing, testing, implementing, and disseminating evidence-based resources and programs to overcome barriers and address gaps in rural health systems, and improve health for rural Americans.
AHRQ-funded training and education initiatives build capacity in rural health facilities, equipping providers with knowledge, tools, and resources to implement evidence-based treatments and practices, ensuring access to quality care for rural patients. This improvement in capacity includes research, dissemination, and implementation into eliminating wasteful and inefficient practices, improved care models, health system resiliency, provider support, effective utilization of health clinics, removal of telehealth barriers, and more.
As rural hospital systems and patients strain under the collapse of insured populations, along with new administrative requirements, it is critical that they have all of the evidence that they need to provide the best care possible to patients, as well as support an overwhelmed workforce. AHRQ is the proven answer for the crisis that rural constituents are facing, the question is, will Congress give it the support it needs?
Learn more about AHRQ’s research and programs that support rural health at ahrq.gov. Read our previous blogs on why AHRQ is a smart investment and the Agency’s essential role in the delivery of high value, quality care. Learn how to stand with AHRQ using our toolkit.