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A MedPage Today opinion article by Terry Adirim argues that federal policy changes could worsen existing rural health care pressures. It cites projected Medicaid reductions under the 2025 budget law and a proposed $103,265 fee on certain H-1B petitions, while noting that a temporary $50 billion rural program may not replace long-term funding.
Federal Medicaid reductions and a proposed fee on some H-1B petitions could add financial and staffing pressure to rural health providers, according to Terry Adirim, a physician and former leader of the military health system, in an October 18 opinion article for MedPage Today. Adirim argues that a temporary federal rural health program will not make up for long-term funding losses facing communities with limited alternatives to local hospitals.
Adirim cites estimates that the 2025 budget reconciliation law, signed by President Donald Trump, will reduce federal Medicaid spending by $911 billion over 10 years and leave 10 million more people uninsured. KFF estimates the law will cut federal Medicaid spending in rural areas by $137 billion over the same period. The figures are projections, not reported outcomes already realized.
Medicaid supports a substantial share of rural care, Adirim writes: it covers one in four rural adults, half of rural births and about one-fifth of inpatient hospital discharges. The article also points to a $50 billion Rural Health Transformation Program as a federal response, but says the funding lasts five years. KFF estimates it equals little more than one-third of projected rural Medicaid reductions, and restrictions on how the money can be distributed may limit direct provider support.
The article identifies physician recruitment as another pressure point. The Department of Homeland Security has proposed a $103,265 fee on H-1B petitions subject to the annual visa cap, in addition to other fees. Adirim cites a 2025 JAMA study finding that more than 11,000 physicians were sponsored by H-1B visas in fiscal year 2024 and that rural counties relied on these physicians at higher rates than urban counties.
Funding and Staffing Risks for Rural Hospitals
The stakes are high because rural facilities often have fewer nearby alternatives when a hospital, maternity unit or specialist service closes. Adirim cites data showing that 193 rural hospitals closed between 2005 and 2024. The share of rural hospitals providing obstetric services fell from 57% in 2010 to 48% in 2022. The Center for Healthcare Quality and Payment Reform estimates that more than 700 rural hospitals—about one-third of rural facilities nationwide—are at risk of closing.
Reduced Medicaid revenue could force providers to cut staff or services, Adirim argues, while higher visa-related hiring costs could make recruiting some physicians more difficult. These are risks described in the opinion article, not confirmation that specific hospitals have made cuts or that the proposed fee has taken effect. For patients, the concern is that fewer local services can mean longer journeys for emergency, maternity and specialist care.
Adirim also cautions against treating telehealth and technology as substitutes for local capacity. A virtual consultation can connect a patient to a distant specialist, but it cannot provide every in-person service or replace a closed hospital. That distinction matters particularly for time-sensitive care, including emergency obstetrics.
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Existing Gaps in Rural Care
The opinion article links the policy concerns to longstanding differences in health outcomes and access. It reports that the rural-urban age-adjusted death-rate gap grew from 7% in 1999 to 20% in 2019, citing the CDC. The CDC has also estimated that tens of thousands of rural deaths from major causes in 2022 were potentially preventable. These figures describe broader conditions; they do not establish that any single federal policy caused the disparities.
Adirim illustrates access barriers with an account from his time leading the military health system. A service member’s child needed developmental evaluation unavailable at the installation hospital or in the surrounding community. After a virtual consultation and an in-person visit several hours away, the military moved the family to another assignment where care was available. Adirim contrasts that option with the limited ability of most rural families to relocate for treatment.
He also cites a KFF/Associated Press survey of rural registered voters: 66% said they were at least somewhat worried about affording health care for themselves or their families. The survey found three-quarters rated local living costs fair or poor, up 25 percentage points from 2017. These are survey responses, not a measure of actual medical bills or coverage losses.
“Rural healthcare does need transformation. But first, it needs survival.”
— Terry Adirim, writing in MedPage Today
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Policy Effects Still Unsettled
The cited figures for Medicaid reductions and increased uninsured numbers are estimates of the 2025 law’s effects. The article does not provide a timeline for when particular rural providers might experience revenue changes or identify specific hospital closures attributable to the law. The scale of any resulting service cuts will depend on implementation and how states and providers respond.
The H-1B fee is described as proposed; the article does not establish that it has taken effect or specify its final scope. It also does not identify how many rural hospitals would face the fee when recruiting physicians. The Rural Health Transformation Program’s rules and distribution of funds could affect how much support reaches individual providers, but the article does not quantify allocations to particular facilities.
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Implementation and Funding Decisions Ahead
The next points to watch are how federal agencies implement the Medicaid provisions and the rural transformation program, including which providers can receive funds and what restrictions apply. Any changes to the program’s rules could affect whether hospitals and clinics can use the money for immediate operating needs.
For physician recruitment, the proposed H-1B fee’s final status and terms will determine whether it adds to the cost of hiring eligible international doctors. The article does not give a decision date. Meanwhile, hospitals, policymakers and rural communities will continue to face questions about sustaining essential services beyond the program’s five-year funding period.
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Key Questions
What federal policies does the article say could pressure rural health care?
Adirim points to projected Medicaid spending reductions under the 2025 budget reconciliation law and a proposed $103,265 fee on certain H-1B petitions. The article argues these could affect provider finances and physician recruitment.
Has the proposed H-1B fee taken effect?
The source describes it as a proposal by the Department of Homeland Security. It does not report that the fee has taken effect or provide a final decision date.
How large are the projected rural Medicaid reductions?
KFF estimates the law will reduce federal Medicaid spending in rural areas by $137 billion over 10 years. This is a projection, not a tally of spending already cut.
Can the Rural Health Transformation Program replace the projected cuts?
The program provides $50 billion over five years. Adirim cites KFF’s estimate that this is little more than one-third of projected rural Medicaid reductions and says restrictions may limit direct provider support. The article does not detail final funding allocations to individual facilities.
Why could rural hospital closures have a different effect?
Adirim argues that rural patients often have fewer nearby alternatives, so losing a hospital or service can mean traveling much farther for care. The article reports that 193 rural hospitals closed from 2005 through 2024, but does not attribute those closures to the policies discussed.
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