The Rural Health Transformation Program (RHTP) represents a $50 billion, five-year federal investment in rural health, the largest in a generation. Washington State, North Carolina, and Connecticut have received year-one funds for their approved plans.
For rural providers nationwide, the window to act strategically is now. Five priorities require immediate attention: implementation, technical support, political risk management, advancing equity, and post-2030 sustainability planning.
Implementation: Act Now
Organizations should map their work against their state’s RHTP plan and its funding priorities. For example, North Carolina’s NC ROOTS funds local health networks, Washington State focuses on hospital modernization and chronic disease prevention, and Connecticut prioritizes expanding Federally Qualified Health Centers (FQHCs).
These four steps matter most in preparing for RHTP funds:
- Build and strengthen relationships with the state agency staff administering these grant dollars
- Assess data infrastructure now; the Centers for Medicare & Medicaid Services (CMS) will annually rescore states on outcomes, and timely, accurate data is essential for renewal
- Ensure contracts and subgrant agreements specify clear deliverable timelines, noting that year one funds must be used by Sept. 30, 2027
- Engage proactively, rather than waiting for grant announcements, with your state agency about application timelines and readiness
Support: Technical Assistance and Capacity Building
Small rural organizations, especially those new to state grants, risk being overlooked in favor of larger, better-resourced systems.
The Rural Health Information Hub provides free tools and guides on funding, compliance, and program design. The National Rural Health Association offers policy updates and peer networks. State Primary Care Associations and Area Health Education Centers (AHECs) often deliver technical assistance, including grant-writing support. The stakeholder engagement infrastructure developed in Washington, North Carolina, and Connecticut can also serve as a resource.
Smaller organizations should contact their state RHTP administrators about simplified application processes or capacity-building grants today.
Funders considering strategic investments in grant-writing capacity and compliance infrastructure for under-resourced rural organizations are essential to achieving equitable RHTP fund distribution.
Policy Risks: Managing Political and Administrative Uncertainty
The CMS Administrator has broad discretion over annual rescoring. The Trump administration has used federal funding as a political pressure tool. Washington, North Carolina, and Connecticut, as Democratic-led states, face increased exposure to such risks.
Organizations can mitigate this risk by:
- Rigorously documenting outcomes, as robust performance records – including subgrantee’s data quality – make states less vulnerable to penalties
- Maintaining relationships with legal and public policy partners who can respond quickly to funding threats. Coalitions of rural providers, advocates, and state officials help ensure accountability
- Avoiding reliance on RHTP funds for operating budgets. These funds should support infrastructure and capacity building, and systems change, not recurring expenses. Treating RHTP as revenue increases exposure to political risk as the 2030 funding cliff approaches.
Equity: Reaching the Most Underserved
Washington State’s 10 percent set aside for Tribal healthcare providers and North Carolina’s county-level targeting of underserved populations are effective models to address health disparities, but stated commitments alone do not ensure health equity or the equitable distribution of RHTP funds.
Best practices to ensure equity include:
- Requiring subgrantee applications to illustrate expected impact on high-need populations
- Disaggregating outcome data by race, income, geography, and insurance status from the start
- Establishing community advisory governance structures with meaningful representation from underserved groups.
Organizations should advocate for explicit equity criteria in state application scoring and notify their state agency if these are missing. Since the NOFO does not require specific equity metrics, states and subgrantees must ensure this rigor.
Sustainability: Planning for 2030
RHTP funding concludes on September 30, 2030. Organizations that plan for this transition now will be better positioned than those that wait for the funding cliff.
The most sustainable use of RHTP funds is to build capabilities that provide ongoing value:
- Value-based payment contracts to ensure long-term revenue streams
- Technology and data infrastructure improvements to reduce administrative costs
- Pipelines to address rural workforce shortages
Connecticut’s focus on preparing providers for alternative payment models and North Carolina’s emphasis on financial sustainability through NC ROOTS reflect this approach.
Organizations should identify complementary funding sources, such as Health Resources and Services Administration (HRSA) rural health grants, state transformation funds, and private philanthropy.
By year two or three, each subgrantee should include sustainability plans that clearly define what will continue after 2030, which costs will end, and what revenue sources will replace RHTP funding.
The Practical Bottom Line
The RHTP is a once-in-a-generation investment with a hard end date. Organizations most likely to achieve lasting rural health improvements are those that:
- Engage proactively with their state
- Invest early in data and compliance infrastructure
- Include equity as an operational priority
- Plan a post-2030 environment at the outset
The funding window is open, but the strategic positioning window is closing.
Visit our Knowledge Hub for the first part of our two-part blog series on the RHTP, as well as analysis of H.R. 1 (The One Big Beautiful Bill Act) in our policy brief and related Our Ideas blogs.