Eighty percent of Texas’ 254 counties are rural. The state is getting $1.4 billion over five years to help improve these residents’ access to healthcare.Healthcare organizations hope to use money for everything from getting MRI machines to offering relocation bonuses to attract much-needed staff.Tight deadlines for grant applications and for reporting on the impacts of the money have made it difficult for some healthcare organizations to participate, however.

In rural Texas, patients and clinics have stories to tell.

When the only pediatrician accepting Medicaid in Victoria, Texas stopped taking it, a local mom was left driving 1.5 hours each way to Corpus Christi to find help for her child’s chronic condition, says Diana Forester, health policy director at Texans Care for Children, which advocates for child and maternal health.

Over the years, Sarah Hohman, director of government affairs at the National Association of Rural Health Clinics, has heard anecdotes about clinics limiting summer hours because their aging HVAC systems broke. “If you’re in Texas, you really can’t see patients in those conditions,” she says.

Residents of Texas’ 202 rural counties often face steeper health challenges and fewer resources to address them, the state says. They’re more likely to be older or have a disability or chronic disease. They’re more likely to be lower income and rely on Medicaid. They’re also more likely to have to trek far distances to find the care they need.

Now Texas has a pot of money to spend on the problem. The federal Rural Health Transformation Program is delivering $50 billion to states over five years to shore up rural healthcare. The program was included in the One Big Beautiful Bill Act after several senators worried rural healthcare would suffer too much from the Act’s cuts to Medicaid. The program is intended to transform rural care, rather than directly replace Medicaid losses, which outstrip the program’s funding.

Last December, Texas learned it would receive $1.4 billion over the five years of the program. Its first-year award, $281 million, is the largest received by any state. States had to get spending plans approved by the Centers for Medicaid and Medicare Services before they could receive funding.

The Lone Star State is channeling the funding into six initiatives related to areas like recruiting and retaining healthcare workers, providing telehealth options and replacing or acquiring medical equipment. It’s been making grants available to qualifying healthcare organizations whose proposals fit those initiatives.

Healthcare organizations and advocates say the money could make a big difference. In June and July, organizations began hearing whether they’d been selected for certain funding awards. Any that received money this summer may need to act fast to detail their progress —states have until August 31 to submit a report detailing their first year of progress. The reports help CMS decide future funding amounts and ensure states are following the rules.

A Dizzying Start
Healthcare providers have had to move fast.

Texas was quicker than some peer states at making grant applications available, but healthcare organizations still didn’t have much time to apply. Some hospitals report as few as 30 days between learning a funding opportunity is available and having to submit a final project, thanks to federal timelines, says Matilin Harvey, grant and special projects coordinator at CHC, a company that owns, manages and consults with rural and community hospitals in Texas and other states.

As of early August, the state had told some of CHC’s hospitals it intended to give them an award, and the parties were negotiating and finalizing details. None had received money yet, but the next deadline is coming fast:

“Hospitals will need to report, I believe, within the first month of receiving funding to show what progress they’ve made,” Harvey says. “It’s very very quick.”

Hohman, of the National Association of Rural Health Clinics, worries that small healthcare clinics nationwide may struggle to meet tight application deadlines, especially because many don’t have even part-time grant writers to help.

Organizations also worry about some federal restrictions.

Healthcare providers’ day-to-day costs have soared, especially around staff and third-party contractors that provide services like running emergency rooms or interpreting radiology scans, says Michael Morgan, CHC’s senior vice president of strategic analysis. Organizations cannot use Rural Health Transformation Program funds to pay down debt or cover these basics.

Some of the program’s grants require organizations to spend their own money first, then get reimbursed, which could strain cash flow, Electra Hospital District CEO Rebecca McCain said in an email shared with Governing. 

Just What the Doctor Ordered

Despite the challenges, healthcare advocates say the program is a unique opportunity.

Its multiyear nature gives organizations time to build up new programs to the point where they’re showing their value and the case can be made to fund them long-term, says Forester, of Texans Care for Children. Texas also added requirements intended to help organizations’ prepare for the fundings’ end: for example, recipients of medical equipment grants must set aside some of their own funds into a savings account reserved for any maintenance or replacement needs down the line.

“Little aspects like that are unique to Texas [and] are going to serve our hospitals very well in the long-term,” CHC’s Harvey says.

And this program specifically supports chronic care programs, which health clinics often want but cannot afford the startup costs for, Hohman says.

Harvey grew up in Gainesville, Texas where her grandparents still live. The local hospital applied and received letters to negotiate on nearly $10 million worth of grants. That doesn’t guarantee the money, but suggests tentative approval. If funds arrive, it could mean hiring an ear, nose and throat specialist; an internal medicine specialist and two family nurse practitioners. It would also allow the hospital to start an after-hours primary care clinic and community fitness center, and replace its MRI machine. Not many grant programs cover imaging equipment.

“I know my grandparents are going to be thrilled with an MRI machine and access to a fitness center,” Harvey says. “There’s not a lot of places to exercise in Gainesville, and so they’re just so excited that they don’t have to drive an hour … for some of these things.”