Fifty State Profiles on Syam Adusumilli

Alaska

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Cluster 3: Frontier and Resource-Adequate States

Alaska enters the Rural Health Transformation Program with conditions that no other state shares. Not extreme rural but genuinely frontier. Not geographically challenging but physically inaccessible. Not underserved but operating healthcare systems designed for realities that continental policy frameworks cannot comprehend. And with $990 per rural resident annually, the third-highest per-capita allocation in the program, Alaska has resources that many states would consider transformative.

Summary: Alaska

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RHTP-17.AK — Fifty State Profiles
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Alaska received $272.2 million in FY2026 RHTP funding, ranking third nationally at $990 per rural resident annually. This allocation reflects formula provisions weighting land area, producing an award disproportionate to population but proportionate to the cost structure of serving communities accessible only by air. The state’s projected ten-year Medicaid cut of $2.0 billion creates a 1.5:1 RHTP-to-Medicaid-cut ratio, among the most favorable in the program. But Alaska’s challenge is not coverage erosion. It is the permanent structural reality that healthcare delivery to remote communities costs more than any per-capita formula assumes, and will continue to cost more regardless of what federal policy provides.

Alabama

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Cluster 4: Non-Expansion High-Burden States

Alabama enters the Rural Health Transformation Program through a lead agency that has never administered a healthcare program of this scale or complexity. The Alabama Department of Economic and Community Affairs manages federal grants for community infrastructure and workforce development. It does not have healthcare policy expertise, clinical knowledge, or existing relationships with the provider networks that will deliver transformation services. This structural choice defines Alabama’s RHTP implementation more than any other single factor.

Summary: Alabama

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RHTP-17.AL — Fifty State Profiles
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Alabama received $203.4 million in FY2026 RHTP funding, with a five-year total of approximately $1.02 billion. At $97 per rural resident annually, Alabama’s per-capita allocation is among the lowest in the program, a direct consequence of its 2.1 million rural residents spreading formula-driven funding across the largest rural population among non-expansion high-burden states. The state faces projected ten-year Medicaid cuts of $2.8 billion, creating a 2.8:1 RHTP-to-Medicaid-cut ratio that appears manageable only because Alabama’s Medicaid program already barely covers anyone. The primary question is not whether the ratio is survivable but whether an economic development agency can execute healthcare transformation in a state where seven rural hospitals have closed since 2011, 41 of 67 counties lack maternity care, and the Black Belt’s life expectancy falls a decade below national averages.

Arkansas

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Cluster 5: High-Complexity Transition States

Arkansas is the only state that has already demonstrated at scale what H.R. 1’s work requirements will produce nationally. In 2018, the state became the first to impose Medicaid work requirements. Within seven months, 18,000 people lost coverage, employment did not increase, medical debt spiked, and a federal judge halted the program. The results were published in the nation’s leading health policy journals. The federal government mandated the experiment anyway.

Summary: Arkansas

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RHTP-17.AR — Fifty State Profiles
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Arkansas received $208.8 million in FY2026 RHTP funding, with a five-year total of approximately $1.04 billion. At $161 per rural resident annually, the per-capita allocation places Arkansas ninth nationally. The state faces projected ten-year Medicaid cuts of $8.2 billion, creating a 7.9:1 RHTP-to-Medicaid-cut ratio that means Arkansas loses $7.90 in Medicaid federal funding for every dollar it receives through RHTP. This Severe Gap classification would be concerning for any state. For Arkansas, it carries particular weight: this is the only state that has already demonstrated at scale what work requirements will produce nationally.

Arizona

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Cluster 3: Frontier and Resource-Adequate States

Arizona presents the most analytically complex implementation environment in the RHTP program. The state’s 41.3:1 Medicaid math ratio is the highest in the nation, its rural Medicaid enrollment the highest nationally, and its governance structure places implementation authority outside state government. For every dollar Arizona invests in rural health transformation, it loses more than forty-one dollars in Medicaid coverage. That mathematical reality shapes every assessment that follows.

Summary: Arizona

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RHTP-17.AZ — Fifty State Profiles
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Arizona received $167 million in FY2026 RHTP funding, substantially below the $200 million requested. At $232 per rural resident annually with a five-year total of approximately $840 million, the allocation might appear adequate in isolation. It is not. Arizona’s 41.3:1 RHTP-to-Medicaid-cut ratio is the highest in the nation. The state faces projected ten-year Medicaid cuts of $34.5 billion, representing 18% of baseline spending and the largest absolute rural Medicaid loss of any state outside Texas and California. For every dollar Arizona invests in rural health transformation, it loses more than forty-one dollars in Medicaid coverage. That mathematical reality shapes every implementation assessment that follows.

California

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Cluster 2: High Medicaid Exposure States

California enters the Rural Health Transformation Program carrying the highest RHTP-to-Medicaid-cut ratio in the nation at 128.3:1. That number, standing alone, tells a story of structural impossibility. But structural impossibility is only the beginning of what makes California’s profile analytically distinct from every other state in the series. What makes California different is not that RHTP cannot solve its problems. No state’s RHTP allocation can offset projected Medicaid losses. What makes California different is that RHTP must implement transformation through administrative systems simultaneously absorbing the most complex set of overlapping policy changes any state has ever attempted to process.

Summary: California

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RHTP-17.CA — Fifty State Profiles
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California received $233.6 million in FY2026 RHTP funding, the fifth-largest award nationally and the largest among high Medicaid exposure expansion states. The five-year projection of $1.17 billion places California among the most generously funded states in absolute terms. Per rural resident, however, the allocation is $87 annually, depressed by the 2.7 million rural population across which funding distributes. These numbers matter less than what they cannot address. California’s 128.3:1 RHTP-to-Medicaid-cut ratio is the highest in the nation. The projected ten-year Medicaid cut of $149.8 billion represents 17% of baseline federal funding, the largest absolute cut of any state by a substantial margin. RHTP cannot meaningfully address a $149.8 billion hole.

Colorado

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Cluster 3: Frontier and Resource-Adequate States

Colorado enters the Rural Health Transformation Program with the administrative sophistication that distinguishes states capable of executing complex federal programs from states that will struggle to absorb the funding they receive. The Department of Health Care Policy and Financing applied expecting $500 million and received over $1 billion. The state had stakeholder engagement processes running before the Notice of Funding Opportunity was released. Applicant FAQs were published within days of the award announcement. An Advisory Committee structure was designed before funds arrived.

Summary: Colorado

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RHTP-17.CO — Fifty State Profiles
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Colorado received $200.1 million in FY2026 RHTP funding, with a five-year total exceeding $1 billion, roughly double what state officials initially anticipated. The Colorado Department of Health Care Policy and Financing applied expecting $500 million and received over $1 billion. This administrative sophistication distinguishes states capable of executing complex federal programs from states that will struggle to absorb the funding they receive. Colorado had stakeholder engagement processes running before the Notice of Funding Opportunity was released. Applicant FAQs were published within days of the award announcement. An Advisory Committee structure was designed before funds arrived. While other states spend 2026 building governance structures, Colorado will be evaluating subaward applications.

Connecticut

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Cluster 1: Low-Constraint Expansion States

Connecticut presents the paradox that makes RHTP’s formula design most visible. The state receives the second-lowest absolute allocation nationally at $154 million, barely ahead of New Jersey and the smallest award in New England. Yet that allocation divided among approximately 195,000 rural residents produces $791 per rural resident annually, placing Connecticut among the highest per-capita allocations in the program. Rhode Island at $6,305 and Wyoming at $554 represent the extremes. Connecticut sits in the upper tier alongside Delaware and New Jersey, states where formula mechanics produce per-capita abundance despite modest absolute investment.

Summary: Connecticut

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RHTP-17.CT — Fifty State Profiles
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Connecticut received $154.2 million in FY2026 RHTP funding, the second-lowest absolute allocation nationally. Yet that allocation divided among approximately 195,000 rural residents produces $791 per rural resident annually, placing Connecticut among the highest per-capita allocations in the program. This mathematical outcome reflects RHTP’s formula structure: equal distribution of half the funds across all states regardless of rural population, with the remaining half allocated based on rural factors. States with small rural populations receive outsized per-capita resources even as their absolute allocations remain modest.

Delaware

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Cluster 1: Low-Constraint Expansion States

Delaware has approximately 400,000 rural residents across two counties, no medical school, and a primary care physician-to-patient ratio in Sussex County that exceeds 2,000:1. The state now receives $739 per rural resident annually to build the healthcare infrastructure that a century of proximity to Philadelphia, Baltimore, and Washington never required it to develop on its own.

State Context
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Delaware has approximately 400,000 rural residents concentrated in Kent and Sussex Counties, the state’s two southern counties that together account for nearly 40% of its population. New Castle County in the north contains Wilmington and the I-95 corridor, where healthcare infrastructure benefits from proximity to Philadelphia’s academic medical centers. The divide is stark. Northern Delaware residents have access to ChristianaCare, Nemours Children’s Health, and the broader Philadelphia provider network. Rural residents in western Sussex County drive 50 miles to see a specialist or wait six months for a primary care appointment.

Summary: Delaware

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RHTP-17.DE — Fifty State Profiles
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Delaware received $157.4 million in FY2026 RHTP funding, with a projected five-year total of approximately $787 million. At $739 per rural resident annually, the per-capita allocation is among the highest in the program, a function of formula mechanics that reward smaller rural populations rather than reflecting exceptional need. Delaware has approximately 400,000 rural residents across two counties, no medical school, and a primary care physician-to-patient ratio in Sussex County that exceeds 2,000:1. The state now receives $739 per rural resident annually to build the healthcare infrastructure that a century of proximity to Philadelphia, Baltimore, and Washington never required it to develop on its own.

Florida

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Cluster 4: Non-Expansion High-Burden States

Florida built its coverage architecture on the ACA marketplace because it refused to expand Medicaid. The strategy worked while enhanced premium tax credits remained in place. 4.7 million Floridians hold marketplace plans, more than any other state, representing 27% of the under-65 population. Among these enrollees, 98% received premium subsidies. Among the 4.7 million, 2.4 million have incomes below 138% FPL, the population that would be covered by Medicaid in expansion states. Florida substituted marketplace dependence for Medicaid expansion, and federal policy subsidized the substitution.

Summary: Florida

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RHTP-17.FL — Fifty State Profiles
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Florida received $209.9 million in FY2026 RHTP funding, translating to $317 per rural resident annually, the highest per-capita allocation among non-expansion high-burden states by a substantial margin. The allocation is 3.7 times Tennessee’s $86, 3.3 times Alabama’s $97, and 2.5 times South Carolina’s $125. This disparity reflects Florida’s relatively small 1.2 million rural population against a total allocation driven by overall state size in the funding formula. But per-capita abundance cannot address Florida’s fundamental problem: the state built its coverage architecture on a marketplace foundation that federal policy now destroys.

Georgia

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Cluster 5: High-Complexity Transition States

Georgia anchors its entire RHTP strategy around preparing rural facilities for the CMS AHEAD model, a value-based payment framework that may define rural healthcare financing after 2030. This is either the most forward-thinking application in the program or a sophisticated plan that arrives too late for the communities that need it most. The distinction depends on whether Georgia’s 20 at-risk rural hospitals survive long enough to participate in the model being built for them.

Summary: Georgia

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RHTP-17.GA — Fifty State Profiles
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Georgia received $218.9 million in FY2026 RHTP funding, with a five-year total of approximately $1.09 billion. At $75 per rural resident annually, the per-capita allocation places Georgia in the lower tier nationally, a consequence of spreading the fifth-largest total award across one of the nation’s larger rural populations of 2.9 million across 120 counties. The state anchors its entire RHTP strategy around preparing rural facilities for the CMS AHEAD model, a value-based payment framework that may define rural healthcare financing after 2030. This is either the most forward-thinking application in the program or a sophisticated plan that arrives too late for the communities that need it most.

Hawaii

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Cluster 1: Low-Constraint Expansion States

Hawaii faces transformation challenges that mainland frameworks cannot address. An island state where more than 95 percent of the land area is classified as rural and healthcare services concentrate on Oahu creates access barriers unlike anything the lower 48 states experience. A Governor’s Office lead structure creates executive coordination capacity while raising questions about operational implementation authority that a health department would provide.

State Context
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Hawaii defies the analytical frameworks built for continental rural America. More than 95 percent of the state’s land area is classified as rural, yet healthcare services concentrate on Oahu to a degree that creates access barriers unlike anything the lower 48 states experience. A resident of Hana on Maui’s eastern coast requiring specialty care faces not a two-hour drive but air travel logistics and costs that mainland rural residents never encounter. Inter-island medical travel represents a healthcare access dimension that no other state confronts.

Summary: Hawaii

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RHTP-17.HI — Fifty State Profiles
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Hawaii received $188.9 million in FY2026 RHTP funding, translating to $450 per rural resident annually and a five-year total of approximately $940 million. When evaluated on a per-rural-resident basis, Hawaii’s funding represents one of the highest investment levels nationally. CMS recognized the strength of the state’s application design, which scored well on competitive program factors. But Hawaii faces transformation challenges that mainland frameworks cannot address. More than 95% of the state’s land area is classified as rural, yet healthcare services concentrate on Oahu to a degree that creates access barriers unlike anything the lower 48 states experience.

Iowa

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Cluster 1: Low-Constraint Expansion States

Iowa became the first state in the nation to award RHTP funding when Governor Kim Reynolds announced $78.6 million in competitive grants on January 30, 2026. While other states remained in planning phases, Iowa had already selected provider recruitment awardees, approved equipment procurement, and begun distributing resources to rural healthcare organizations. This execution velocity reflects both administrative capacity and a transformation vision that predated federal funding.

Summary: Iowa

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RHTP-17.IA — Fifty State Profiles
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Iowa received $209 million in FY2026 RHTP funding, the second-highest absolute allocation nationally after Texas. At $218 per rural resident annually, the per-capita allocation falls in the middle range. Iowa became the first state in the nation to award RHTP funding when Governor Kim Reynolds announced $78.6 million in competitive grants on January 30, 2026. While other states remained in planning phases, Iowa had already selected provider recruitment awardees, approved equipment procurement, and begun distributing resources to rural healthcare organizations.

Idaho

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Cluster 3: Frontier and Resource-Adequate States

Idaho enters the Rural Health Transformation Program with conditions that should place it firmly in the favorable category. Medicaid expansion since 2020, approved by nearly 61 percent of voters. An integrated Department of Health and Welfare with clear authority. A Rural Health Taskforce created by executive order to guide RHTP planning. And $291 per rural resident annually, a per-capita allocation that provides meaningful investment capacity for a state where geography and distance define healthcare access.

Summary: Idaho

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RHTP-17.ID — Fifty State Profiles
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Idaho received $186 million in FY2026 RHTP funding, approximately 93% of the $200 million requested. The five-year total reaches approximately $930 million, translating to $291 per rural resident annually. Idaho enters the program with conditions that should place it firmly in the favorable category: Medicaid expansion since 2020 approved by nearly 61% of voters, an integrated Department of Health and Welfare with clear authority, a Rural Health Taskforce created by executive order to guide planning, and a 3.1:1 RHTP-to-Medicaid-cut ratio among the most favorable in the program.

Illinois

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Cluster 2: High Medicaid Exposure States

Illinois presents one of the most mathematically stark cases in the RHTP portfolio. The state received the third-largest award nationally at $193.4 million for FY2026, yet faces projected Medicaid cuts that dwarf this investment by a factor of 47 to 1. For every dollar Illinois invests through RHTP, the state loses $47.10 in federal Medicaid support over the transformation period. This ratio places Illinois among the most exposed states in the nation, creating what state officials openly characterize as a transformation mandate that cannot mathematically offset the coverage erosion accompanying it.

Summary: Illinois

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RHTP-17.IL — Fifty State Profiles
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Illinois received $193.4 million in FY2026 RHTP funding, the third-largest award nationally. Yet this investment faces projected Medicaid cuts that dwarf it by a factor of 47 to 1. For every dollar Illinois invests through RHTP, the state loses $47.10 in federal Medicaid support over the transformation period. This ratio places Illinois among the most exposed states in the nation, creating what state officials openly characterize as a transformation mandate that cannot mathematically offset the coverage erosion accompanying it.

Indiana

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Cluster 2: High Medicaid Exposure States

Indiana pioneered consumer-directed Medicaid. Before most states accepted the Affordable Care Act’s expansion terms, Indiana negotiated a Section 1115 waiver that introduced Personal Wellness and Responsibility accounts, premium contributions tied to income, and coverage tiers that rewarded health engagement with better benefits. The Healthy Indiana Plan became a national model for conservative innovation in public health coverage, proving that Republican governors could expand Medicaid through mechanisms that aligned with their values.

Summary: Indiana

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RHTP-17.IN — Fifty State Profiles
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Indiana received $206.9 million in FY2026 RHTP funding, exceeding its $200 million request. The five-year projection of $1.03 billion provides substantial investment capacity at $122 per rural resident annually. Governor Mike Braun’s GROW initiative represents one of RHTP’s most thoughtfully designed implementation frameworks, featuring eight regional coalitions, 12 coordinated programs, and explicit gubernatorial branding. The problem is not design quality. The problem is that GROW’s October 2026 launch date means transformation resources arrive after coverage erosion has already begun.

Kansas

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Cluster 4: Non-Expansion High-Burden States

Kansas has the most favorable Medicaid Math ratio among non-expansion high-burden states, the highest per-capita allocation, the strongest institutional architecture, and the most ambitious transformation target. It also has more rural hospitals at immediate risk of closure than any state in the program. The disconnect between fiscal metrics and operational reality is Kansas’s defining analytical tension.

The state’s 3.0:1 ratio, $256 per-capita allocation, and three-layer implementation structure would place Kansas among low-constraint expansion states or frontier states if expansion status were not a factor. Non-expansion holds Kansas among non-expansion high-burden states, where it serves as the boundary case demonstrating what transformation capacity looks like when everything except coverage policy aligns.

Summary: Kansas

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RHTP-17.KS — Fifty State Profiles
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Kansas received $221.9 million in FY2026 RHTP funding, the sixth-highest award nationally and $256 per rural resident annually, the second-highest among non-expansion high-burden states behind Florida’s $317. The state’s 3.0:1 RHTP-to-Medicaid-cut ratio is the most favorable among non-expansion high-burden states by a significant margin. Tennessee’s 6.5:1 is the next closest. Kansas has a three-layer implementation structure with the Kansas Department of Health and Environment, the Kansas Rural Health Innovation Alliance, and the University of Kansas Health System Care Collaborative. These metrics would place Kansas among low-constraint expansion states if expansion status were not a factor.

Kentucky

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Cluster 2: High Medicaid Exposure States

Kentucky enters RHTP implementation with a record that should have positioned it as a transformation success story. The state that did things right faces the possibility that doing things right does not matter when federal policy withdraws the conditions that made it possible. Early Medicaid expansion in 2014 stabilized rural hospitals during a period when non-expansion neighbors hemorrhaged facilities. Tennessee lost 15 rural hospitals. Kentucky lost four. The coverage gains were not abstract. One in three Kentuckians receives healthcare through Medicaid or KCHIP, and in the rural counties where RHTP investment is concentrated, that ratio approaches one in two.

Summary: Kentucky

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RHTP-17.KY — Fifty State Profiles
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Kentucky received $212.9 million in FY2026 RHTP funding, the ninth-highest nationally, translating to $114 per rural resident annually and a five-year total of approximately $1.06 billion. The application was accepted in full by the Trump administration, a notable outcome for a Democratic governor’s submission that reflects clinical specificity rather than political alignment. Kentucky enters RHTP implementation with a record that should have positioned it as a transformation success story. Early Medicaid expansion in 2014 stabilized rural hospitals during a period when non-expansion neighbors hemorrhaged facilities. Tennessee lost 15 rural hospitals. Kentucky lost four.

Louisiana

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Cluster 5: High-Complexity Transition States

Louisiana expanded Medicaid in 2016 and watched its uninsured rate plummet from 16% to 8.3%. The expansion was a policy success that created the state’s current vulnerability. With 1.6 million Louisianans enrolled in Medicaid, including 37% of the rural population, the program is not supplemental coverage but the dominant payer across rural healthcare delivery. The federal cuts now target that dominance directly.

Louisiana’s 25.9:1 RHTP-to-Medicaid-cut ratio is among the most severe in the program. For every dollar the state receives in transformation investment, it loses $25.90 in Medicaid revenue. This is not a ratio that transformation can offset. It is a ratio that reveals the fundamental mismatch between what RHTP provides and what coverage erosion takes away.

Summary: Louisiana

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RHTP-17.LA — Fifty State Profiles
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Louisiana received $208.4 million in FY2026 RHTP funding, with a five-year total of approximately $1.04 billion. At $154 per rural resident annually, the per-capita allocation places Louisiana in the middle tier nationally. Louisiana expanded Medicaid in 2016 and watched its uninsured rate plummet from 16% to 8.3%. The expansion was a policy success that created the state’s current vulnerability. With 1.6 million Louisianans enrolled in Medicaid, including 37% of the rural population, the program is not supplemental coverage but the dominant payer across rural healthcare delivery.

Massachusetts

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Cluster 3: Frontier and Resource-Adequate States

Massachusetts enters the Rural Health Transformation Program with institutional sophistication that no other state matches and a rural footprint so modest that transformation success would demonstrate proof of concept more than population-scale impact. The state has the most developed payment reform infrastructure in the country through MassHealth’s accountable care organization partnerships. The analytical question is whether RHTP adapts that infrastructure for rural settings or treats rural Massachusetts as a separate implementation challenge disconnected from the innovation MassHealth has already demonstrated.

Summary: Massachusetts

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RHTP-17.MA — Fifty State Profiles
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Massachusetts received $162 million in FY2026 RHTP funding, approximately 20% below the state’s $1 billion five-year request. The award translates to $681 per rural resident annually using census-based population, the highest per-capita allocation of any state with substantial rural health infrastructure. That funding concentration creates transformation capacity that larger rural states cannot match, but it also raises questions about whether Massachusetts’ experience can inform rural health policy nationally.

Maryland

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Cluster 3: Frontier and Resource-Adequate States

Maryland enters the Rural Health Transformation Program having already built what many consider the essential enabling condition for alternative architecture: payment model reform that frees rural providers from fee-for-service volume dependence. For over 40 years, the Health Services Cost Review Commission has regulated hospital rates across all payers. That model is now in flux, transitioning to federal control precisely as RHTP implementation begins. Maryland’s implementation environment is shaped by payment model uncertainty rather than rural health conditions alone.

Summary: Maryland

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RHTP-17.MD — Fifty State Profiles
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Maryland received $168.2 million in FY2026 RHTP funding, translating to $374 per rural resident annually and a five-year total of approximately $840 million. The state’s five-year request of $1 billion was reduced by approximately 16%. Maryland enters RHTP having already built what many consider the essential enabling condition for alternative architecture: payment model reform that frees rural providers from fee-for-service volume dependence. For over 40 years, the Health Services Cost Review Commission has regulated hospital rates across all payers, ensuring Medicare, Medicaid, and commercial insurers pay identical prices for identical services at the same hospital. That model is now in flux.

Maine

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Cluster 1: Low-Constraint Expansion States

Maine presents an implementation paradox that the Rural Health Transformation Program’s designers did not anticipate. The state possesses nearly every favorable condition: Medicaid expansion since 2019, integrated departmental authority, strong intermediary infrastructure, bipartisan congressional support for the application, and per-capita funding that places it comfortably in the program’s upper tier. Yet Maine enters RHTP facing hospital financial distress more acute than most non-expansion states, maternity care collapse that has shuttered eleven birthing units in a decade, and a guaranteed gubernatorial transition in November 2026 that introduces implementation uncertainty at precisely the moment when institutional memory matters most.

Summary: Maine

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RHTP-17.ME — Fifty State Profiles
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Maine received $190 million in FY2026 RHTP funding, with a projected five-year total approaching $950 million. The $306 per rural resident annually places Maine in the upper allocation tier. The state possesses nearly every favorable condition: Medicaid expansion since 2019, integrated departmental authority, strong intermediary infrastructure, bipartisan congressional support including Senator Susan Collins who helped architect RHTP nationally, and a 2.9:1 ratio that is favorable but not protective. Yet Maine enters RHTP facing hospital financial distress more acute than most non-expansion states, maternity care collapse that has shuttered eleven birthing units in a decade, and a guaranteed gubernatorial transition in November 2026.

Michigan

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Cluster 2: High Medicaid Exposure States

Michigan’s rural hospitals told the state what they needed. The Michigan Health and Hospital Association formed a task force. Hospital executives provided recommendations. They asked for funding that would address immediate survival needs: fill access gaps, stabilize operating revenue, keep emergency departments open. The Michigan Department of Health and Human Services submitted an application that “basically didn’t take any of our recommendations into account” according to MHA communications director Kyrsten Newlon. The state proposed technology and innovation while its rural hospitals pleaded for survival.

Summary: Michigan

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RHTP-17.MI — Fifty State Profiles
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Michigan received $173.1 million in FY2026 RHTP funding, with a five-year total of approximately $870 million. At $87 per rural resident annually, the allocation falls below national averages and substantially below neighboring states. A state with top-ten rural population received bottom-ten funding, ranking 43rd out of 50 states in total allocation. Ohio received $202 million. Iowa secured $209 million. The application controversy ensures transformation implementation begins with rural providers distrusting the agency administering their rescue.

Minnesota

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Cluster 2: High Medicaid Exposure States

Minnesota built what other states did not attempt. The Basic Health Program operating as MinnesotaCare covers approximately 98,000 residents with household incomes between 138% and 200% of the federal poverty level, one of only three such programs nationally alongside New York and Oregon. In 2023, 91% of MinnesotaCare’s $676.5 million costs were financed through federal pass-through funding that substitutes for ACA premium subsidies. The program demonstrates what state-level coverage commitment can achieve when federal resources align with state ambition.

Summary: Minnesota

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RHTP-17.MN — Fifty State Profiles
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Minnesota received $193.1 million in FY2026 RHTP funding and approximately $970 million over five years. At $151 per rural resident annually, this ranks third highest nationally among per-capita allocations. Minnesota built what other states did not attempt. The Basic Health Program operating as MinnesotaCare covers approximately 98,000 residents with household incomes between 138% and 200% of the federal poverty level, one of only three such programs nationally. In 2023, 91% of MinnesotaCare’s $676.5 million costs were financed through federal pass-through funding that substitutes for ACA premium subsidies.

Missouri

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Cluster 2: High Medicaid Exposure States

The state that voters forced to expand Medicaid in 2020, that has not had a single rural hospital close since expansion took effect, and that now faces $14.3 billion in federal Medicaid cuts threatening to undo the very coverage gains that stabilized its rural healthcare system. Missouri’s ToRCH pilot provides a tested model for community-based transformation, but the question is whether the model can scale fast enough to outrun the fiscal erosion approaching from federal policy.

Summary: Missouri

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RHTP-17.MO — Fifty State Profiles
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Missouri received $216.3 million in FY2026 RHTP funding, the ninth-largest award nationally, with a five-year total of approximately $1.08 billion. At $114 per rural resident annually, Missouri ranks 36th nationally in per-capita allocation. The state that voters forced to expand Medicaid in 2020 has not had a single rural hospital close since expansion took effect. Missouri now faces $14.3 billion in federal Medicaid cuts threatening to undo the very coverage gains that stabilized its rural healthcare system.

Mississippi

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Cluster 4: Non-Expansion High-Burden States

Mississippi is the anchor state for compound disadvantage. Every structural barrier the Rural Health Transformation Program was designed to address exists here at maximum intensity, and the one policy tool that could most meaningfully alter the trajectory of rural health in the state has been refused for more than a decade. The Commonwealth Fund’s 2025 State Health System Performance Scorecard ranks Mississippi dead last nationally across 50 measures of access, affordability, prevention, treatment, outcomes, and equity. The state leads the nation in fetal mortality, infant mortality, and pre-term birth. It leads in deaths from heart disease, cancer, stroke, and Alzheimer’s. It has the highest poverty rate, the lowest life expectancy, and a public health investment of $15.97 per resident annually against a national average nearly two and a half times that figure. Mississippi does not illustrate non-expansion high-burden conditions. It defines the category’s floor.

Summary: Mississippi

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RHTP-17.MS — Fifty State Profiles
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Mississippi received $205.9 million in FY2026 RHTP funding, ranking sixth nationally. The five-year total projects to $1.03 billion. Mississippi is the anchor state for compound disadvantage. Every structural barrier the Rural Health Transformation Program was designed to address exists here at maximum intensity. The Commonwealth Fund’s 2025 State Health System Performance Scorecard ranks Mississippi dead last nationally across 50 measures. The state leads the nation in fetal mortality, infant mortality, and pre-term birth. It leads in deaths from heart disease, cancer, stroke, and Alzheimer’s. It has the highest poverty rate, the lowest life expectancy, and public health investment of $15.97 per resident annually against a national average nearly two and a half times that figure.

Montana

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Cluster 3: Frontier and Resource-Adequate States

Montana secured $233.5 million in FY2026 RHTP funding, the fourth-largest first-year award in the nation, trailing only Texas, Alaska, and California. The award reflects both the state’s genuine rurality and the strength of an application developed through extensive stakeholder engagement: a 900-registrant webinar, over 300 formal RFI responses, tribal consultation with all eight nations, and direct engagement with twenty external stakeholder groups. Governor Greg Gianforte and DPHHS Director Charlie Brereton positioned the award as validation of Montana’s collaborative approach to rural health planning.

Summary: Montana

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RHTP-17.MT — Fifty State Profiles
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Montana received $233.5 million in FY2026 RHTP funding, the fourth-largest first-year award in the nation, trailing only Texas, Alaska, and California. At $425 per rural resident annually, the allocation provides substantial per-capita investment capacity. The five-year total reaches approximately $1.17 billion. The award reflects both the state’s genuine rurality and the strength of an application developed through extensive stakeholder engagement: a 900-registrant webinar, over 300 formal RFI responses, tribal consultation with all eight nations, and direct engagement with twenty external stakeholder groups.

North Carolina

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Cluster 5: High-Complexity Transition States

State Context
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North Carolina is the most analytically complex state in the Rural Health Transformation Program. Every structural challenge the program was designed to address converges here: the second-largest rural population in the country (3.4 million across 85 counties), the most recent Medicaid expansion among large states (December 2023), a per-capita RHTP allocation so low it constrains the scope of achievable transformation ($63 per rural resident annually), and a 21.2:1 Medicaid Math ratio that places it firmly in the structural contradiction tier. North Carolina does not merely illustrate high-complexity transition state characteristics. It defines the category’s outer boundary.

Summary: North Carolina

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RHTP-17.NC — Fifty State Profiles
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North Carolina received $213.0 million in FY2026 RHTP funding, the second-largest award nationally. The five-year total reaches $1.07 billion. At $63 per rural resident annually, North Carolina has the lowest per-capita allocation among large rural population states. North Carolina is the most analytically complex state in the Rural Health Transformation Program. Every structural challenge the program was designed to address converges here: the second-largest rural population in the country (3.4 million across 85 counties), the most recent Medicaid expansion among large states (December 2023), and a 21.2:1 Medicaid Math ratio that places it firmly in the structural contradiction tier.

North Dakota

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Cluster 1: Low-Constraint Expansion States

North Dakota possesses the most favorable RHTP-to-Medicaid-cut ratio in the entire program. At 1.3:1, the state receives nearly equal transformation investment relative to projected Medicaid losses. Vermont at 1.6:1 is close. Every other state faces ratios ranging from Maine’s 2.9:1 to Mississippi’s 400+:1. This mathematical reality, combined with expansion state status and low implementation constraints, plus a newly inaugurated governor who convened a special legislative session within weeks of taking office, creates implementation conditions that approach optimal.

Summary: North Dakota

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RHTP-17.ND — Fifty State Profiles
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North Dakota received $199 million in FY2026 RHTP funding with a five-year projected total near $1 billion. At $398 per rural resident annually, the allocation is among the highest per-capita nationally. North Dakota possesses the most favorable RHTP-to-Medicaid-cut ratio in the entire program. At 1.3:1, the state receives nearly equal transformation investment relative to projected Medicaid losses. Vermont at 1.6:1 is close. Every other state faces ratios ranging from Maine’s 2.9:1 to Mississippi’s 400+:1.

Nebraska

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Cluster 3: Frontier and Resource-Adequate States

Nebraska enters the Rural Health Transformation Program with conditions that define what frontier and resource-adequate state membership looks like in the agricultural heartland. Medicaid expansion since 2020. An integrated Department of Health and Human Services with clear authority. Eighty-eight of 93 counties classified as rural, with 30 designated as frontier. More than 60 critical access hospitals forming the densest per-capita CAH network in the country. And $303 per rural resident annually, a per-capita allocation that provides meaningful investment capacity without the extreme ratios that characterize states with smaller rural populations.

Summary: Nebraska

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RHTP-17.NE — Fifty State Profiles
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Nebraska received $218.5 million in FY2026 RHTP funding, the eighth-largest award nationally. The state’s submitted application requested $200 million annually, meaning CMS awarded approximately 9% more than planned. The five-year total reaches approximately $1.09 billion. At $303 per rural resident annually, the per-capita allocation provides meaningful investment capacity without the extreme ratios that characterize states with smaller rural populations.

New Hampshire

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Cluster 3: Frontier and Resource-Adequate States

New Hampshire secured the largest Rural Health Transformation Program award in New England, a distinction that reflects both the state’s rural healthcare needs and its aggressive pursuit of federal resources. Governor Kelly Ayotte personally advocated with CMS Administrator Mehmet Oz and HHS Secretary Robert F. Kennedy Jr. to maximize the state’s allocation. The result: $204 million in first-year funding for a state that expected far less.

Summary: New Hampshire

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RHTP-17.NH — Fifty State Profiles
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New Hampshire received $204 million in FY2026 RHTP funding, the largest award in New England and approximately $474 per rural resident annually. The five-year total exceeds $1 billion. Governor Kelly Ayotte personally advocated with CMS Administrator Mehmet Oz and HHS Secretary Robert F. Kennedy Jr. to maximize the state’s allocation. This political investment paid immediate dividends. Whether the programmatic investments that follow will produce comparable returns depends on execution capacity that remains unproven.

New Jersey

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Cluster 1: Low-Constraint Expansion States

New Jersey received the smallest total Rural Health Transformation Program award nationally at $147 million. It also received the highest per-capita allocation at $1,067 per rural resident. These apparently contradictory facts reflect the same underlying reality: New Jersey has very few rural residents, and RHTP’s formula rewards that scarcity. A small denominator generates large per-capita figures regardless of total investment.

The more consequential number is the Medicaid ratio. At 39:1, New Jersey faces the most unfavorable mathematical relationship between RHTP investment and Medicaid erosion of any state in the nation. For every dollar RHTP provides, $39 in Medicaid cuts occur. No amount of transformation excellence can overcome arithmetic this severe.

Summary: New Jersey

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RHTP-17.NJ — Fifty State Profiles
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New Jersey received $147 million in FY2026 RHTP funding, the smallest total allocation nationally. The five-year total approaches $740 million. New Jersey also received the highest per-capita allocation at $1,067 per rural resident. These apparently contradictory facts reflect the same underlying reality: New Jersey has very few rural residents, and RHTP’s formula rewards that scarcity. A small denominator generates large per-capita figures regardless of total investment.

New Mexico

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Cluster 1: Low-Constraint Expansion States

New Mexico enters RHTP as an expansion state with nationally recognized transformation infrastructure, yet faces the paradox that defines large rural population states: favorable conditions for implementation during a period when the Medicaid foundation that expansion built now faces significant erosion.

New Mexico presents a deceptive simplicity. The state’s rural health infrastructure carries nationally recognized innovations that most states only aspire to develop. Project ECHO, launched at the University of New Mexico Health Sciences Center in 2003, pioneered the telementoring model now deployed across all 50 states and 43 countries. The state’s Community Health Worker certification program, formalized through Senate Bill 58 in 2014, established a framework that federal agencies and other states have studied as a template. The New Mexico Social Drivers of Health Collaborative has built SDOH integration infrastructure before SDOH became a federal policy priority.

Summary: New Mexico

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RHTP-17.NM — Fifty State Profiles
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New Mexico received $211.5 million in FY2026 RHTP funding, translating to $252 per rural resident annually and a five-year total of approximately $1.06 billion. New Mexico enters RHTP as an expansion state with nationally recognized transformation infrastructure, yet faces the paradox that defines large rural population states: favorable conditions for implementation during a period when the Medicaid foundation that expansion built now faces significant erosion.

Nevada

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Cluster 3: Frontier and Resource-Adequate States

Nevada enters RHTP implementation with an unusual convergence: RHTP investment and statewide Medicaid managed care expansion arrive simultaneously, creating an implementation environment where transformation and system restructuring compete for the same administrative bandwidth. The question is whether managed care transition accelerates or undermines transformation capacity.

State Context
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Nevada’s rural health geography defies simple characterization. The state contains 11 frontier counties and 3 rural counties out of 17 total, covering vast territory with minimal population density. Carson City, Douglas, Lyon, and Storey counties lie within commuting distance of Reno. The remaining rural and frontier counties stretch across the Great Basin Desert, where distances between communities can exceed a hundred miles and the nearest hospital may be hours away.

Summary: Nevada

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RHTP-17.NV — Fifty State Profiles
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Nevada received $179.9 million in FY2026 RHTP funding, translating to $346 per rural resident annually and a five-year total of approximately $900 million. Nevada enters RHTP implementation with an unusual convergence: RHTP investment and statewide Medicaid managed care expansion arrive simultaneously, creating an implementation environment where transformation and system restructuring compete for the same administrative bandwidth.

New York

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Cluster 2: High Medicaid Exposure States

New York built what other states would not attempt. The state implemented Medicaid expansion immediately upon ACA passage. It created the Essential Plan under Section 1332 waiver authority, extending coverage to individuals up to 250% of the federal poverty level with zero premiums and minimal cost-sharing. It covers approximately 500,000 lawfully present immigrants who would otherwise be ineligible for federal Medicaid matching, a population that exists because of the Aliessa v. Novello decision, a 2001 Court of Appeals ruling that New York’s constitution requires Medicaid-equivalent coverage regardless of federal eligibility. Over 8 million New Yorkers receive coverage through Medicaid and the Essential Plan, approximately 40% of the state’s population. This is the most expansive public health coverage architecture in the nation.

Summary: New York

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RHTP-17.NY — Fifty State Profiles
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New York received $212.1 million in FY2026 RHTP funding, with $1.06 billion projected over five years, translating to $106 per rural resident annually. New York built what other states would not attempt. The state implemented Medicaid expansion immediately upon ACA passage, created the Essential Plan extending coverage to 250% of the federal poverty level with zero premiums, and covers approximately 500,000 lawfully present immigrants who would otherwise be ineligible. Over 8 million New Yorkers receive coverage through Medicaid and the Essential Plan, approximately 40% of the state’s population. This is the most expansive public health coverage architecture in the nation.

Ohio

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Cluster 2: High Medicaid Exposure States

Governor John Kasich expanded Medicaid in 2013 over fierce legislative opposition, invoking Matthew 25 and the duty to serve “the least of these.” The expansion brought coverage to more than 700,000 Ohioans and stabilized rural hospitals that had been hemorrhaging losses from uncompensated care. It was, for a decade, proof that a Republican governor could defy his party’s orthodoxy on healthcare and produce outcomes that vindicated the decision.

Summary: Ohio

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RHTP-17.OH — Fifty State Profiles
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Ohio received $202 million in FY2026 RHTP funding, ranking 25th among states in absolute dollars. The five-year projection reaches $1.01 billion. At $72 per rural resident, Ohio ranks 46th nationally in per-capita allocation, a formula-driven disconnect between documented need and actual investment. Governor John Kasich expanded Medicaid in 2013 over fierce legislative opposition, invoking Matthew 25 and the duty to serve “the least of these.” The expansion brought coverage to more than 700,000 Ohioans and stabilized rural hospitals. That foundation is now being dismantled.

Oklahoma

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Cluster 5: High-Complexity Transition States

Oklahoma ranks 49th in health system performance. Sixty-four percent of rural hospitals face closure risk. The state has the worst breast cancer mortality in the nation. These are the conditions Oklahoma must transform with $223.5 million annually and what no other state possesses: 39 federally recognized tribes operating extensive health systems that already serve millions of rural residents. Cherokee Nation operates the largest tribally managed health system in the country. The question is whether tribal health integration accelerates transformation beyond what standalone state efforts could achieve, or whether Oklahoma’s near-worst starting position proves too steep a climb regardless of federal investment.

Summary: Oklahoma

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RHTP-17.OK — Fifty State Profiles
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Oklahoma received $223.5 million in FY2026 RHTP funding with a projected five-year total of approximately $1.12 billion. The state ranked third nationally in annual award amount, behind only Texas and California. At $240 per rural resident annually, Oklahoma’s per-capita allocation is among the most favorable among high-complexity transition states. Oklahoma ranks 49th in health system performance. Sixty-four percent of rural hospitals face closure risk. The state has the worst breast cancer mortality in the nation. These are the conditions Oklahoma must transform with what no other state possesses: 39 federally recognized tribes operating extensive health systems that already serve millions of rural residents.

Oregon

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Cluster 1: Low-Constraint Expansion States

Oregon enters the Rural Health Transformation Program with institutional infrastructure that most states would require a decade to build. Sixteen Coordinated Care Organizations already function as regional health authorities integrating physical, behavioral, and dental care across defined populations. The Oregon Health Authority operates with genuine cross-program authority and a payment reform orientation that predates RHTP. A dedicated Tribal initiative reserves 10 percent of funding for nine federally recognized tribes. And Governor Tina Kotek has demonstrated commitment to rural health through state investments targeting maternity care stabilization.

Summary: Oregon

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RHTP-17.OR — Fifty State Profiles
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Oregon received $197.3 million in FY2026 RHTP funding, slightly below the $200 million national average. At $253 per rural resident annually, Oregon places in the middle tier. The five-year total approaches $1 billion. Oregon enters the Rural Health Transformation Program with institutional infrastructure that most states would require a decade to build. Sixteen Coordinated Care Organizations already function as regional health authorities integrating physical, behavioral, and dental care across defined populations. The Oregon Health Authority operates with genuine cross-program authority and a payment reform orientation that predates RHTP.

Pennsylvania

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Cluster 2: High Medicaid Exposure States

Pennsylvania enters the Rural Health Transformation Program with the third-largest rural population in the nation, a provider landscape already experiencing contraction, and a Medicaid funding formula that makes it one of the most exposed expansion states to OBBBA’s fiscal provisions. The state’s 47.3:1 RHTP-to-Medicaid-cut ratio is not driven primarily by work requirements but by provider tax restrictions and state-directed payment caps that will compress hospital reimbursement rates in ways RHTP investment cannot offset. Understanding Pennsylvania’s trajectory requires understanding that this is fundamentally a payment crisis masquerading as a transformation opportunity.

Summary: Pennsylvania

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RHTP-17.PA — Fifty State Profiles
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Pennsylvania received $193.3 million in FY2026 RHTP funding, ranking fourth nationally in total award. The five-year projection reaches $967 million. At $107 per rural resident annually, the allocation is adequate for meaningful intervention but not for systemic transformation at Pennsylvania’s scale. Pennsylvania enters the program with the third-largest rural population in the nation (1.8 million residents across 48 rural counties), a provider landscape already experiencing contraction, and a Medicaid funding formula that makes it one of the most exposed expansion states to OBBBA’s fiscal provisions.

Rhode Island

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Cluster 1: Low-Constraint Expansion States

Rhode Island receives $6,248 per rural resident annually, a per-capita allocation 95 times what Texas receives. The state’s “rural” designation covers 18 towns totaling 196,000 people in the nation’s smallest state, communities that are 40 minutes from Providence rather than hours from any hospital. The formula that created the Rural Health Transformation Program produces its most extreme test case here: whether a program designed for frontier hospitals and agricultural communities can meaningfully transform healthcare in exurban New England towns with limited local capacity but reasonable proximity to urban providers.

Summary: Rhode Island

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RHTP-17.RI — Fifty State Profiles
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Rhode Island received $156.2 million in FY2026 RHTP funding with a projected five-year total of approximately $781 million. At $6,248 per rural resident annually, Rhode Island receives a per-capita allocation 95 times what Texas receives. The state’s “rural” designation covers 18 towns totaling 196,000 people in the nation’s smallest state, communities that are 40 minutes from Providence rather than hours from any hospital. The formula that created the Rural Health Transformation Program produces its most extreme test case here.

South Carolina

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Cluster 4: Non-Expansion High-Burden States

South Carolina stabilized its rural hospitals through state-directed payments. The mechanism allowed the state to use hospital provider taxes to boost Medicaid reimbursement rates to near-private-insurance levels, generating approximately $150 million annually in revenue that kept vulnerable facilities viable. This was not a permanent solution. It was a workaround within a fundamentally broken coverage architecture that the state has refused to fix through Medicaid expansion. The workaround worked. For two years.

Summary: South Carolina

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RHTP-17.SC — Fifty State Profiles
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South Carolina received $200 million in FY2026 RHTP funding with a five-year total of approximately $1.0 billion. At $125 per rural resident annually, the per-capita allocation falls below the national average. South Carolina stabilized its rural hospitals through state-directed payments, a mechanism that boosted Medicaid reimbursement rates to near-private-insurance levels, generating approximately $150 million annually in revenue that kept vulnerable facilities viable. This was not a permanent solution. It was a workaround within a fundamentally broken coverage architecture that the state has refused to fix through Medicaid expansion.

South Dakota

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Cluster 3: Frontier and Resource-Adequate States

South Dakota enters the Rural Health Transformation Program with a combination of conditions that most states cannot replicate. A 0.9:1 RHTP-to-Medicaid-cut ratio places it near parity between transformation investment and projected coverage losses. Medicaid expansion since November 2023, implemented via ballot initiative despite gubernatorial opposition. The fourth-lowest population density in the continental United States, but a hospital infrastructure that has avoided the closures plaguing peer states. $514 per rural resident annually provides meaningful per-capita investment without the extreme ratios that characterize the smallest rural populations. And a provider landscape dominated by three integrated health systems capable of deploying resources at scale.

Summary: South Dakota

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RHTP-17.SD — Fifty State Profiles
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South Dakota received $189.5 million in FY2026 RHTP funding with an estimated five-year total of approximately $950 million. At $514 per rural resident annually, the allocation provides substantial per-capita investment capacity that places South Dakota in the top tier nationally. A 0.9:1 RHTP-to-Medicaid-cut ratio places it near parity between transformation investment and projected coverage losses. These conditions permit something most states cannot attempt: genuine transformation rather than managed decline.

Tennessee

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Cluster 4: Non-Expansion High-Burden States

Tennessee enters the Rural Health Transformation Program with conditions that expose a question the state has avoided for seven years: what happens when a healthcare monopoly fails its accountability requirements and the state responds by lowering the requirements? Ballad Health operates 20 hospitals across a 29-county region spanning the Tennessee-Virginia border, serving 1.1 million residents with no competing hospital system. The Certificate of Public Advantage that waived antitrust protections in 2018 was granted in exchange for quality commitments, charity care obligations, and community benefit investments. Ballad has failed most of these commitments. The state has not enforced consequences.

Summary: Tennessee

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RHTP-17.TN — Fifty State Profiles
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Tennessee received $206.9 million in FY2026 RHTP funding with a five-year total of $1.03 billion. At $86 per rural resident annually, the allocation places Tennessee in the lower tier of non-expansion state per-capita funding. Tennessee enters the program with conditions that expose a question the state has avoided for seven years: what happens when a healthcare monopoly fails its accountability requirements and the state responds by lowering the requirements?

Texas

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Cluster 2: High Medicaid Exposure States

The state with the largest rural population in America, the highest uninsured rate in the nation, and the most rural hospitals at risk of closure receives the lowest per-capita RHTP allocation of any state at $65 per rural resident. Texas faces $31.3 billion in Medicaid cuts over ten years while receiving $1.4 billion in transformation funding, producing the program’s most severe mathematical mismatch between investment and erosion.

Summary: Texas

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RHTP-17.TX — Fifty State Profiles
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Texas received $281.3 million in FY2026 RHTP funding, the largest absolute award in the program, with a five-year total of approximately $1.41 billion. At $65 per rural resident annually, Texas has the lowest per-capita allocation of any state. Rhode Island receives $6,305 per rural resident. The state with the largest rural population in America, the highest uninsured rate in the nation, and the most rural hospitals at risk of closure receives the lowest per-capita RHTP allocation because the formula’s equal distribution of 50% of funding regardless of rural population size creates this mathematical reality.

Utah

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Cluster 3: Frontier and Resource-Adequate States

Utah approaches the Rural Health Transformation Program with a core financing principle that shapes everything the state proposes: use one-time funding to convert short-term investments into lasting operational efficiencies and policy reforms. This is not boilerplate grant language. Utah has built its reputation on delivering healthcare outcomes at lower cost than peer states. The RHTP application extends that efficiency orientation to transformation itself.

The question is whether efficiency principles designed for stable policy environments translate to an environment where Medicaid erosion, legislative hostility to expansion, and federal program uncertainty create instability that efficiency cannot optimize away.

Summary: Utah

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RHTP-17.UT — Fifty State Profiles
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Utah received $195.7 million in FY2026 RHTP funding, approximately $288 per rural resident annually. The five-year total approaches $1 billion. Utah approaches the Rural Health Transformation Program with a core financing principle that shapes everything the state proposes: use one-time funding to convert short-term investments into lasting operational efficiencies and policy reforms. Utah has built its reputation on delivering healthcare outcomes at lower cost than peer states. The RHTP application extends that efficiency orientation to transformation itself.

Virginia

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Cluster 2: High Medicaid Exposure States

Virginia frames rural health transformation primarily as a technology and infrastructure challenge. The CareIQ initiative alone commands $282 million for EHR modernization, telehealth expansion, and AI-powered clinical tools. This is the largest single initiative in Virginia’s application and among the most technology-heavy framings in the program.

The technology emphasis may be strategically correct. Virginia’s rural providers face documented infrastructure gaps that limit their capacity to participate in modern healthcare delivery. But technology deployment without concurrent workforce development is a documented failure mode, and Virginia’s 30.2:1 RHTP-to-Medicaid-cut ratio means the coverage foundation beneath these technology investments is eroding faster than any transformation can build.

Summary: Virginia

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RHTP-17.VA — Fifty State Profiles
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Virginia received $189.5 million in FY2026 RHTP funding, translating to $111 per rural resident annually and a five-year total of approximately $950 million. Virginia frames rural health transformation primarily as a technology and infrastructure challenge. The CareIQ initiative alone commands $282 million for EHR modernization, telehealth expansion, and AI-powered clinical tools. This is the largest single initiative in Virginia’s application and among the most technology-heavy framings in the program.

Vermont

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Cluster 1: Low-Constraint Expansion States

Vermont enters the Rural Health Transformation Program with conditions that most states would trade for without hesitation. Medicaid expansion since 2014. A unified Agency of Human Services with genuine cross-departmental authority. The nation’s most developed primary care infrastructure through the Blueprint for Health. Participation in CMMI’s AHEAD model providing a payment reform pathway through 2035. A governor with 74 percent approval who has championed healthcare transformation as fiscal pragmatism rather than ideological project. And $424 per rural resident annually, a per-capita allocation that places Vermont in the top tier of the program.

Summary: Vermont

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RHTP-17.VT — Fifty State Profiles
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Vermont received $195 million in FY2026 RHTP funding with an estimated five-year total of approximately $975 million. At $424 per rural resident annually, the allocation provides meaningful per-capita investment capacity. Vermont enters the Rural Health Transformation Program with conditions that most states would trade for without hesitation. Medicaid expansion since 2014. A unified Agency of Human Services with genuine cross-departmental authority. The nation’s most developed primary care infrastructure through the Blueprint for Health. Participation in CMMI’s AHEAD model providing a payment reform pathway through 2035. A governor with 74% approval who has championed healthcare transformation as fiscal pragmatism.

Washington

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Cluster 2: High Medicaid Exposure States

A tri-agency co-lead structure, the highest Medicaid exposure ratio among expansion states with high Medicaid burden, and a 2026 gubernatorial transition create implementation complexity that bipartisan application development cannot resolve.

Washington possesses the most favorable combination of enabling conditions of any state facing severe fiscal exposure: full nurse practitioner practice authority, CHW Medicaid billing through a 2024 State Plan Amendment, 29 federally recognized tribes with dedicated RHTP funding and government-to-government governance, a decade of value-based payment experience, full telehealth parity, and the University of Washington’s nationally recognized Rural Health Research Center. Very few states stack this many alternative architecture enabling conditions simultaneously. Oregon is the only comparable peer. Yet Washington’s 40.6:1 ratio means fiscal emergency may force conventional hospital triage rather than the alternative architecture deployment these conditions would enable. The tragedy is not lacking the prerequisites for transformation. It is having them and potentially never getting to use them.

Summary: Washington

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RHTP-17.WA — Fifty State Profiles
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Washington received $181.3 million in FY2026 RHTP funding, translating to $162 per rural resident annually and a five-year total of approximately $910 million. A tri-agency co-lead structure, the highest Medicaid exposure ratio among expansion states with high Medicaid burden, and a 2026 gubernatorial transition create implementation complexity that bipartisan application development cannot resolve.

Wisconsin

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Cluster 5: High-Complexity Transition States

Wisconsin designed its own path to universal coverage: BadgerCare Plus covers adults up to 100% of the federal poverty level while marketplace subsidies cover everyone above. The arrangement cost Wisconsin $1.9 billion per biennium in forgone federal matching funds but eliminated the coverage gap that plagues other non-expansion states. Now federal policy closes that path behind it. Work requirements arrive for the population Wisconsin already covers. Marketplace subsidies expire in 2026. Wisconsin receives $203.7 million for rural health transformation in a state where two hospitals and 19 clinics closed in a single month in 2024.

Summary: Wisconsin

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RHTP-17.WI — Fifty State Profiles
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Wisconsin received $203.7 million in FY2026 RHTP funding with a projected five-year total of approximately $1.02 billion. At $147 per rural resident annually, the allocation falls below the national average. Wisconsin designed its own path to universal coverage: BadgerCare Plus covers adults up to 100% of the federal poverty level while marketplace subsidies cover everyone above. The arrangement cost Wisconsin $1.9 billion per biennium in forgone federal matching funds but eliminated the coverage gap that plagues other non-expansion states. Now federal policy closes that path behind it.

West Virginia

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Cluster 5: High-Complexity Transition States

West Virginia’s overdose deaths dropped 42 percent between early 2024 and early 2025. That decline, the steepest in the state’s history, was driven by Medicaid. The 2018 Section 1115 waiver that opened Medicaid reimbursement for residential substance use treatment, medication-assisted therapy, and peer recovery support created the infrastructure that moved the state from national crisis epicenter toward measurable recovery. By 2022, MAT treatments had increased 137 percent from 2017 levels. The state added 1,800 Medicaid-reimbursed residential treatment beds and 330 behavioral health peer support professionals. Overdose fatalities in the twelve months ending February 2025 fell to 766, down from a pandemic peak above 1,500 in 2021.

Summary: West Virginia

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RHTP-17.WV — Fifty State Profiles
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West Virginia received $199.5 million in FY2026 RHTP funding, translating to $229 per rural resident annually. West Virginia’s overdose deaths dropped 42% between early 2024 and early 2025. That decline, the steepest in the state’s history, was driven by Medicaid. The 2018 Section 1115 waiver that opened Medicaid reimbursement for residential substance use treatment, medication-assisted therapy, and peer recovery support created the infrastructure that moved the state from national crisis epicenter toward measurable recovery. MAT treatments increased 137% from 2017 levels. The state added 1,800 Medicaid-reimbursed residential treatment beds and 330 behavioral health peer support professionals.

Wyoming

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Cluster 3: Frontier and Resource-Adequate States

Wyoming receives the second-highest per-capita allocation in the program at $554 per rural resident annually. It has the fewest rural residents to spend it on. The state confronts the question that per-capita funding adequacy cannot answer: how do you build a healthcare workforce in places where almost nobody lives? The perpetuity fund concept Wyoming proposed represents the most intellectually serious sustainability strategy any state has developed. Whether CMS permits it determines whether Wyoming’s contribution to the national RHTP conversation is innovation or deferral.

Summary: Wyoming

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RHTP-17.WY — Fifty State Profiles
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Wyoming received $205 million in FY2026 RHTP funding, the second-highest per-capita allocation in the program at $554 per rural resident annually, with a five-year total of approximately $1.02 billion. Wyoming is the least populous state in the nation and among the most geographically isolated. Its 370,000 rural residents are scattered across 97,813 square miles in what the state’s application describes as “a large archipelago spread out over a vast sea of sagebrush.” The state confronts the question that per-capita funding adequacy cannot answer: how do you build a healthcare workforce in places where almost nobody lives?

RHTP Series 17 | TD 17-A

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Lead Agency Verification Tracker: Section 1
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Technical Document | Series 17: Fifty State Profiles Production Support Document: Not for Publication Status: Complete: 50/50 Confirmed Last Updated: February 2026

Purpose
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This tracker provides the lead agency reference layer for all 50 Series 17 state profiles. Section 2 of each profile requires a confirmed lead agency designation, authority gap assessment, and source citation. This document consolidates confirmed agencies, flags structural anomalies relevant to the authority gap analysis, and notes five cluster assignment discrepancies between the YAML extraction and the Production Sequence.

Where the Analysis Lands

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Martha Samples is a care coordinator at a critical access hospital in West Virginia. She has worked there for fourteen years. She knows which patients will not come to appointments because they cannot afford the gas. She knows which families have lost Medicaid coverage and are rationing insulin. She knows that the hospital’s transformation plan, written in response to RHTP requirements, describes a telehealth expansion that depends on broadband infrastructure her county does not have and will not have before the plan’s deadlines arrive.

Fifty State Profiles on Syam Adusumilli

Alaska

Summary: Alaska

RHTP-17.AK — Fifty State Profiles #

Alabama

Summary: Alabama

RHTP-17.AL — Fifty State Profiles #

Arkansas

Summary: Arkansas

RHTP-17.AR — Fifty State Profiles #

Arizona

Summary: Arizona

RHTP-17.AZ — Fifty State Profiles #

California

Summary: California

RHTP-17.CA — Fifty State Profiles #

Colorado

Summary: Colorado

RHTP-17.CO — Fifty State Profiles #

Connecticut

Summary: Connecticut

RHTP-17.CT — Fifty State Profiles #

Delaware

State Context #

Summary: Delaware

RHTP-17.DE — Fifty State Profiles #

Florida

Summary: Florida

RHTP-17.FL — Fifty State Profiles #

Georgia

Summary: Georgia

RHTP-17.GA — Fifty State Profiles #

Hawaii

State Context #

Summary: Hawaii

RHTP-17.HI — Fifty State Profiles #

Iowa

Summary: Iowa

RHTP-17.IA — Fifty State Profiles #

Idaho

Summary: Idaho

RHTP-17.ID — Fifty State Profiles #

Illinois

Summary: Illinois

RHTP-17.IL — Fifty State Profiles #

Indiana

Summary: Indiana

RHTP-17.IN — Fifty State Profiles #

Kansas

Summary: Kansas

RHTP-17.KS — Fifty State Profiles #

Kentucky

Summary: Kentucky

RHTP-17.KY — Fifty State Profiles #

Louisiana

Summary: Louisiana

RHTP-17.LA — Fifty State Profiles #

Massachusetts

Summary: Massachusetts

RHTP-17.MA — Fifty State Profiles #

Maryland

Summary: Maryland

RHTP-17.MD — Fifty State Profiles #

Maine

Summary: Maine

RHTP-17.ME — Fifty State Profiles #

Michigan

Summary: Michigan

RHTP-17.MI — Fifty State Profiles #

Minnesota

Summary: Minnesota

RHTP-17.MN — Fifty State Profiles #

Missouri

Summary: Missouri

RHTP-17.MO — Fifty State Profiles #

Mississippi

Summary: Mississippi

RHTP-17.MS — Fifty State Profiles #

Montana

Summary: Montana

RHTP-17.AK — Fifty State Profiles
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RHTP-17.AL — Fifty State Profiles
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RHTP-17.AR — Fifty State Profiles
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RHTP-17.AZ — Fifty State Profiles
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RHTP-17.CA — Fifty State Profiles
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RHTP-17.CO — Fifty State Profiles
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RHTP-17.CT — Fifty State Profiles
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State Context
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RHTP-17.DE — Fifty State Profiles
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RHTP-17.FL — Fifty State Profiles
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RHTP-17.GA — Fifty State Profiles
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State Context
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RHTP-17.HI — Fifty State Profiles
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RHTP-17.IA — Fifty State Profiles
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RHTP-17.ID — Fifty State Profiles
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RHTP-17.IL — Fifty State Profiles
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RHTP-17.IN — Fifty State Profiles
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RHTP-17.KS — Fifty State Profiles
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RHTP-17.KY — Fifty State Profiles
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RHTP-17.LA — Fifty State Profiles
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RHTP-17.MA — Fifty State Profiles
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RHTP-17.MD — Fifty State Profiles
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RHTP-17.ME — Fifty State Profiles
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RHTP-17.MI — Fifty State Profiles
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RHTP-17.MN — Fifty State Profiles
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RHTP-17.MO — Fifty State Profiles
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RHTP-17.MS — Fifty State Profiles
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RHTP-17.MT — Fifty State Profiles
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State Context
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RHTP-17.NC — Fifty State Profiles
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RHTP-17.ND — Fifty State Profiles
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RHTP-17.NE — Fifty State Profiles
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RHTP-17.NH — Fifty State Profiles
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RHTP-17.NJ — Fifty State Profiles
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RHTP-17.NM — Fifty State Profiles
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State Context
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RHTP-17.NV — Fifty State Profiles
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RHTP-17.NY — Fifty State Profiles
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RHTP-17.OH — Fifty State Profiles
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RHTP-17.OK — Fifty State Profiles
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RHTP-17.OR — Fifty State Profiles
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RHTP-17.PA — Fifty State Profiles
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RHTP-17.RI — Fifty State Profiles
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RHTP-17.SC — Fifty State Profiles
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RHTP-17.SD — Fifty State Profiles
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RHTP-17.TN — Fifty State Profiles
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RHTP-17.TX — Fifty State Profiles
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RHTP-17.UT — Fifty State Profiles
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RHTP-17.VA — Fifty State Profiles
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RHTP-17.VT — Fifty State Profiles
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RHTP-17.WA — Fifty State Profiles
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RHTP-17.WI — Fifty State Profiles
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