Austin internist Maria Monge, MD, is hopeful new federal funding could close gaps in rural care in Texas – with a few important conditions.
According to a Texas Medical Association analysis, 10% of the state’s population lives in designated rural counties, with a direct patient care physician for every 1,128 people. By comparison, nonrural counties have one direct care physician for every 465 people.
A federal initiative aims to close that health care inequity. Starting this year, the Rural Health Transformation Program (RHTP), created by the One Big Beautiful Bill Act (OBBBA), will provide up to $50 billion distributed among all approved U.S. states over five years, $10 billion per year. The funding is meant to help states redesign and strengthen their rural health care systems by improving access, quality, workforce, innovation, and technology.
To be eligible for funding, states had to submit a one-time application to the Centers for Medicare & Medicaid Services (CMS). The Texas Health and Human Services Commission (HHSC) sought public comments from stakeholders, including TMA, to contribute ideas for how the state should apply for funding to bolster rural health care and filed one sweeping application on Nov. 6, 2025.
TMA was “instrumental” in helping to provide feedback and support proposals to HHSC by the Texas Public Health Coalition (TPHC), said Dr. Monge, TPHC chair. The coalition, of which TMA is a member, is comprised of over 30 health professional organizations dedicated to disease prevention and health promotion in Texas.
“TMA did a fantastic job of reaching out to rural physicians for input and then bringing that back to incorporate into [that feedback],” said Dr. Monge, vice chair of TMA’s Council on Science and Public Health.
Texas’ application, “Rural Texas Strong: Supporting Health and Wellness,” requested $1 billion in total over the course of the five-year program. The plan includes six key initiatives covering each of Texas’ 202 rural counties (the state has 254 counties in all). The initiatives include:
- Grants to rural hospital districts that fund initiatives to reduce chronic disease through prevention, wellness, and nutrition services;
- Investments into technology that will establish patient-facing health portals that facilitate health information exchanges between patients, physicians, and payers;
- Efforts to invest in and support artificial intelligence technologies used to bridge service gaps in rural communities;
- Workforce recruitment and retention efforts that attract rural health care workers through career development, scholarships, relocation payments, and training programs;
- Initiatives that improve rural cybersecurity defenses to protect patient data; and
- Upgrading equipment in rural hospitals and clinics.
“Rural health care is critical for the continued health and well-being of Texans across our great state,” said Gov. Greg Abbott in a press release. “To keep Texas thriving, we must strengthen our rural hospitals, expand access to critical mental and physical health care, and help reduce chronic disease through wellness and nutrition initiatives. Working with our federal partners, we will ensure Texans from every corner of the state have greater access to the quality health care services they need and deserve.”
Texas’ final submission did include chronic disease prevention initiatives that TPHC advocated for in its public feedback to HHSC. Although TMA’s suggestion for creating a new state grant program to fund dedicated rural physician training tracks was not included, the association is analyzing the potential for one of HHSC’s stated goals to create residency and fellowship programs in rural areas.
Per CMS, states’ applications must have addressed at least three of the RHTP’s goals to:
- Support evidence-based rural health initiatives that promote preventive health and address root causes of diseases;
- Help rural clinicians become long-term access points for care by improving efficiency and sustainability;
- Attract and retain the health care workforce by strengthening recruitment and retention of medical professionals in rural communities;
- Spark the growth of innovative care models to improve health outcomes, coordinate care, and promote flexible care arrangements; and
- Foster use of innovative technologies that promote efficient care delivery, data security, and access to digital health tools by rural facilities, clinicians, and patients.
CMS based initial workload funding amounts on the information provided in the grant application and government data sets. A total of 23 factors were considered in the prioritization process, encompassing three major areas. One is data that describes the rural nature of a state, such as the size of the rural population – for which Texas leads the nation. The other major areas included the strength of the program initiatives presented in the state’s grant application and current state policies.
Half of the $50 billion in allotted funding will be distributed equally among all approved states with the remaining half allocated through a grant process by CMS based on unique factors, including the percentage of the state’s population that is in a rural area, the amount and condition of rural health facilities in the state, and other factors to be specified by CMS.
Texas’ application includes a strategy for transforming rural health that focuses on “the next generation of the small-town doctor and team.” While this is not fully explained, TMA is evaluating other portions of the state application indicating independent physician practices may be eligible for funding opportunities, along with hospitals, rural health clinics, federally qualified health centers, behavioral health providers, and a list of other entities. Still other initiatives hint at ways to boost Medicaid payment rates for rural physicians and hospitals.
Amarillo family medicine physician Rodney Young, MD, regional chair of the Texas Tech University Health Sciences Center’s Department of Family and Community Medicine, is “cautiously optimistic” that federal funding will help support Texas’ rural communities and Texas will find ways to “create opportunities for physicians to go to rural areas.”
“We are long overdue for attention to be given to health care access in rural areas. Hopefully this infusion of resources will give us the opportunity to do some things that we have been unable to do because of limited resources,” he said.
Meanwhile, TMA is reviewing what appears will be a competitive process for physicians and others to apply for any federal funds Texas receives, should CMS approve the state’s application. As of this writing, CMS was expected to announce RHTP awardees by Dec. 31, 2025. (Read Texas Medicine Today for updates.)
Since any funding Texas receives will expire in five years, however, Dr. Young has reservations that unless ongoing methods of financial assistance are identified, programs started under the federal transformation program could be left without support.
“The wise use of the money will be to go to programs that hopefully are able to be sustained with other funding pathways, whether those are local or through the state,” the TMA’s Board Trustee said.
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