This blog series takes a closer look at targeted health priorities being advanced by states in their Rural Health Transformation program (RHTP) applications. As authorized under the One Big Beautiful Bill Act (OBBBA), the Centers for Medicare and Medicaid Services (CMS) will provide states with $50 billion over 5 years to strengthen and modernize health care in rural communities. Each state developed a plan in their applications to expand health care access, strengthen workforces, build infrastructure and technology, and support care delivery innovation within rural communities. CMS has awarded RHTP funds to states for the first year, ranging from $147 to $281 million.
Rural Health Resources
Primary care is a critical source of health care for rural communities. Research shows that primary care both improves health outcomes — including reduced hospitalizations and management for chronic disease — and lowers health care costs for patients.
Rural populations face unique challenges that limit access to primary care. These barriers include distance to care, provider shortages, or a lack of broadband that may limit virtual care. Through the recent opportunity of the Rural Health Transformation Program (RHTP), many states are investing in primary care infrastructure and advancements to address these rural-specific barriers while also aligning with broader state primary care priorities.
Current State Efforts to Improve Primary Care Access
States have already made progress in implementing strategies to develop and strengthen primary care delivery systems. These priorities, outlined in NASHP and Milbank Memorial Fund’s report, Implementing High-Quality Primary Care: A Policy Menu for States, may be further advanced through state RHTP plans. Priorities include:
- Strengthening partnerships and cross-sector coordination
- Reforming payment and delivery systems
- Reducing barriers to care
- Developing and advancing the primary care workforce
- Building provider capacity and integrating services
Primary Care and Rural Health: Key Themes in State RHTP Plans
Improving Coordination of Care between Primary Care, Specialty Care, and Behavioral Health
Coordination of care between primary care providers and other specialty care, including behavioral health, improves overall health outcomes and ensures patients get connected to proper services, regardless of their point of entry into the healthcare system. States may use RHTP funds to improve coordination through network- and relationship-building or implementing integration models into existing primary care practices.
- Arkansas proposed the PACT initiative (Promoting Access, Coordination, and Transformation), which integrates primary care, specialty care, preventive screenings, and telehealth services into rural communities while fostering locally driven Clinically Integrated Networks to improve efficiency, data sharing, and regional collaboration. NASHP’s Rural Health Transformation Program: State Focus on Behavioral Health blog post also highlights opportunities to integrate behavioral health into primary care settings.
Reforming Payment and Delivery Systems
States are increasingly looking to move away from traditional fee-for-service payment models, which reward higher volumes of service delivery, to value-based payment (VBP) models, which incentivize high quality team-based care for patients. VBP implementation, however, requires significant upfront investment in both infrastructure and staffing, often limiting providers’ ability and desire to make the switch. The RHTP offers a funding source that could be used to support the development of value-based payment (VBP) models or fund resources and technical assistance in support of practice transformation.
- North Carolina’s proposed initiative will provide technical assistance, infrastructure funding, and coordination of regional coalition networks to develop and administer paired rural VBP strategies to build capacity for rural primary care providers and hospitals.
Developing and Advancing the Primary Care Workforce
Nearly all rural counties face critical shortages of health professionals, including primary care providers (PCPs), who are less likely to practice in rural areas due to limited resources and financial disincentives. Through the RHTP, states may reduce barriers to joining the primary care workforce by implementing recruitment and residency incentives and offering training and retention programs in rural areas.
- Delaware’s proposed initiative creates the state’s first medical school with a Primary Care-Rural Health track and offers financial awards to Delaware medical students who commit to practicing in rural areas after graduation.
Expanding Access to Services through Partners
Primary care services delivered through trusted community partners or non-traditional settings, such as schools, mobile units, and certified community behavioral health centers (CCBHCs), may better reach rural community members who otherwise lack access to a usual source of primary care. States can use RHTP program funds to explore these partnerships through pilot programs or by supporting staffing and infrastructure improvements through existing relationships.
- A proposed initiative in Minnesota’s plan will use mobile units to deliver local care for physical and oral health. Kansas proposed to leverage the state’s already robust community health worker (CHW) program by deploying CHWs in rural primary care clinics and CCBHCs at the rate of 20 per year.
Reducing Barriers to Care through Technology Upgrades
Telehealth services can eliminate some of the unique challenges rural communities face in accessing primary care, such as distance to care and travel considerations. At the same time, many rural communities lack the technology infrastructure for both delivering and receiving telehealth services. RHTP funding may be used to enhance telehealth infrastructure and technology capabilities in both practice and community settings.
- A proposed initiative in Georgia creates access points to primary care in rural, underserved communities by collaborating with local rural health care providers to place telehealth point-of-service primary care pods where a brick-and-mortar clinic is not feasible.
Investing in Existing Primary Care Practices through Infrastructure or Seed Funding
Primary care practices may lack funding and resources to invest in practice improvements, which can include technology improvements, capital upgrades, or updated certifications. RHTP funding offers an opportunity for states to invest directly in existing practices, promoting sustainability and better positioning them to be a reliable source of care for rural community members for years to come.
- A proposed initiative in Maryland will provide seed funding to support providers as they fill patient panels and advance their practices. This will ultimately achieve sustainability for salaries and operational costs through billing for services and realizing earned savings through value-based care arrangements and alternative payment model.
States with Comprehensive Approaches to Primary Care in RHTP Plans
Both Alaska and Maine’s proposals feature investments across several priority areas in primary care, including workforce solutions, payment reform, coordination across providers, and decreasing barriers to care.
- Proposed initiatives in Alaska include investing in primary care workforce and facility improvements, creating telehealth-enabled specialty care access programs, scaling value-based care programs, and supporting regional care coordination.
- Proposed initiatives in Maine include development of a statewide virtual quick care telehealth program, development of an alternative payment model that moves away from fee-for-service payment, weekly primary care co-location within CCBHC sites, and specialist consultation services for primary care clinicians.
Next Steps: NASHP’s Continued Work in Rural Health and Primary Care
Having only recently been awarded funding from CMS, states are in very early stages of RHTP implementation. As states move forward with implementing plans, it will be important to engage primary care associations and other key partners to inform primary care-related investments and programs in the RHTP. States can also support a comprehensive primary care strategy by coordinating with external and internal partners to ensure alignment of goals and strategies.
NASHP will continue to support states across primary care and broader rural health policy spaces. For more information on NASHP’s primary care related work, including an opportunity to join a state-only learning network focusing on increasing access to primary care in rural communities, please fill out this interest form.
Note: The examples highlighted here are taken from publicly available state RHTP applications prior to December 29, 2025. These strategies may continue to evolve, as states finalize plans and begin implementation of activities in the coming months.
