Session Recap
Health & Human Services Committee
79th CSG West Annual Meeting
Salt Lake City, Utah
The Policy Challenge of Keeping Rural Health Alive
The challenges impacting rural health care in the West are not abstract. As legislators described during the session, communities across the region are confronting the real-world consequences of a strained system: hospital closures, shuttered maternity wards, and families driving hours to access care that is no longer available close to home. Committee Co-Chair Colorado Representative Matt Soper, who also chairs the board of a rural special district hospital in Colorado, framed it plainly—when a labor and delivery unit closes, it is not just a health care problem. It is an economic development problem, one that signals to a community that its future is uncertain.
Congress responded to this crisis with the Rural Health Transformation (RHT) Program—a $50 billion investment over five years designed to stabilize rural health infrastructure. But funding alone does not guarantee results. The criteria governing eligibility for RHT funding is broad, the oversight infrastructure in most states is still being built, and states are simultaneously projected to lose $137 billion in rural Medicaid funding over the next decade. The question is not whether the money arrived. The question is whether it is working—and whether anyone is watching closely enough to know.
That question anchored the CSG West Health and Human Services Committee session at the 79th Annual Meeting in Salt Lake City. Co-chaired by Washington Representative My-Linh Thai and Representative Soper, the session brought together Western legislators and Ben Eikey, Manager of State Training and Development at the Levin Center for Oversight and Democracy at Wayne State University.
Key Takeaways
1. The RHT Program is a once-in-a-generation investment, but funding alone does not guarantee outcomes.
The RHT Program provides $50 billion to states over five years to stabilize rural health infrastructure. But as Representative Soper made clear from the outset, the existence of funding does not ensure that it reaches the communities most in need. States are simultaneously projected to lose $137 billion in rural Medicaid funding over the next decade, with an expected 21% decline in Medicaid reimbursement to rural hospitals. The result is a fiscal environment in which the RHT Program must do significant work just to offset anticipated losses—not merely accelerate gains.
Because the eligibility criteria are broad, RHT funding could theoretically flow to an urban-based entity, such as a university research center, rather than a rural hospital or clinic struggling to remain open. As Representative Soper observed, some Colorado providers are weighing whether to pursue new technology grants at the expense of sustaining essential services like labor and delivery. Without active legislative oversight, implementation may diverge significantly from legislative intent.
- Federal investment: $50 billion in federal RHT funding over five years
- Medicaid pressures remain significant: States are projected to lose $137 billion in rural Medicaid funding over the next decade
- Rural hospitals face reimbursement cuts: Medicaid reimbursement to rural hospitals is expected to decline by 21%
- State-directed payments are limited: Only 15% of RHT funds may be used for state-directed payment
2. Proactive oversight—not reactive response—is the standard legislators should set now.
Most legislative oversight is reactive: a program fails, a problem emerges, and the legislature scrambles to respond. The RHT Program offers a different opportunity. Legislators know the funding is coming, they know the pressure on rural health systems is intensifying, and they know implementation will unfold over years. This creates a narrow window to address problems before they become crises.
Eikey framed this as the session’s central argument: the most effective oversight is fact-based, bipartisan, forward-looking, and solution oriented. It views oversight not as a confrontational posture, but as a continuous process that unfolds alongside implementation rather than in response to its failures. Several of his ten best practices resonated strongly during the discussion:
- Prioritize information gathering over confrontation
- Treat oversight as a continuous process, not a single hearing
- Institutionalize the use of evidence, including audits and performance evaluations
- Assign oversight of the RHT Program to a specific legislative entity—a task force, committee, or interim study—and give it responsibility throughout implementation
- Require agencies to regularly report key metrics and monitor early warning signs, including hospital closures, rising ER utilization, behavioral health access gaps, and eligibility processing backlogs
- Conduct field hearings and site visits to hear directly from hospital administrators, Medicaid recipients, disability advocates, and rural EMS providers
3. Western states are already developing oversight models and learning from each other.
A structured state-by-state discussion revealed a range of approaches already underway across the region.
- Utah: Established a dedicated legislative oversight committee for the RHT Program, which held its first meeting in June 2026 and a second in July, with the next grant application cycle already on its radar.
- Alaska: Implemented a deliberative partnership between the legislature and the department administering RHT funds, with an advisory council representing both legislative and major provider groups.
- New Mexico: Built behavioral health and Medicaid trust funds to insulate those systems from oil-and-gas revenue volatility, while highlighting its All-Payer Claims Database as a tool for evaluating program impact.
- Hawaii: Proactively overhauled its air ambulance system in anticipation of RHT eligibility, while navigating federal rules around duplication of existing state services.
- Washington: Shared a sobering example of Centers for Medicare & Medicaid Services (CMS) rulemaking impact: funding intended for 1,500 vulnerable individuals was reduced to 90 eligible recipients under new federal rules, forcing the legislature to revisit allocations in the next session.
Colorado’s experience offered a cautionary note: even when a legislature passes a law requiring hospitals to report service line closures, the resulting reports can be presented in a format so opaque they offer little practical value. Effective oversight requires not just reporting requirements, but requirements that specify how information must be presented.
“Unless you were to actually look at the raw data… what we actually ended up getting was not that useful. It was like, ‘That’s nice,’ a five-minute read and move on. What else?”
— Representative Matt Soper, Colorado
4. The tools for oversight already exist—legislators need to use them.
One of the session’s most practical contributions was a clear taxonomy of the six avenues through which state legislatures can conduct oversight: oversight partners (such as ombudsman offices, legislative auditors, performance evaluators), the appropriations process, committee oversight, advice and consent, contract monitoring, and administrative rule review. Eikey placed particular emphasis on contract monitoring, as the bulk of RHT funding will flow through contracts and grants that may be invisible to the legislature without active tracking requirements.
The discussion also highlighted a striking practical reality: when one state legislative auditor asked how many active contracts existed statewide, no one had the answer because no agency or office had been assigned to track them. The lesson for RHT oversight is direct: never assume someone else is counting.
State examples illustrated what strong oversight looks like in practice:
- Montana: A 2018 legislative audit of the state’s Medicaid program identified weaknesses in eligibility verification and provider oversight, leading to reforms that measurably improved program integrity.
- Idaho: The Office of Performance Evaluations established a structured, transparent Medicaid rate review process, moving from reactive problem-solving to routine monitoring.
- New Mexico: A legislative finance unit conducted a secret shopper survey revealing Medicaid patients made an average of six phone calls to secure a primary care appointment—and sixteen calls to access behavioral health services.
- Indiana: An interim task force on healthcare costs produced recommendations that were substantially implemented, and the state continues to monitor healthcare affordability trends.
5. Mental health and crisis care remain urgent priorities— Utah offers a model worth watching.
The session closed with a preview from Utah Representative Steve Eliason of the CSG West Annual Meeting policy tour to the Huntsman Mental Health Institute’s Crisis Care Center—a facility he described as potentially the nation’s crown jewel of crisis care. The center operates 24 inpatient beds alongside a no-refusal crisis stabilization unit with 30 to 35 recliners that accepts law enforcement drop-offs and walk-ins alike. It has served approximately 12,000 patients since opening just over a year ago, with all insurance carriers and Medicaid voluntarily covering the cost of services.
Eliason traced the facility’s origins to a 2019 visit to a crisis receiving center in Nashville, illustrating how some of the most powerful policy models emerge. Legislators see existing models firsthand, ask thoughtful questions, identify opportunities for improvement, and adapt those lessons to meet the needs of their own states.
What’s Next for Rural Health Oversight in the West?
The RHT Program is still in its early stages and in most states the oversight infrastructure is still being built. The window for proactive action is now and legislators who are not yet engaged have an opportunity to act before implementation decisions become difficult to reverse.
- Second-round RHT grant applications are already underway: Legislators who were not involved in reviewing the first round should prioritize securing that role before the next application cycle closes.
- CMS rulemaking continues to evolve: Washington experience—where 1,500 intended beneficiaries became just 90 eligible recipients under new federal rules—demonstrates how regulatory changes can reshape legislative intent without active monitoring.
- Payment error rates warrant close attention: Under H.R. 1, states whose payment error rates exceed specified thresholds face reductions in RHT allocations, creating a direct fiscal incentive for compliance oversight.
- Behavioral health access in rural communities remains at acute risk: Legislators should treat it as a leading indicator of broader system stress.
The CSG West Health and Human Services Committee will continue advancing these conversations. Drug pricing and 340B program reform, which Representative Thai identified as growing priorities, are on the agenda for future sessions. Ben Eikey and the Levin Center’s State Oversight Academy remain available as resources for states building or refining their oversight frameworks.