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The past few weeks have been monumental in terms of proposed changes to federal healthcare legislation. In an attempt to stay current with how things could change on that front, I've put together some thoughts on the fiscal year 2025 budget reconciliation bill, otherwise known as the "Big Beautiful Bill." The bill itself is broad and sweeping, so I've chosen to focus on the healthcare implications of the bill's provisions.

Before you run away with your hands in the air yelling, "No more politics!" I've tried to turn down the political temperature and focus on facts and figures; specifically, we'll zoom in on how the bill would affect rural healthcare providers.

As I alluded to off the top, on May 22 the House of Representatives passed the fiscal year 2025 budget reconciliation bill. I'm going to resist calling the bill by its more marketing-friendly name, the "Big Beautiful Bill," and will instead refer to it as the "BBB."

In its current form, the BBB enacts deep cuts to several programs including Medicaid. According to a recent report by the Georgetown University Center for Children and Families (CCF), the bill cuts federal support for Medicaid by $800 billion over 10 years.

That's concerning enough, but aspects of Medicare, the Affordable Care Act (ACA), and Health Savings Accounts are also in the crosshairs. For starters, the bill doesn't extend the enhanced premium tax credits, also known as ACA marketplace subsidies, past 2025. According to the Center on Budget and Policy Priorities, these tax credits help "more than 22 million people buy insurance on the marketplace."

At the end of the day, millions of people would likely lose their health insurance.

In a recent opinion piece on MSNBC, the authors noted that if significant cuts are made to Medicaid, it would create a "domino effect, leading to inferior, more expensive health care — and, therefore, worse health — for virtually all Americans, including those with insurance provided by their employers."

It's important to note that the BBB, which passed the House narrowly and now faces opposition by deficit hawks in the Senate, is due to be voted on this week by the upper chamber. If only a few conservative senators break ranks with their party, there's a chance this legislative process will temper the proposed cuts to healthcare. But in the unlikely event that all provisions are kept intact, we're looking at a very different federal insurance environment from the one we've known for many years.

The impact of such a bill, says the MSNBC article, wouldn’t just be felt by individuals: state governments, hospitals, and health workers would also feel the pinch. In other words, healthcare would be asked to do more with fewer resources. And if people start losing their insurance, it will l likely have a cascading effect across all of medicine.

This idea of a domino effect is one I've seen discussed often: reducing federal matching funds for the ACA Medicaid expansion, for instance, or instituting work requirements make it harder for people to qualify for insurance. The uninsured become sicker and seek care in emergency departments, hospitals can't collect money from low income patients, and healthcare gets more expensive for everyone.

Among the biggest potential losers in the scenario outlined above are rural healthcare providers. That's because there is a very real possibility that, if the House bill passes the Senate and is signed into law by the president, many rural hospitals and health clinics across the country will he forced to curtail services.

A recent article in The Hill made the stakes clear:

"Nineteen percent of Americans, or over 72 million, are insured by Medicaid and the share of the 66 million rural Americans on Medicaid is even higher at 23 percent."

The article goes on to cite a June 2025 study by the Center for Healthcare Quality and Payment Reform that estimates that over 300 rural hospitals face an “immediate risk” of closure – and this after nearly 200 rural hospitals have already closed in the last twenty years. The majority of these hospitals are in states that didn't expand Medicaid under the Affordable Care Act.

Now that we have a solid background on what the BBB is all about, let's look at rural health data from Data.gov to examine trends in what are called Rural Health Clinics (RHCs). While these clinics primarily care for Medicare patients, given the instability that the BBB could cause no matter what type of insurance a given person may have, these entities might feel the reverberations.

It's helpful to get a baseline for how many entities have enrolled as RHCs over the past few years so that, if some form of the BBB should become law, we can track how many of them remain in the program going forward.

Since we're looking at CMS data, that organization defines RHCs as follows:

"For RHC purposes, any area that is not defined by the U.S. Census Bureau as urbanized is considered non-urbanized. RHCs are located in areas that are designated or certified by the Secretary of the Department of Health and Human Services as Health Professional Shortage Areas (HPSA) or Medically Underserved Areas (MUA). A Clinic cannot be Medicare approved concurrently as a RHC and a Federally Qualified Health Center."

Federally Qualified Health Centers are distinct from RHCs in the following ways:

"Medicare-certified rural health clinics (RHC) are located in a rural areas (sic) designated as a shortage area, is not a rehabilitation agency or a facility primarily for the care or treatment of mental diseases. Federally qualified health centers (FQHC) are located in both rural/urban areas designated as a shortage area."

It may be worthwhile charting state-level changes in FQHCs as well, but for now we'll confine our exploration to RHCs. Let's first look at the top five states in which RHCs operate. These states include Kentucky, Texas, Missouri, Tennessee, and Illinois, respectively. In the graph below I've tracked the number of RHCs registered in each of these states between 2023 and 2025.

Data courtesy of Data.gov

To make it easier to see how these top five states stack up, I've put their numbers together in table form:

Data courtesy of Data.gov

There isn't much surprising about these numbers, aside from the fact that besides Missouri, every state has gained more RHCs each year. For a look at the states with the largest changes in enrollment, I made a chart showing the five states with the biggest changes in terms of percentage (North Carolina, Indiana, Arkansas, New Hampshire, and Utah). The chart also shows the five states with the largest percentage drop in the number of RHCs. It will be interesting to track this as the BBB makes its way through Congress and, possibly, to the president's desk.

Data courtesy of Data.gov