How do we ensure access to affordable, high quality healthcare for rural residents? How can
Medicare and Medicaid reimbursement methods allow rural healthcare facilities to keep their doors
open? How can we attract healthcare providers to rural communities? Questions like these, along with countless
others, are the basis of rural health policy.
Rural health policymaking takes place at the federal, state, and local levels of government. The process
includes defining a problem, collecting data, researching solutions, choosing a course of action, implementing
the plan, and
evaluating the results. During each step, policymakers must weigh economic, political, social, legal, ethical,
and administrative factors. Formulating rural health policy involves many people and organizations,
- Lawmakers and elected officials
- Government agencies
- Membership associations
- Rural health researchers
- Rural healthcare providers
- Rural patients
- Rural individuals, community-based organizations, businesses, and other stakeholders
These groups work individually and collectively to identify improvements to the provision of healthcare services
in rural communities.
Frequently Asked Questions
What types of issues does rural health policy address?
Rural health policy addresses many of the same issues as the broader realm of health policy, such as access to care, quality
improvement, cost containment, and healthcare system redesign. However, rural health policy focuses specifically
on how policy choices affect rural communities, populations, and healthcare facilities. Health policy issues of
interest for rural stakeholders include:
It is important to remember, however, that policy issues change over time. As one problem is addressed through
policy channels, other problems persist and new issues emerge. Priorities may shift when there is a change in
the political leadership. Changes in public sentiment also play a role in determining which issues receive
What role does the federal government play in the rural health policy process?
At the federal level, the Executive, Legislative, and Judicial Branches of
government conduct the formal policymaking process.
Headed by the President of the United States, the Executive Branch plays a strong leadership role in the
policymaking process. The Executive Branch is charged with executing and enforcing the laws as passed by
Congress. Executive departments and agencies assist the President in carrying out the daily administrative
tasks of the federal government. Through the annual executive
budget process, the President is able to set national spending priorities. How the President
chooses to allocate resources during his/her tenure can have a major impact on rural healthcare. Another
important role of the executive branch is the rulemaking
process, which allows federal agencies to determine how laws and policies are interpreted and
implemented after receiving public input on proposed rules.
The Legislative Branch of government, or Congress, is composed of two chambers: The U.S. House of
Representatives and the U.S. Senate. Elected representatives within each chamber carry out the formal legislative process at the
federal level. All federal legislative powers are granted solely to Congress. Congress also holds the
“power of the purse,” controlling federal government spending through the appropriations process. At least 11
committees between the House and Senate have some influence over various aspects of rural health policy. The
informally organized, bipartisan Senate Rural Health Caucus
and House Rural Health Care Coalition help focus legislative attention and provide a forum for
addressing rural healthcare issues. Several agencies within the Legislative Branch, such as the Congressional Budget Office (CBO) and Library
of Congress (LOC), provide support and information services to members of Congress.
Composed of the Supreme Court of the United States and other federal courts, the Judicial Branch interprets
the meaning of laws, applies laws to specific cases, and determines the constitutionality of
legislation and regulations. Decisions issued by federal courts sometimes affect health policy and rural
healthcare in substantial ways.
What is the role of the Federal Office of Rural Health Policy (FORHP)?
Operating within the Health Resources and Services Administration (HRSA), the Federal Office of Rural Health Policy
(FORHP) was created by Section 711 of the Social
Security Act in 1987, and is charged with the following tasks:
Inform and advise the Secretary of the U.S. Department of Health and Human Services (HHS) on matters
affecting rural healthcare and hospitals.
Coordinate activities within HHS that relate to rural healthcare.
Establish and maintain a rural health information clearinghouse.
Administer grants, cooperative agreements, and contracts to provide technical assistance and other
activities that support healthcare in rural areas.
In this unique capacity, FORHP serves as a voice for rural communities in federal actions related to health and
healthcare. Another primary function of FORHP is providing management and support services for the National Advisory Committee on
Rural Health and Human Services (NACRHHS). NACRHHS is a 21-member panel of rural experts that
provides recommendations to the Secretary of HHS on issues related to rural health and human services.
Which federal agencies participate in the rural health policy process?
Along with the Federal Office of Rural Health
Policy (FORHP), the following agencies work to address rural health policy issues:
U.S. Department of Health and Human Services Agencies
Agency for Healthcare Research and Quality (AHRQ)
Works collaboratively to make healthcare affordable, safer, higher quality, equitable, and more accessible
through evidence-based research.
Centers for Disease Control and Prevention (CDC)
Conducts research and provides health information to protect Americans from health, safety, and security
Centers for Medicare & Medicaid Services (CMS)
Administers Medicare, Medicaid, the Children's Health Insurance Program (CHIP), and the Health Insurance
Marketplace. Within CMS, the Rural Health Council works to ensure CMS initiatives appropriately address
rural healthcare concerns. In addition, the CMS
Innovation Center supports the development and testing of new healthcare payment and service
Health Resources and Services Administration (HRSA)
Works to improve health and healthcare access to people who are geographically isolated and/or economically
or medically vulnerable through its various bureaus. In addition to FORHP, HRSA contains the Bureau of Health Workforce (BHW) and Bureau
of Primary Health Care (BPHC), which runs the community health center program, as well as the Maternal and Child Health Bureau (MCHB).
Indian Health Service (IHS)
Provides health services to American Indians and Alaska Natives.
National Institutes of Health (NIH)
Provides leadership, direction, and funding for programs designed to improve the health of the U.S. by
supporting research in human diseases; human growth and development; the biological effects of environmental
contaminants; mental, addictive, and physical disorders; and the collection, dissemination, and exchange of
information in medicine and health. Consists of 27 Institutes and Centers, including the National Institute on Aging, National
Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), and the National Institute on Minority Health and Health Disparities
Office of the Assistant Secretary for Planning and Evaluation
Advises the Secretary of the Department of Health and Human Services on health, human services, and science
and data policy development. Conducts research and evaluation, develops policy analyses, and estimates the
cost and benefits of policy alternatives under consideration.
Substance Abuse and Mental Health Services Administration (SAMHSA)
Provides leadership and supports programs and services to advance behavioral health nationwide. Works to
reduce the impact of substance use disorders and mental illness through prevention, treatment, and
Other Executive Branch Departments and Offices
Office of National Drug Control Policy (ONDCP)
Leads and coordinates national drug control policy and is part of the Executive Office of the President.
U.S. Department of Agriculture (USDA)
Works to provide economic opportunity through innovation, and provide leadership on issues related to food,
agriculture, natural resources, rural development, and nutrition. Agencies within the USDA that
emphasize rural health-related issues include the Economic Research
(ERS), Food and Nutrition Service (FNS) and Rural Development (RD).
U.S. Department of Housing and Urban Development (HUD)
Supports rural hospitals through the Federal Housing Administration's Section 242 Mortgage Insurance for
U.S. Department of Transportation (DOT)
Works to ensure an accessible, safe, convenient, and reliable transportation system that serves vital
national interests. Supports rural healthcare, particularly rural emergency medical services, through the
National Highway Traffic Safety Administration's (NHTSA) Office of EMS.
Veterans Health Administration Office of Rural Health (VHA
Works to improve rural veterans' access to quality healthcare.
Independent Congressional Agencies
How does the rural health policymaking process work?
An issue or idea related to rural health may emerge through research findings or concerns expressed by groups or
individuals. Oftentimes, because of their advocacy function, membership organizations raise awareness of issues
in the public arena. There
are countless ways in which an issue may come to the forefront, and rarely do two policies follow the exact same
At the federal level, once a problem and potential policy solution are identified, policymakers in the U.S. Senate and U.S. House of
Representatives may craft legislation intended to address the issue. This legislation development
process often includes input from a variety of experts and interested parties, including through Senate or House committee hearings, where witnesses invited
for their expertise or viewpoint provide testimony and answer questions. If the legislation is passed,
signed by the President, and becomes law, then federal agencies with jurisdiction over the related policy or
program will be called upon to administer regulations and enforce the law. To increase the likelihood of getting
passed, rural health legislation commonly becomes part of a larger bill such as an appropriation bill.
Occasionally, the President may issue executive actions to implement policy. On the federal level, executive orders are often instructions
directing federal agencies to conduct certain policy actions and are published along with regulations in the Federal Register.
State-level policymaking involves many players. Policies become law once approved by the state's legislative
body and signed by the state's governor. Regulation and enforcement of state-level policies becomes the
responsibility of state agencies, similar to the process at the federal level. However, due to a level of state
sovereignty as defined by U.S. law, variation amongst enforcement methods exists between states. Table 4.5 in
the Council of State Governments' The Book of
the States provides a state-by-state overview of the powers of governors to
issue executive orders.
At both the state and federal levels, the process of identifying and addressing issues through policy is
iterative. Each time a change is made, policymakers, researchers, and interested parties examine the results,
look for ways to improve the solutions, and begin the process again. Evaluation and data reporting requirements
for federally-funded programs and rural health research help support this process.
How do researchers support rural health policy?
Rural health researchers focus their efforts on identifying, understanding, and solving problems related to the
provision of healthcare in rural communities, as rural areas face many unique healthcare challenges. Research findings help
inform policymakers and stakeholders about
disparities or other prevalent issues that should be addressed. Additionally, research related to rural
populations and rural healthcare facilities helps forecast the effects of policy on rural healthcare access, and
predicts potential unintended consequences of proposed policies.
Researchers may also be tasked with evaluating program performance. In this role, researchers identify which
programs and methods are effective, and which are not. The evaluation process helps facilitate
best practices and ensures resources are being used in the most effective manner.
Through the Federal Office of Rural Health Policy, the federal government funds a number of rural health research centers and analysis
initiatives across the U.S. For information about current rural health research projects, please see
the Rural Health Research Gateway. For additional
information about rural health research, see the Conducting
Rural Health Research, Needs Assessment, and Program Evaluation topic guide.
What role do membership organizations play in advocating for rural health issues?
Membership organizations work with policymakers to inform them on issues and challenges affecting the rural
health community. These organizations often communicate important messages by producing documents, sponsoring or
attending conferences, maintaining an online presence, and communicating directly with lawmakers and regulators.
Membership organizations also keep their members informed by tracking pending legislation and regulations. When
new laws pass and regulations are issued, membership organizations relay important provisions to ensure their
members are aware of the policy change.
As part of their advocacy function, membership organizations help mobilize members and connect them with state
and federal legislators. State associations play an important role in educating and advocating for state
action and help inform national associations about the implications of national policies at the state and
community level. Oftentimes, as a way to focus efforts and set priorities, groups of individuals with
similar interests assemble within the organization to form an interest group or committee. This model allows
diverse interests to voice their
opinions, while working towards common goals within the framework of the larger organization. Other
major functions of membership organizations include education, policy formation, research, and technical
Membership organizations with interests in rural health include:
American Academy of Family Physicians (AAFP)
Represents the interests of family physicians, including those working in rural areas.
Association's Rural Health Services
Represents and supports America's small and rural hospitals through advocacy, communication, education,
technical assistance, and policy development and analysis.
American Public Health Association (APHA)
Works to improve the health of the public by influencing federal policies and setting priorities in public
Association of State and Territorial Health Officials (ASTHO)
Represents public health agencies and professionals in the U.S.
National Association for Rural Mental Health (NARMH)
Provides a forum for rural mental health professionals, consumers, and advocates to identify issues, share
models and innovations, and inform state and national rural mental health policy.
National Association of Community Health Centers (NACHC)
Dedicated to improving and expanding America's network of community health centers through advocacy,
technical assistance, training, and research. Primary goal is to improve healthcare access for the medically
underserved and uninsured.
National Association of County and City Health Officials (NACCHO)
Focuses on serving local health departments through networking, offering programs and resources, and
supporting effective public health systems and practices.
National Association of Rural Health Clinics
Works with Congress, federal agencies, and other rural health stakeholders to improve, promote, expand, and
protect the Rural Health Clinic program.
National Hospice and Palliative Care Organization (NHPCO)
Represents America's hospice and palliative care programs and professionals and works to improve
end-of-life and palliative care for patients with serious and life-limiting illnesses and their families.
National Organization of State Offices of Rural Health (NOSORH)
Provides technical assistance and support to enhance the capacity of State Offices of Rural Health, with the
goal of improving access to, and the quality of rural healthcare.
National Rural Health Association (NRHA)
Leads nationwide rural health efforts related to policy, education, advocacy, and communication.
State Rural Health Associations
Organizes and focuses rural health efforts within the individual states.
What resources are available to stay current on evolving rural health policy?
Several government agencies, membership organizations, research centers, and nonprofit organizations at the
national and state levels serve as resources to stay current on rural health policy issues. The following lists,
while not exhaustive, include resources representing a variety of rural health interests:
Resources on Federal Policy
Resources on State Policy
Note: there will be variation among states.
State Offices of Rural
State-level offices coordinate statewide efforts to improve healthcare delivery systems in rural
communities. They are also tasked with collecting and disseminating information, and providing technical
assistance to public and nonprofit entities. All 50 states currently have a SORH.
State Rural Health Associations (SRHAs)
Advocacy groups that focus statewide efforts and provide forums for collaboration within each state.
Regional Primary Care Associations (PCAs)
Organizations that offer training and technical assistance (T/TA) to safety-net providers.
State and Territorial Health Officials
Oversee state/territorial health departments and implement state laws affecting them. Often lead or serve on
boards and commissions related to public health issues.
State Long-Term Care Associations
Trade associations that work to enhance long-term care services through advocacy, education, and
How can I influence rural health policy?
There are many ways to engage in the rural health policy making process. Many membership
organizations help their members connect with state and federal legislators and ask their members for
feedback on policy proposals. Writing op-eds in a local paper or attending a public meeting hosted by lawmakers
is another way to make government officials aware of current issues affecting your facility or the health of
in your community.
Federal agencies post drafts of new or revised regulations in the Federal
Register and often accept comments from the public before the final rule is published. Interested
stakeholders, from membership organizations to corporations to individuals, can submit letters describing their
concerns of how the proposed rules will impact their interests and or voice support of these policies. Agencies
also post information on public meetings and requests for nominations for advisory committees in the Federal
Register. Similar opportunities to comment on proposed regulations exist at the state level as well.