How the Trump Administration Should Reinvest in Rural America

Like the rest of the country, rural America is waiting anxiously to see the impact of the Trump administration, particularly after a series of budget cuts and spending freezes have prompted growing concern in the farming community. Purdue University professors of public health Randolph Hubach and Cody Mullen offered their recommendations for three ways the new administration could successfully invest in rural America in a recent op-ed in The Conversation. Mullen and Hubach spoke recently with Spotlight about their piece; the transcript of that conversation has been lightly edited for length and clarity.

Why don’t we dive right in on your three ways the new administration could invest in rural America.

Cody Mullen: The first thing is really rural healthcare access and there are multiple factors associated with that. We know that rural healthcare is one of the largest employers in rural communities, so we want to ensure that there’s appropriate access to healthcare for the citizens living there, but then also for the employees that are drawn into rural communities.

Rural populations tend to be on the older end of the spectrum as well as lower income, so the hospitals’ reimbursement mechanisms tend to disproportionately be Medicare and Medicaid. Changes in those programs significantly affect rural America and we’ve seen roughly 170 rural hospitals close since the passage of the Affordable Care Act in 2010. Those vary by state, but we see the highest percentage of hospitals closing in states when Medicaid was not expanded, leading us to hypothesize that there’s a linkage between individuals willing to cover some of the costs of their services with Medicaid compared to higher rates of uninsured populations where hospitals are consuming the bad debt. So, I think one of the areas that we recommend is really looking at how do government programs help ensure that informed access.

One way is the Low Volume Hospital Adjustment Act, which gives a Medicare payment adjustment to hospitals with low patient volumes. That expires at the end of March of this year and needs to be discussed during the new budget cycle. In addition, there’s an action that was implemented during the first Trump administration that gives hospitals the designation of rural emergency hospital or REH and allows them to change the services that they offer. They can decrease or actually eliminate their inpatient care, but they’re able to offer emergency department care, outpatient care, skilled nursing facilities, and observational beds for up to 24 hours for patients.

Lastly in the healthcare space, we also recognized that during the pandemic, telehealth was really, really strong and we saw a lot of laws changed to allow for telehealth to be used more easily and freely in rural America. But as the pandemic has ended, a lot of those laws are set to go back to the prior-pandemic laws sometime in 2025. We’re urging the administration and Congress to really try to codify some of those huge wins that we saw in telehealth access and to look at what the requirements should be for a patient to utilize telehealth.

Is there any level of bipartisan support for extending some of those telehealth provisions?

There’s huge bipartisan support. We saw some of those easements and policies start under President Trump’s first administration at the early days of the pandemic and they were advocating for some of these changes as advocates and allies were.

And on Medicaid expansion, you still have 10 states that haven’t taken that up. Do you see any real likelihood of that changing given the new administration and the new Congressional majority?

I think Medicaid expansion is probably not something that we’re going to see soon. But I think knowing that there’s this direct tie between Medicaid expansion or Medicaid access and rural hospitals staying open or potentially closing, it’s important for us to make sure that as we look at potential changes in Medicaid under the new administration that decrease Medicaid reimbursement, that we realize that those changes could disproportionately affect rural facilities.

And do your concerns include a wider implementation of work requirements, which I think we all sort of expect with the new administration.

I think any change to Medicaid that could cause individuals to not be able to enroll when needed or because they don’t qualify anymore could directly tie into decreased access to care and decrease reimbursement to facilities when patients come in needing care.

Should we move to point two Randy?

Randy Hubach:  Sure, I’ll take this one on. Housing is a concern we hear constantly when we are out in rural and local communities here in Indiana. And it’s not just rural newcomers, folks who are being priced out of urban environments, who are being affected but also folks who might be at retiring age and are looking to have something that’s much more affordable. We have this situation where you’re having folks from urban spheres moving into the rural areas, but at the same time, within these rural areas, we’re not seeing the development of new housing. And so, we have a limited supply, but a higher demand. And when you have migrant populations who are working seasonally in certain areas, that increases the need for housing in some of these spaces. When we haven’t had the investment within a lot of these communities, the quality of these houses sometimes has deteriorated.

There’s been bipartisan support in the past for measures like the Neighborhood Homes Investment Act but there also is this new opportunity of using the Section 502 Direct Loan Program through the U.S. Department of Agriculture to subsidize mortgages for low-income applicants. On a personal note, my mother-in-law and her husband just bought a home in rural Oklahoma through this mechanism. They wouldn’t have been able to purchase a new home without it. And it got them into a better living environment. I think a lot of us who come from family rural spaces have really benefited from these projects.

We’re urging an expansion of those subsidized mortgages, especially when we have increased mortgage rates nationwide, but then also increased investment in roads and railways, as we saw with the Department of Transportation during the Biden administration. We’d like to also see that within the Trump administration to make sure that we have good infrastructure within these spaces and ways that we can motivate builders and the like to increase access to new or high-quality homes.

And point number three?

Hubach: One of the challenges we have—and this is part of what we’re hearing from communities and when we think about the national dialogue related to agriculture and farmland within the U.S.—is that even though a large portion of land is still designated for agricultural use, we see that there is less acreage each time we’re doing a census. Part of this phenomenon is how these lands are being bought, by either companies outside the U.S. or other countries as well. And that’s usually the concern that we hear is that foreign nations, especially China, are buying land, within these rural spaces, even though it counts for a smaller portion.

But I think one of the big things we see is that we don’t have as many of those generational farmers. And as this current generation is starting to become older, that puts a large amount of acreage, about 360 million acres, that could be transferred in some way. And we can start to think of a couple possibilities within that.

I take my story from my family who’s from outside Sioux Falls, South Dakota, where we have a couple hundred acres that my great grandparents were the last generation to farm. Our family decision was to lease that land to other family farmers at a discounted rate to make sure that it could be still used by the local community. One of the challenges that comes with that is who has the stewardship of the land? And so, when we think of people working with the health of soil, working with those kinds of in-absentia owners to make sure that you’re rotating crops, treating the soil, making sure you’re keeping the high-quality soil there, that’s a big concern.

The other aspect is if families do decide to sell, who’s going to buy it? Is this going to be more industry who are doing larger corporate farming, or will it be used in other types of ways? This becomes essential because if it’s a local family farm or local business that does buy it, the funds that they receive from using that land are usually being invested back into the community. But when we have the introduction of more corporate farming, those funds are not necessarily going back into the community.

There’s been policy proposed in the previous Congress that had bipartisan support, such as the Farm Transitions Act, that we hope will be reintroduced within the current Congress and will really examine how we can look at farming transitions and how that might impact locally owned farms and hopefully enhance the next generation of farmers. We also know there is a large group, about 30% of farmers, who’ve been in business for a shorter period of time and so how do we use and leverage USDA and other types of programs that allow new farmers to purchase more acreage that they can then locally farm and then reinvest in those communities too. When you think about cycles of poverty and cycles of not being able to purchase a large farm and having to lease land out, how could we create incentive programs that are going to best fit folks who want to stay local?

That covers the piece, but if I could ask a couple of other questions while I have you. For either of you, do you think there will be a Farm Bill this year?

Mullen: I think we need to wait to see the details of the reconciliation bill and the discussions that the House and Senate are having. If there’s agreement on some of those priorities, then absolutely yes on the Farm Bill, but if there’s a lot of debate that needs to occur on reconciliation between the two chambers, there may be less legislation we see introduced this year.

Anything to add, Randy?

Hubach: I completely agree with that. The Farm Bill I think would be a prime opportunity for both political parties to come together and meet in the middle.

And then finally, obviously it’s been a very tumultuous and confusing time with the new administration, but I’m just wondering if you’ve seen any particular signs or indications of how active it might be in terms of rural policy. Are you optimistic, pessimistic or more wait and see?

Hubach: I think on my end I’m going to take a little bit more of an optimistic approach. If we think of the testimony of RFK Jr. during his hearings, a couple things that came out in a positive light were rural and tribal. When you think about the Health Resources Services Administration and the Substance Abuse and Mental Health Services Administration, who have a lot of funding that impact rural and underserved communities, when the first grants come out in the next couple weeks from this administration, those are the signs that we’re looking for. Post-COVID, if we think of opioid use and substance use disorder, rural America has been disproportionately impacted, so what priorities are the new administration going to support? I think we’re in kind of a wait and hold period, but my hope is that rural is going to remain a priority with some folks. Cody, your thoughts?

Mullen: I think it’s good to be optimistic and I think there’s a lot of potential given that this is a bipartisan issue. I think there also is this prioritization of giving back to the states and let them decide what action should be taken. Rural is so different from state to state that giving the states that authority with federal resources could be very positive.