Rural Populations Timeline

Rural Populations Timeline

1963

1946

1971

1965

1977

Medicaid Creation

Hospital Survey and Construction Act

Health Professions Education Assistance Act

Area Health Education Center (AHEC) program

Rural Health Clinics Services Act

1997

Telemedicine and Rural Health Outreach Grants

1983

1986

Consolidated Omnibus Budget Reconciliation Act

Medicare Prospective Payment System

1985

1990

Balanced Budget Act & State Children’s Health Insurance Program

Emergency Medical Treatment and Labor Act

2010

2015

2002

2003

Maternal Care Deserts

2013

Opioid Use Disorder

Pill Seeking Stigma

Medicare Modernization Act

The Great Rural Closure

2018

2020

The Cares Act of 2020

2016

2017

2019

Bipartsian Budget Act of 2018

SAGES/ERAS Society Manual of Enhahnced Recovery

The American Healthcare Act of 2017

Patient Protection and Affordable Care Enhancement Act

References

Adashi, E. Y., O’Mahony, D. P., & Cohen, I. G. (2025). Maternity Care Deserts: Key drivers of the National Maternal Health Crisis. The Journal of the American Board of Family Medicine, 38(1), 165–167. ASHP. Ashp issue brief: The Bipartisan Budget Act of 2018 analysis of health provisions. ASHP Issue Brief: The Bipartisan Budget Act of 2018 Analysis of Health Provisions. (2018). https://www.ashp.org/advocacy-and-issues/key-issues/other-issues/additional-advocacy-efforts/ashp-issue-brief-the-bipartisan-budget-act-of-2018-analysis-of-health-provisions?loginreturnUrl=SSOCheckOnly BallotPedia. (n.d.). American Health Care Act of 2017 - Ballot Pedia. American Health Care Act of 2017. https://ballotpedia.org/American_Health_Care_Act_of_2017 Bazzoli, G. J., Lindrooth, R. C., Hasnain-Wynia, R., & Needleman, J. (2004). The Balanced Budget Act of 1997 and U.S. hospital operations. Inquiry : a journal of medical care organization, provision and financing, 41(4), 401–417. https://doi.org/10.5034/inquiryjrnl_41.4.401 Brown, J. K., Singh, K., Dumitru, R., Chan, E., & Kim, M. P. (2018). The benefits of enhanced recovery after surgery programs and their application in cardiothoracic surgery. Methodist DeBakey cardiovascular journal. https://pmc.ncbi.nlm.nih.gov/articles/PMC6027721/#:~:text=ERAS%20promotes%20a%20decrease%20in,postoperative%20complications%2C%20and%20hospital%20costs Cooper, Z., Kowalski, A., Powell, E. N., & Wu, J. D. (2024). Politics and health care spending in the United States: A case study from the passage of the 2003 Medicare Modernization Act. Journal of Health Economics, 95, 102878. Edmunds, M., & Coye, M. J. (1998). Overview of the state children’s health insurance program. In www.ncbi.nlm.nih.gov. National Academies Press (US). https://www.ncbi.nlm.nih.gov/books/NBK230573/ Febres-Cordero, S., Shasanmi-Ellis, R. O., & Sherman, A. D. (2023). Labeled as “drug-seeking”: Nurses use harm reduction philosophy to reflect on mending mutual distrust between healthcare workers and People Who Use Drugs. Frontiers in Public Health, 11. Field, M. J. (1996). Evolution and Current Applications of Telemedicine. Nih.gov; National Academies Press (US). https://www.ncbi.nlm.nih.gov/books/NBK45445/ Golder, H. J., & Papalois, V. (2021). Enhanced recovery after surgery: History, key advancements and developments in transplant surgery. Journal of clinical medicine. https://pmc.ncbi.nlm.nih.gov/articles/PMC8069722/ Grogan, C. M. (2025). Medicaid’s political development since 1965: How a fragmented and unequal program has expanded. Journal of Health Politics, Policy and Law, 50(2), 137–164. https://doi.org/10.1215/03616878-11567692 Haggerty, T., Sedney, C. L., Dekeseredy, P., Capehart, K. D., & Pollini, R. A. (2023a). “you didn’t have a choice, but to be on your train. the train was moving”: West Virginia Pharmacists’ perspectives on opioid dispensing during the evolution of the opioid crisis. Journal of the American Pharmacists Association, 63(3), 863–872. https://doi.org/10.1016/j.japh.2023.02.004 H.R.1425 - 116th congress (2019-2020): Patient Protection and Affordable Care Enhancement Act | congress.gov | library of Congress. H.R.1425 - Patient Protection and Affordable Care Enhancement Act. (2019, February 28). https://www.congress.gov/bill/116th-congress/house-bill/1425 Jost, T. (2017). House passes AHCA: How it happened, what it would do, and its uncertain Senate Future | Health Affairs Forefront. House Passes AHCA: How It Happened, What It Would Do, And Its Uncertain Senate Future. https://www.healthaffairs.org/content/forefront/house-passes-ahca-happened-would-do-and-its-uncertain-senate-future Lee, J. H., Wheeler, D. C., Zimmerman, E. B., Hines, A. L., & Chapman, D. A. (2023). Urban–rural disparities in deaths of despair: A county-level analysis 2004–2016 in the U.S. American Journal of Preventive Medicine, 64(2), 149–156. Miller Temple, K. (2022). Rural Health Clinic Program at 45 Years: Created for Access and Still Delivering Care. Rural Health Information Hub. https://www.ruralhealthinfo.org/rural-monitor/rhc-program Office of Law Revision Counsel. (n.d.). §293c. Educational assistance in the health professions regarding individuals from disadvantaged backgrounds. 42 USC 293C: Educational assistance in the Health Professions regarding individuals from disadvantaged backgrounds. https://uscode.house.gov/view.xhtml?req=%28title%3A42+section%3A293c+edition%3Aprelim Overview of the Emergency Medical Treatment and Active Labor Act (EMTALA) and Emergency Abortion Services. (2026, March 29). https://www.congress.gov/crs-product/IF12355 Rosoff, A. J., Field, R. I., & Orlando, A. W. (2025). The government built it, and the private sector came: For-profit health care, government support, and the road from public service to private equity. American Journal of Law & Medicine, 51(2), 337–351. https://doi.org/10.1017/amj.2025.10070 Scott S. J. (1984). The Medicare prospective payment system. The American journal of occupational therapy : official publication of the American Occupational Therapy Association, 38(5), 330–334. https://doi.org/10.5014/ajot.38.5.330 Stansberry, T. T., Roberson, P. N., & Myers, C. R. (2023). U.S. Rural Hospital Care Quality and the effects of hospital closures on the health status of rural vulnerable populations: An integrative literature review. Nursing Forum, 2023, 1–16. https://doi.org/10.1155/2023/3928966 U.S. Department of Labor. (n.d.) (2026). Continuation of Health Coverage - COBRA | U.S. Department of Labor. Dol.gov. https://www.dol.gov/general/topic/health-plans/cobra U.S. Department of the Treasury. About the cares act and the consolidated appropriations act (2026, February 18). https://home.treasury.gov/policy-issues/coronavirus/about-the-cares-act#:~:text=The%20Coronavirus%20Aid%2C%20Relief%2C%20and,%2C%20small%20businesses%2C%20and%20industries Vyas, K. J. (2023). Review of the Area Health Education Center Scholars Didactic Curricula: A federal program for students interested in rural health. Journal of Medical Education and Curricular Development, 10. https://doi.org/10.1177/23821205231175030

Maternal Care Deserts

~ Starting point for a decade-long wave of more than 100 rural hospital closures and over 500 obstetric unit shutdowns~ Median travel distances increased by approximately 20 miles for general care and 40 miles for specialized treatment ~ Directly correlated with a rise in maternal mortality and reduced access to life-saving care in rural areas.

(Adashi et al., 2025)

PILL SEEKING STIGMA

~ Pain became the fifth vital sign, encouraging clinicians to treat pain more aggressively~ Heavily impacted regions where they rely on manual labor (mining, construction) ~ Rising prices of physical therapy and rehab made long term opioid prescriptions common

(Febres-Cordero et al., 2023)

Abigail Yates

Medicare Prospective Payment System

This change that was made to the medicare system allowed for hospitals to be paid for each diagnosis-related group (DRG). Originally, hospitals were paid for the cost to operate. Since hospitals in rural areas have lower amounts of patients, they were not receiving enough money to cover operational costs. This hurt rural hospitals, leading to closures. In later years, the impact on rural hospitals became clear, and adjustments were made to the bill to support rural areas (Scott, 1984).

While this bill was in place, hospitals in rural areas were forced to downsize, close, or limit the different healthcare services they offered. This led to people who resided in rural areas to have to travel farther for specialized care. This caused marginalization in rural populations.

Abigail Yates

Telemedicine and Rural Health Outreach Grants

This grant made telehealth and rural outreach programs more accessible and sustainable. This benefited rural populations by giving access to those who couldn’t attend appointments in person. An example is the $700,000 grant to Eastern Oregon Human Services Consortium to demonstrate the use of telehealth in the rural population of eastern Oregon (Field, 1996).

These grants widely benefited rural populations because they allowed everyone to seek care from their home. People in rural populations often don't have transportation, can't afford to travel far, or are unable to get to appointments due to disabilities.

American Health Care Act of 2017

This Act was proposed to replace the Afforable Care Act, aiming to re-structure the U.S. Healthcare Coverage, but not passed into law. This act aimed to reduce Medicaid expansion, eliminate income-based subsidies, and introduce age-based tax credits. This represented a move towards decreasing federal involvement in healthcare and resided concerns about reduced access to care for low-income and vulnerable populations This highlights the political efforts to redefine healthcare accessibility and funding. (BallotPedia, n.d.) (Jost, 2017)

The Cares Act of 2020

This act was passed in response to the COVID-19 pandemic to provide emergency economic and healthcare support. It provided direct payments to individuals, funding for hospitals, expansion of telehealth, and support for healthcare providers. This showed how policies must adapt to emergency public health needs. (U.S. Department of Treasury, n.d.)

SAGES/ERA Society Manual of Enhanced Recovery

Surgeons, anesthesiologists, nurses, and physiotherapists wrote this program for gastrointestinal surgery. The program is practice and evidence based guide to implement enhanced recovery after surgery protocols:- Early mobilization -Pain control - Nutrition This decreases the length of stay, complications post-op, and costs for patients. This matters by showing patient-centered care by improving with efficiency rather than changing insurance coverage. (Brown et al., 2018) (Golder & Papalois, 2021)

Rural Health Clinics Services Act

Gave Medicare and Medicaid reimbursement for services provided by physician extenders (NP and PA) who work in rural and medically underserved communities. Also, it allows NPs and PAs to provide primary care services as long as a physician is present in the facility every two weeks (Miller Temple, 2022).

OPIOID USE DISORDER

~ Significant Surge: Opioid use disorder (OUD) quadrupled compared to previous years.~ A positive link was identified between the rise in opioid prescriptions and an increase in opioid-related deaths and overdoses. ~ Economic Impact: Patients with OUD faced longer hospital stays and significantly higher medical bills than those without the disorder. ~ By 2009, approximately 250,000 U.S. high school students were believed to have OUD in addition to non-medical opioid use. ~ Death Toll: Annual overdose deaths involving prescription opioids rose to over 16,000 ~ West Virginia Senate Bill 273: Provided a legal shield for pharmacists, allowing them the right to refuse or deny inappropriate prescriptions.

(Hagerty et al., 2023)

(Lee et al., 2023)

Hospital Survey and Construction Act

Also called the Hill-Burton Act, it increased the amount of hospitals and the beds in hospitals to better support the population. It was a six-billion-dollar program that included loans and grants that made hospitals comply with regulations to increase access, which also included nondiscrimination rules (Rosoff et al., 2025).

Health Professions Education Assistance Act

Gives funding to students who want to study medicine and to build new hospitals and health facilities in exchange for students practicing in areas that are underserved (§293c. Educational assistance in the health professions regarding individuals from disadvantaged backgrounds).

This act was passed by congress, in which it addressed funding gaps and helped stabilize key programs. The act extended funding for the Children's Health Insurance Program (CHIP) for four more years and provided financial support for commmunity health centers.Also included Medicare payment adjustments and spending increases. This protected healthcare accessibility for children and underserved poulations and reinforced essential healthcare infrastructure. This demonstrates a bipartisan effort to maintain stability in healthcare despite ongoing political debtate. (ASHP,2018).

Bipartisan Budget Act of 2018

March 2022

WHO releases data showing that the COVID-19 pandemic triggered a 25% increase in anxiety and depression worldwide, with young people and women at the highest risk. The number of recorded deaths due to COVID-19 reaches 976,229, with more than 79,853,683 total reported cases of the virus in the U.S.

Patient Protection and Affordable Care Enhancement Act

This act was proposed to legislation, but not enacted, aiming to strengthen and expand the ACA rather than replace it. It increased premium tax credits, worked to reduce prescription drug costs, and supported Medicaid expansion. This act improved afforability of health insurance and expanded access to care for middle to low income individuals. This reflected a policy shift back toward increasing healthcare coverage and affordability. (H.R.1425,2019)

MEDICARE MODERNIZATION ACT

~ Legislation Passed (2003)~ Introduction of Medicare Part D (2006): voluntary prescription drug coverage ~ Designed to alleviate the financial burden on the elderly population ~ Significantly increased the utlization of presccription drugs among the elderly ~ Linked to better patient adherence to medication regmins and improved health for seniors

(Cooper et al., 2024)

March 2022

WHO releases data showing that the COVID-19 pandemic triggered a 25% increase in anxiety and depression worldwide, with young people and women at the highest risk. The number of recorded deaths due to COVID-19 reaches 976,229, with more than 79,853,683 total reported cases of the virus in the U.S.

Medicaid creation

Gives medical insurance to those who do not make a certain amount of money. Allows special designations such as being a critical access hospital if there are less than 25 beds, in a rural area, average length of stay for patients is less than 96 hours and are at least 35 miles away from another hospital. The creation of critical access hospitals was made to reduce the financial vulnerability that rural hospitals have (Stansberry et al., 2023).

March 2022

WHO releases data showing that the COVID-19 pandemic triggered a 25% increase in anxiety and depression worldwide, with young people and women at the highest risk. The number of recorded deaths due to COVID-19 reaches 976,229, with more than 79,853,683 total reported cases of the virus in the U.S.

The Great Rural Closure

Starting in 2013, 101 rural hospitals shut down, representing 4% of all rural hospitals in the United States. Many had to drive an additional 20+ miles for an ER and an additional 40+ miles for alcohol and drug related treatment (GAO, 2021).

Abigail Yates

Balanced Budget Act & State Children’s Health Insurance Program

Balanced Budget Act (1997): This act was a Medicare reformation that helped rural areas by creating ‘critical access hospitals’ and preventing rural hospitals from being shut down (Bazzoli et. al, 2004).

State Children's Health Insurance Program (1997): This program was designed to help children from low-income and rural families obtain health insurance (Edmunds & Cole, 1998).

Area Health Education Center (AHEC) program

Created to train, recruit, and retain healthcare professionals in rural and medically underserved communities. It also allows the students to supplement education with experience by dedicating two years to working in rural and underserved communities (Vyas, 2023).

Abigail Yates

Emergency Medical Treatment and Labor Act

This act forced hospitals to treat those without insurance and without a way to pay in emergencies. Originally, hospitals had been refusing to treat those without a way to pay. This benefited rural populations as many who live in rural areas are stuck in poverty (Statman, 2023).

This directly benefited people living in rural populations because it allowed them access to emergency care. This bill stated that all patients who need screening or emergency services can receive them even without a means to pay.

Abigail Yates

Consolidated Omnibus Budget Reconciliation Act

This act allowed people who lost their jobs to continue using their employer’s health insurance during a short period of unemployment. Unfortunately, this temporary health insurance had high copays, which would have made it hard for rural populations to benefit (Department of Labor, 2026).

The Consolidated Omnibus Budget Reconciliation Act (COBRA) didn't help or harm rural populations. In order to use COBRA, you had to be on your employer's insurance originally. If you were eligible for COBRA, the insurance made you pay all premiums, which were up to 102% of the cost of the plan. Most people in rural areas didn't have enough money to use COBRA because of the high premiums.