The Rural Health Transformation Program: trends in projected scores and actual awards.

Introduction: Recent legislation will substantially reduce Medicaid spending and coverage but also created a temporary Rural Health Transformation Program (RHTP), which may partially offset cuts. The extent to which the RHTP will attenuate rural health care cuts depends both on how the federal government allocates RHTP funds and how states spend the money received. Methods: We reviewed RHTP scoring criteria and collected relevant publicly available data for each state. We calculated the number of points likely to be allocated for each measurable scored factor, analyzed funding actually awarded for fiscal year 2026 (FY2026), and evaluated associations with anticipated rural Medicaid funding losses and partisanship. Results: The association between RHTP point allocations and estimated cuts was statistically significant, both overall and when subsetting to the rural facility and population score factors, which include statutorily mandated criteria. However, the measurable state policy- and data-driven factors-which primarily reflect state policy choices-are not significantly associated with expected rural funding cuts. Estimated scores and actual awards for FY2026 favored Republican-leaning states, even after conditioning on anticipated Medicaid cuts or rural population size. Conclusion: Key design choices in RHTP legislation and implementation had important consequences for the distribution of funds.