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In an October 18, 2026, opinion article, Terry Adirim argues that federal Medicaid reductions and a proposed H-1B visa fee could further strain rural health care. The piece cites rural hospitals’ financial vulnerability and reliance on Medicaid and internationally recruited physicians; the fee is proposed, and the cited effects are estimates rather than settled outcomes.
In an October 18 opinion article, physician and former military health system leader Terry Adirim argues that federal Medicaid reductions and a proposed fee on some H-1B visa petitions could further weaken rural health care. The article says rural providers already face hospital closures, workforce shortages and limited alternatives for patients, while the law’s estimated Medicaid reductions could threaten a major source of hospital financing.
Adirim cites estimates that the 2025 budget reconciliation law will reduce federal Medicaid spending by $911 billion over 10 years and leave 10 million more people uninsured. KFF estimates the law will reduce federal Medicaid spending in rural areas by $137 billion over the same period. Those are projections, not reported outcomes already observed. Medicaid covers about one in four rural adults, half of rural births and roughly one-fifth of inpatient hospital discharges, according to the article.
The article also describes a proposed $103,265 fee on H-1B petitions subject to the annual visa cap, on top of other fees. Adirim cites a 2025 JAMA study that found more than 11,000 physicians were sponsored through H-1B visas in fiscal year 2024, with rural counties relying on H-1B-sponsored physicians at a higher rate than urban counties. The fee’s final status and its effects on hiring are not established in the supplied material.
Adirim points to a five-year, $50 billion Rural Health Transformation Program as a federal response, but argues it cannot replace lasting financing. KFF estimates the program’s funding is a little more than one-third of projected rural Medicaid reductions. The article says restrictions on how the funds can reach providers could limit their use for immediate needs, and notes that the American Hospital Association has urged the Centers for Medicare & Medicaid Services to allow more direct and flexible support.
Medicaid Supports Rural Hospitals
The potential stakes go beyond hospital budgets. When a rural hospital cuts staff or services, residents may have fewer nearby options for emergency, maternity and specialist care. Adirim argues that Medicaid functions as part of the health-care infrastructure in rural communities because it pays for a substantial share of births and hospital stays.
The article gives examples of services that are difficult to replace at a distance: a remote consultation may help connect a patient to a specialist, but it cannot provide an emergency procedure locally. That makes the combination of financial pressure and recruitment challenges relevant to access and travel times, not only to providers’ finances. The scale of any resulting service cuts or closures remains uncertain.
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Closures and Care Gaps
Adirim reports that 193 rural hospitals closed between 2005 and 2024. The Center for Healthcare Quality and Payment Reform estimates that more than 700 rural hospitals—about one-third of rural facilities nationwide—are at risk of closing. These figures describe closures to date and an outside estimate of risk; they do not establish that every facility identified will close.
Rural maternity services have also contracted: the share of rural hospitals providing obstetric care fell from 57% in 2010 to 48% in 2022, according to the article. It cites CDC data showing the age-adjusted rural mortality rate was 7% higher than the urban rate in 1999 and 20% higher in 2019. Adirim also recounts a case from his time leading the military health system in which a family had to travel for a child’s specialist evaluation and was later moved to a different assignment. He uses the example to contrast military families’ ability to relocate with the limited choices many rural residents have.
““Rural healthcare does need transformation. But first, it needs survival.””
— Terry Adirim, author of the MedPage Today opinion article
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Policy Effects Still Unsettled
The supplied material does not establish the final implementation details of the proposed H-1B fee, which petitions would be affected in practice, or whether the proposal will change physician recruitment. It also provides projections for Medicaid spending and coverage rather than measured results after the law’s implementation.
It remains unclear how much of the Rural Health Transformation Program’s funding will reach individual hospitals and clinics, how restrictions will be applied, and whether the program will avert service cuts or closures. The article does not identify specific facilities expected to close as a direct result of the law or fee.
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Funding Rules and Visa Proposal
The next developments to watch are federal decisions on how the Rural Health Transformation Program will distribute funds and whether CMS changes the restrictions described by Adirim. Those details will help show what support providers can access during the program’s five-year term.
The status of DHS’s proposed H-1B petition fee is another open issue, as are its final cost and effect on rural recruitment. Meanwhile, the spending and coverage estimates cited in the opinion article will need to be compared with later implementation data to determine how rural hospitals, services and patients are affected.
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Key Questions
What federal policy changes does the article focus on?
It focuses on estimated Medicaid reductions under the 2025 budget reconciliation law and a proposed $103,265 H-1B petition fee for petitions subject to the annual visa cap. The fee is described as proposed, not as a confirmed final policy.
How much could rural Medicaid funding fall?
KFF estimates a reduction of $137 billion in federal Medicaid spending in rural areas over 10 years. That is a projection cited in the opinion article, not a confirmed amount already lost.
What is the Rural Health Transformation Program?
The article describes it as a $50 billion program lasting five years. Adirim argues that its funding cannot substitute for sustained financing and says restrictions may limit how directly it can support providers.
Could the H-1B proposal affect rural doctors?
Adirim argues that adding a large fee could make recruiting internationally sponsored physicians harder for rural hospitals. The article cites rural counties’ reliance on H-1B-sponsored physicians but does not establish what effect the proposal will have if implemented.
Source: rss
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