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A medical emergency can happen to someone at any time or location, but not everyone has equal access to potentially lifesaving care when they need it the most. In 2021, died in the middle of the night on the side of the road in rural Mississippi while pregnant and in labor. The hospital in her town closed in 2013, so she and her husband had to drive almost 30 minutes to the next town over to find an emergency room. As Stribling’s husband, Byron, would recount after the loss of his wife: “[The] majority of the people who live in Humphreys County know that if you call the ambulance, with us not having actual emergency rooms here, it usually takes a while.” In 2023, like the Striblings lived in rural areas.

Unfortunately, many others like Harmony Stribling have faced similar challenges to accessible health care. The Huguley family, from rural Troup County, Georgia, had their first child born preterm and needed to spend 12 weeks in a neonatal intensive care unit in Atlanta. According to the child’s father, Serkeith, “I shouldn’t have to take to know that my baby is OK. To not have that kind of health care readily available, it’s nerve-racking, disheartening, because you’re helpless as a parent.”

In rural areas across the Deep South (Alabama, Florida, Georgia, Louisiana and Mississippi), hospitals are closing, leaving many people with nowhere to turn for critical care. New analysis from the Southern Poverty Law Center (�����Խ�) found that at least 99 rural hospitals are at risk of closing across those states, with more than half of Alabama’s share of rural hospitals at risk. A hospital was considered at risk if it had more than three years of negative patient service margins.

In a region that already experiences poorer health outcomes than the rest of the nation, this will undoubtedly prove deadly. Rather than stem the bleeding, lawmakers have chosen to worsen the wound by making deep cuts to health care programs for the people who need them most.

This report will highlight the need to support rural health care facilities already dwindling across the South, and how these same facilities have been challenged by laws like HR 1.

The Status of Health Care Access Across the Deep South

The Deep South, particularly its rural residents, are requiring medical care like Importantly, Black people are more likely to experience those health conditions compared to white people, including . These challenges are directly related to access to health care and the legacy of racial inequity built into the present-day infrastructure.

Congressional policymakers passed the Budget Reconciliation Bill, , in the summer of 2025. Once fully implemented, it will impact access to government assistance programs by cutting federal funding available to states, endangering these communities further. The impacted programs include state Medicaid programs among other basic-needs assistance programs for people with low incomes.

Rural hospitals are already limiting services and shutting down. Between 2005 and 2023, at least across the country stopped offering , or admitting into a hospital for close supervision from a physician. (For the purposes of this paper, we define “rural” according to the .) Based on �����Խ� data collection from the , at least 34 of those hospitals are located in the Deep South. The result of this includes increased travel times for rural residents, many of whom with their lives after they could not reach the emergency room in time.

Ultimately, rural hospitals are often the only place to turn for health care. People living in rural areas often (impacting their ability to access telehealth services), decreased rates of insurance coverage, and .

Rural residents face increased obstacles to accessing a doctor and emergency room while their counterparts living outside of rural areas do not. Evidence finds that hospital access is unequal based on community type. For example, a 2018 Pew Research Center study found that rural Americans live an average of , compared with 5.6 miles for people in suburban areas and 4.4 miles for those in urban areas.

Why Are Rural Hospitals Under Strain?

Simply put, sustainability and finances for both hospitals and patients keep rural hospitals running in the red.

Across all five Deep South states, counties with high poverty and Medicaid participation tend to host hospitals with the slimmest profit margins — meaning even more hospitals are at risk of closing, leaving residents without a hospital in close reach. The costs of delivering patient services, staff, and other expenses are factored into hospital operating margins. Additionally, hospitals that serve predominantly Black counties tend to also be critically strained with their operating costs, and at a higher risk of closing or limiting services.

, or refundable tax credits that help individuals and families purchase through the Health Insurance Marketplace, were originally established through President Obama’s . During the acute years of the COVID-19 pandemic, the enhanced tax credits were created to help keep insurance affordable by lowering insurance premium costs for even more people—those whose income exceeds 400% of the federal poverty level (or up to $62,600 for a single adult and $128,600 for a household of four in 2025), allowreing millions more people to access health insurance than with the previous income-based premium tax credits (see Table 2). Notably, at the end of 2025, the enhanced Premium Tax Credit (ePTC) subsidies expand affordability for marketplace premiums.

ePTCs Kept Insurance Affordable, Coverage Will Drop for Millions Following Expiration

Without the ePTC to keep premium costs down, , but that does not mean people stop getting sick. In fact, evidence shows that people will delay care or — and hospitals will be left to foot the bill for uninsured and uncompensated care. Without the renewal of ePTCs, rural hospital revenues could following the anticipated mass coverage loss.

As such, HR 1 will further weaken the rural hospital system in the Deep South unless policymakers work to protect their rural residents and hospitals.

By ensuring all residents across the Deep South have adequate and equitable health care, regardless of their ZIP code, income or health insurance status, policymakers can protect their most vulnerable communities. But instead, the Deep South endures some of the worst health disparities across the country, already locking far too many people out of health care. For example, to experience preventable chronic illness, diabetes and high blood pressure. Further, these disparities widen when considering race. For example, Black Mississippians had the highest death rate from heart disease, high blood pressure, stroke and diabetes in the state in 2023. Black Floridians were more likely to die from kidney disease compared to white Floridians in 2024, even though many cases of kidney disease are preventable.

Health Care Is a Basic Need, Helps People, and Helps Economies

Health care inequities in the U.S. date back to the country’s very founding. As a direct result of their race and freedom status, Black people were often unable to see the doctor when they needed to. Continuing to the present day, to health care and worse health outcomes compared to white people, and people of color more generally (Hispanic, Black, and American Indian or Alaska Native) remain compared to their white counterparts.

Visiting the doctor depends on whether one can afford it. The current U.S. health care system relies heavily on insurance to serve as the patient’s primary funding mechanism to ensure that doctors and hospitals get paid from providing care. Research finds that people without health insurance (under age 65, before they are able to access Medicare) are more likely to report their health care expenses. Further, are more likely to have trouble paying their medical bills compared to their urban counterparts, and the disparity widens when race is factored in.

Of note, , including positions that offer employer-provided coverage. Rural residents of color, particularly a larger proportion of Black and Hispanic people, were to pay their medical bills compared to white people. However, it should be noted that a large proportion of white people living in rural areas were also unable to afford their medical costs. Indeed, being insured of medical debt and impacts people across the board, regardless of race.

While Deep South residents are less likely to be able to afford their medical expenses, the Deep South states (except Louisiana, which expanded its program in 2016) have not taken the federal funding available to expand their Medicaid programs and cover people with incomes up to 138% of the federal poverty level (about $20,780 a year for an individual and $35,630 a year for a family of three). While states have the discretion to do so, the federal government offers that expand Medicaid by increasing funding to help cover the additional people receiving program assistance. Importantly, expanding Medicaid helps people with incomes that are too high to qualify, but too low to afford insurance through the marketplace without assistance. An estimated across Alabama, Florida, Georgia and Mississippi would gain coverage if their states adopted the Medicaid expansion. People of color make up a of people in the Medicaid coverage gap.

Aside from the general funding incentives, there are several benefits to helping people — especially rural communities — continue accessing the doctor regularly. The primary benefit is that healthier . Rural Southern communities are already at an increased risk for a weakened economy because of decreased opportunities, industry loss and subsequent rural flight. From an economic perspective, of preventable illness and mortality, while also ensuring patients make use of the available health care resources when necessary. A vibrant rural health care network supports a healthy community and healthy workforce, and contributes to the local economy by recruiting employees to rural hospitals and care centers.

Components and Consequences of HR 1

Based on the chart below (see Table 3), several rural hospitals across the Deep South are operating at a loss — meaning these hospitals are particularly vulnerable to any changes that may affect their community’s ability to afford or qualify for health care.

In 2025, HR 1 was enacted by the Trump administration, containing some of the — further devastating the health care infrastructure across the country, and especially in the rural Deep South. Federal policymakers chose to cut over $1 trillion of federal funding from health care programs and ultimately create more barriers for people in need of health care. The Congressional Budget Office forecasts that because of these programmatic changes.

Consequently, people who are uninsured are less likely to be able to afford health care, resulting in decreased funding and use for rural hospitals. , those ePTC subsidies expired despite calls for policymakers to keep health care affordable and extend credits beyond 2025. These tax credits have helped people afford their insurance premiums, especially those in the Deep South.

Early research suggests that some premium , leaving many unable to afford insurance on their own and ineligible for assistance through programs like Medicaid in nonexpansion states (like those in the Deep South). Despite to force the conversation among policymakers, efforts have been unsuccessful to revive the ePTC as of February 2026. Early reporting suggests that across the country dropped coverage after the expiration. As a result, individuals and families across the country, including in the Deep South, will begin feeling the ripple effects of living without insurance coverage.

There are other aspects of HR 1 that will impact everyone across the U.S., but especially Southern rural communities. Notably, in 2027, people ages 19-64 will be subject to work requirements and eligibility redeterminations at least every six months for Medicaid expansion states like Louisiana. In December 2025, the Centers for Medicare and Medicaid Services (CMS) , yet it is still unclear how states will have to administer these policy changes. Notably, nonexpansion states are trying to impose work reporting, and some proposals go beyond HR 1’s requirements (e.g., ). However, one thing is still clear: at promoting work, largely because most people receiving government assistance are already working.

By design, people who would otherwise qualify for assistance from participating in the program. The verification process also places undue burden on states who are required to enforce and monitor participation in work. As a result of this new policy, more people will be locked out from health care, especially in the Deep South.

Rural Health Transformation Fund Cannot Save Ailing Hospitals, Builds the Plane While Flying

The damage to health care access caused by HR 1 goes beyond the impact of the . Independent research from KFF estimates that Medicaid program federal spending will be permanently cut by .

Attempting to counter the impact of the Medicaid cuts, the Rural Health Transformation Fund (RHTF) was created to allocate $50 billion to states in grants for health care efforts across a five-year period, though not every state gets the same amount. will be split evenly among states, states have more rural hospitals or rural hospitals at risk of closing than others. Of the second half, will be allotted to states based on a points-based system calculated by the CMS administrator, and the remainder will go to states that score well on initiatives that mirror the Trump administration’s interests.

States submitted their funding applications , and the first-year state award amounts were announced in (see Table 4). Notably, the — available only for five years — while the cuts to Medicaid are permanent.

Rather than use the money to strengthen rural hospitals currently operating in the negatives, the Trump administration asked that the states spend the money on “transformational ideas,” and states complied to this request in their applications for funding. All 50 states, including those in the Deep South, have prioritized investing in technology innovation including, but not limited to, like telehealth and patient care monitoring. For example, Florida proposed to expand access by , telehealth and new rural practice sites. According to �����Խ� analysis, Florida’s current rural hospital ecosystem has a high closure rate combined with small rural counties and high Medicaid dependence.

Lawrence Medical Center in Moulton, Alabama, in May 2025, leaving Lawrence County . The hospital blamed the number of uninsured patients as one of the reasons for its emergency room closure. According to the Alabama Hospital Association, are operating in the red.

The appropriated $50 billion will do little to insulate rural communities and hospitals from the imminent damage of HR 1, especially if states are focusing on delivering funds to those who invest in technology. Further, the rural South is still experiencing digital exclusion and does not have access to the same kind of technology available to those in more populated areas. For example, the Joint Center on Political and Economic Studies found that nearly 36% of the rural South’s residents lack the option to subscribe to fixed broadband. Another estimated 38% of Black households in the rural South do not have broadband. With the focus of the RHTF on transformational ideas, and states interpreting that to mean investing in technological advancement, hospitals struggling to keep their beds filled, lights on, and staff paid will certainly be left behind. Additionally, without intentionality, state’s RHTF investments will widen the racial health disparities already in existence by further locking out Black rural Southerners from care.

Policy Recommendations

It may take time, but there is hope and a way forward — one that involves protecting rural hospital access and the communities that rely on the lifesaving care they provide, especially for pregnant people who must travel across counties during a medical emergency.

A strong rural health care system creates healthy people, healthy families and a healthy economy. For these reasons and more, the �����Խ� recommends federal policymakers across the Deep South preserve their rural health care infrastructure by doing the following:

• Reverse the cuts in HR 1. There is still time to reverse the cuts and increased barriers to government assistance programs, including Medicaid, by undoing the decisions made in the past.
• Extend marketplace-enhanced Premium Tax Credits to ensure people have access to health insurance across the Deep South. Access to health care not only saves lives, but it keeps people and families able to see the doctor when they need and it helps them better afford their medical bills.

Additionally, state policymakers across the Deep South can preserve their rural health care infrastructure by doing the following:

• Expand existing health care operations and target state funds to save hospitals in severe financial distress. States have the discretion to keep rural hospitals open, and communities benefit most when hospitals can continue offering a wide range of services, including an emergency room.
• Support the continued operation of Medicaid and other safety net programs by committing the necessary funding and widening eligibility for access. States can and should ensure their communities are able to access Medicaid. States should also continue investing in providing its residents health care, even when the federal government has found it unimportant to do so. States can do this by expanding the Medicaid program and streamlining the program’s application process.
• Prioritize the Rural Health Transformation Fund for rural hospitals that are in severe financial distress. Work within the confines of the RHTF to “innovate”( rural hospitals and systems that are already in place as required by the RHTF grant stipulations, not create new ones without investing in those that already exist.

Acknowledgments

The Southern Poverty Law Center would like to thank the organization’s regional and federal policy teams, and Delvin Davis, policy research manager, for their support in guiding and reviewing this report. Thank you also to Sara Moore, data and research analyst, for their contributions to the report.

Image at top by the �����Խ�.