Access to affordable healthcare has become the defining concern of leaders in rural America.

Sixty-three percent of rural physicians identify it as the top issue policymakers should address, according to athenahealth’s 2026 Physician Sentiment Survey; that’s 12 points higher than their urban and suburban counterparts, and a figure that has surged 25 points in just two years. Rural physicians also report constant burnout at a rate of 67%, with 69% reporting they’ve considered leaving the medical profession entirely.

“Rural hospitals and independent practices serve as primary access points in many communities,” said Joe Ganley, vice president of government and regulatory affairs at athenahealth. “Ensuring they can modernize and remain financially stable is essential to preserving access over the long term.”

These numbers have real consequences: can patients afford care? Is there a facility nearby to deliver it? Are there enough clinicians left to staff it?

HR-1 and federal policy changes are amplifying all three challenges. Potential adjustments to Medicaid eligibility, uncertainty around 340B pharmaceutical funding, and the budget provisions of HR-1 are creating what leaders on the ground described as a funding cliff that will fall hardest on the organizations serving patients who have nowhere else to go.

But the Rural Health Transformation Program, which directs $50 billion to rural healthcare providers over the next five years, offers some relief. Healthcare organizations and companies, including athenahealth, have emphasized the importance of federal support efforts to strengthen rural healthcare and streamline technology investments that can help rural hospitals survive and thrive.

Building a talent pipeline
At the heart of every rural access challenge is the question of who will actually deliver the care. For Kelly Macken Marble, CEO of Osceola (Wis.) Medical Center, that question is urgent and personal. She’s recruited 10 clinicians in the past year and a half, but recruitment alone isn’t the answer if the environment drives people out.

In an effort to improve retention, she is pursuing two parallel workforce initiatives. The first targets moral injury — systematically identifying the administrative burdens that pull clinicians away from patient care and working to eliminate them. The second is participation in a Wisconsin statewide effort to reduce the stigma around physicians seeking mental health support, including addressing fears about licensure consequences for those who do.

“We need to take care of our teams, first and foremost, so they can take care of patients,” she said.

The physician survey data reinforces why this matters beyond the individual: reducing administrative tasks tops the list of what rural physicians say would most simplify care delivery (51%), and 40% are considering major operational changes to offset financial burdens. When the system fails to support clinicians, it accelerates the very workforce shortage that makes access worse for patients.

“It’s really hard to run a practice and it’s hard to run a community health center because of all the administrative workflow burdens that surround care delivery. The caregivers are awesome, but it’s really hard to manage all of the unnecessary complexity of care for patients, and all the transactional and administrative work that goes along with that,” said Mr. Ganley. “At athenahealth, we try to build products and services that make that work easier. Our mantra is curing complexity.”

Expanding what’s possible
For rural hospitals operating without the scale of larger systems, survival increasingly depends on adding services that serve both the community and the balance sheet and finding creative ways to fund them.

Raymond Hino, CEO of Southern Coos Hospital and Health Center in Bandon, Ore., has been doing exactly that. When Rite Aid closed its local storefront with almost no warning — leaving the coastal town without its only major retail pharmacy — Southern Coos was already 12 months into planning a pharmacy of its own. It opened in June 2025, and the community’s need was immediately apparent.

“Our utilization numbers have been much higher than what we initially anticipated,” Hino said. “We thought we were going to have a gradual ramp up over six to nine months, but we got fairly busy pretty quickly.”

The pharmacy is one piece of a broader expansion. Mr. Hino invested $800,000 to renovate the hospital’s sterile processing department and reopen a surgery program shuttered during the pandemic. He’s launching group psychiatric therapy for seniors through a partnership with Senior Life Solutions, targeting depression, loneliness, and caregiver burnout in a retirement-heavy community. The hospital also received a $171,000 grant from the Bandon Dunes Golf Resort’s charitable foundation to fund a master facility plan for the next generation of the hospital’s physical footprint.

Osceola is on a similar trajectory. Ms. Macken Marble is adding 20,000 square feet, opening a second clinic in Minnesota, and building out substance use withdrawal treatment services, a gap her county data identified as the highest unmet need in the region. But just identifying the need doesn’t mean a new service line will make financial sense for the organization.

“We’ve got to be really smart about what we add and when we add it. We don’t want to overextend ourselves so that if we do experience a reduction in reimbursement, we’ve got the financial bandwidth to manage that.”

As healthcare providers expand services and locations, the need for more communication and interconnected systems increases. Interoperability has been a challenge in healthcare for many years and athenahealth is committed to being part of the solution.

“Physicians continue to report difficulty exchanging information across systems, and most say those gaps increase stress,” said Mr. Ganley. “In rural settings, where care coordination often spans multiple organizations, fragmented data translates into additional work for already lean teams.”

Other industries are much more interoperable and serve as a model for healthcare. The end goal: to share information across platforms and provide better patient care.

“Healthcare ought to be technology agnostic and platform-agnostic. We’ve built a lot of infrastructure over the last 10 years to make that possible,” said Mr. Ganley. “Right now, we’re getting everybody over the hump so they are comfortable with it. We’ve built the ability to do it from a technology and privacy standpoint, and we need to break some of the old business models a bit more so folks are comfortable moving health information.”

Financing the Mission
None of this expansion happens without financial discipline, and the policy headwinds are making that discipline harder to maintain. For Sham Firdausi, deputy CFO of the County of Santa Clara Health System — one of the nation’s largest public safety net systems, serving nearly 2 million California residents regardless of their ability to pay — the stakes are existential. HR-1 alone represents a projected shortfall approaching $1 billion for the system by 2028.

“Constraint breeds innovation,” Mr. Firdausi said. “When the traditional approaches don’t work, we’re forced to think differently.”

His response is operational: embedding finance leaders within clinical teams, standardizing revenue cycle processes end-to-end, and pursuing payer-provider partnerships that leverage his background on the health plan side. Nationally, the physician survey found that 49% of physicians are more concerned about claim denials than declining reimbursement rates, a signal that operational efficiency has become as critical as advocacy.

For Mr. Hino, the long-term financial answer lies in collective action. He’s working with Oregon’s state government and the Rural Health Transformation Program to build a clinically integrated network among 13 rural independent hospitals, giving small, unaffiliated facilities the scale for value-based contracts.

“We have several very excited and motivated hospitals that are excited about partnering together and we believe that through the partnership, we’re going to create new and more beneficial payer contracting, which would be so important,” he said. “That’s something I’m really looking forward to in the coming year.”

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