One State’s Sprint for its Share of Trumps’ $50B Rural Health Fund

Dan Gorenstein (DG): Last November, every state in the nation pitched the Trump administration for how to spend $50 billion to transform rural health care. 

The ideas the White House liked best would get more money. It was a competition.

news clip: The state of Idaho is seeking up to a billion dollars in federal funding to help transform health care in rural communities across the state

news clip: The West Virginia Rural Health Transformation Fund application is now available.

news clip: Washington Gov. Bob Ferguson announced the state has applied for the federal Rural Health Transformation program.

DG: For states, the whole endeavor has been fast-paced and daunting. 

They had just 52 days to come up with ideas.

And if they fell short, they risked losing out on a big cash infusion, just as states begin to brace for a major cut to federal health funding. 

In Maryland, this pressure-filled task fell to Elizabeth Kromm. 

Elizabeth Kromm (EK): This is something that can be solved. But there’s sort of getting through and solving it, versus getting through and winning.

DG: This is part two of our look at this huge, one-time investment in rural health, and how one state looked to make the most of it. 

We followed Elizabeth over those 52 days as she balanced White House and state policy priorities, juggled competing demands, and hunted for ideas to make headway on endemic problems in rural America. 

Today, we hear how Elizabeth had to be ready to make hard choices if the state got less than that it hoped. And, finally, she finds out just how much Maryland is gonna get.

From the studio at the Leonard Davis Institute at the University of Pennsylvania, I’m Dan Gorenstein. This is Tradeoffs.

*****

DG: When Republicans in Congress created the $50 billion fund last summer, they set a few ground rules. 

One: every state would get at least some money, assuming the administration approved their plan. 

But the Trump administration got to hand out a lot of it, ranking states on White House priorities. The administration had until December to announce the awards. 

Mehmet Oz: We have just started to get the scores back from grading these applications, which are done by outside experts and we will allot all that money by the 31st of this month. 

DG: Here’s the catch: How much Maryland gets will create a new round of hard choices for Elizabeth. 

The Trump administration told each state to build a $200 million dollar a year budget for five years … a billion bucks per state. 

So that’s what Elizabeth did. 

But, she knows Maryland won’t get that much because the White House and Congress gave preference to states more rural than Maryland. 

EK: I think I was always thinking we’d end up at like 120, if I were betting. So maybe we get a little more, maybe it’s a little bit less. I mean, maybe it ends up being, like 102 million. I mean, who knows?

DG: The difference between Elizabeth’s ballpark estimate, and $200 million a year, that’s a big difference. 

Maryland would need to cut its plans in half, under the worst-case scenario. 

Elizabeth prepared for this uncertainty, uncertainty being a hallmark of health policy under the Trump administration. 

Elizabeth needed some wiggle room. So, she took a page from the White House playbook. 

EK: To maximize our flexibility, we decided that we would basically put a call out for the best ideas and  then award grants to those projects that were really seen as the best way to make a difference and and show impact.

DG: The number and size of grants could go up or down – depending on how much the state gets.

A lot of what Maryland wants to do, get more people into health jobs, expand ways people can get medical care, feed people more locally grown food, all depends on the fate of those grants. 

Mike Salvadge is one of many people hoping to get a piece of it, but his odds of getting money go down if the administration sharply scales back Maryland’s award. 

DG: Mike’s the emergency medical services chief for Allegany County in western Maryland. 

He’s got ambulances stationed at seven locations in a county that stretches across 430 square miles – almost as big as the city of Los Angeles.

Unlike LA, a lot of those miles are mountains and wilderness.

Melanie Evans (ME): I feel like we’re in a forest.

Mike Salvadge (MS) We are in the forest. This is this is very, very forest-esque.

DG: Tradeoffs reporter Melanie Evans rode along with Mike one day last November to get a clearer sense of what it takes to do his job.

ME: Emergencies, Mike tells me, bring ambulances up narrow and winding roads to reach houses perched on hillsides.

MS: It’s it’s very steep and just it’s almost like they just went right up the mountain, cut a new road in a new spot, put some houses, went up the mountain a little bit, cut a new road, put some houses in.

ME: Mike’s job is to make sure help shows up quickly in an emergency, anywhere its needed: the forest, remote farms, mountain trails.

MS: You get kids that ride on four wheelers and they crash them. Happens all the time up here.

ME: Have you had to rescue someone on an ATV?

MS: Several times.

ME: I mean, this seems like a stupid question, but I’m going to ask it. How is it different rescuing someone on an ATV than with, like, a ambulance?

MS: If it were in the back of our ambulance, it’s our home turf. When you have to go up into the woods seven miles, you have to gather up all of your stuff out of that ambulance, put it on to an ATV. Hopefully you did not forget anything.

ME: Practicing emergency medicine out here is more work, it takes more time. 

That’s a problem for Mike. 

When one ambulance is tied up, other crews are forced to cover more ground.  

With each additional 911 call, that problem gets compounded. 

MS: There are several times a day, probably 50% or more of the days, where, between the city and the county, every single ambulance is on a call at the same time.

ME: Mike says, when that happens, the entire emergency response system can be  stretched to its limit. 

What frustrates him is that his ambulances are often out on calls that – in theory – could be avoided. 

People with manageable problems, say an older person confused about her meds.

A quick fix, if she had a way to get to the doctor’s office.

But without a ride, simple problems like these fester. 

MS: They will wait and wait and wait and wait until they are so sick that they know that they can’t do anything themselves, and then they’ll call. And then then they’re in the hurt locker because they’ve gone so far down that it’s hard to get them back out of it, but it happens all the time.

ME: Then there are calls that bring ambulances to an emergency… that isn’t. Low-grade symptoms that could be evaluated in a clinic. Someone who needs a lift to dialysis. 

Mike sees the new rural health fund as a great shot to hire community paramedics, basically, first-responders trained to handle an emergency – but also prevent one. 

MS: You’re going to call us. We’re going to take you to the emergency room. That’s just the way the system is. It’s the way the system has been for decades. we’re trying to do better.

ME: Maryland agrees that community paramedics, and other ways to bring medical care to people, would be a great use for the new rural funds. 

Mike wants to see  community paramedics step in early, helping some Allegany folks avoid a crisis and keep less-urgent calls out of the emergency room. 

And this, in turn, would keep ambulances and paramedics available for more urgent calls. 

MS: Let’s free these people up from these things. So in case something legitimate serious happens, they’re there, they’re available, they can get there quick.

ME: Mike says he’d spend the money on equipment, training and, for a few years, salaries. Over time, payments from health insurers would cover the tab. 

These are start-up costs, Mike says, that Allegany County can’t afford. 

MS: That grant would probably make or break us. It’s something we probably could pretty easily put into motion, should we be awarded some funding. I don’t see it happening for several years if we’re not able to secure that. 

ME: He’s hoping his idea will be a winning one. One that can save lives. 

He knows first-hand the risks that someone may die needlessly when his EMS system is overextended.

A few summers back, both ambulances at Mike’s station were called out runs, non-urgent ones.

MS: You always get a little bit of groaning and moaning when the call comes out, and it sounds like something that probably doesn’t necessarily require an ambulance call. It’s more of a routine thing.

ME: Another paramedic, Christina Koontz, had dropped in on her day off. 

And a 911 call came in. 

Christina Koontz (CZ): It was a breathing difficulty, which, can go from absolutely nothing to like, oh, crap, this is serious.

MS: I looked at Christina and I asked her. Can you run this call with me? 

ME: With no ambulance available they jumped in a fully stocked SUV, what they use for a backup.

It’s got everything they need, except a stretcher and somewhere to put the patient if they need to go to the hospital.  

ME: From the moment Christina and Mike lay eyes on the patient, they realize the SUV they drove up in is the problem. 

CK: [Yeah] I’m like, uh oh (laughs).

ME: To a paramedic, ‘uh oh’ is serious. 

CK: Do I have the equipment to help them or to fix them? Maybe. Maybe not. Maybe they need something that only a hospital has. 

ME: The two decide the patient needs to get to the hospital now. But the ambulance is still a ways out.

Then, Mike’s radio squawks.

There’s another person struggling to breathe, a few doors away.

Mike rushes down the block.

MS: We make jokes and stuff for, like, maybe the neighbor saw and was just very curious. And then I walked in the door. I was like, nope, the neighbor’s trying to die, too.

ME: Two paramedics working on two patients, desperately trying to buy time until ambulances show up. 

CK: It could have been five minutes. It could have been 15 minutes whenever you’re working like that. I mean, time, time goes by pretty quick.

ME: This is what it looks like to be a paramedic in Allegany County. 

All that strain on the system, over-extended resources, plugging holes in rural health care, strain that puts lives at risk, it all lands on paramedics and first responders. 

And it takes a toll. 

MS: I can tell you from experience that the first time you’re answering one of these calls that you don’t really need to be there, and then something serious happens that you could have been there right away, and there’s a negative outcome. You feel like garbage for weeks, months, years sometimes. 

ME: Finally the first ambulance arrives. Then the other. Both patients made it to the hospital safely.

Christina tells me she understands that day could have gone differently. 

CK: I mean, luckily for those two people, I happen to walk in. Mike was there. But had we not have been there, I mean, they they could have waited, Could that have meant life or death? Yeah, it could have.

ME: Mike knows that Maryland has prioritized projects like community paramedics for the new rural money, a way to improve critical emergency services for places like Allegany County. 

The reality is that if the Trump Administration awards the state less than it budgeted for, there will be less money to go around. 

That could mean less resources for the farming infrastructure the state wants to get healthier food into the hands of Marylanders. 

That could mean less money for the community paramedics – first responders who could be the difference between getting to the hospital on time or not.

Mike tells me, no matter how long his odds are, he’s going to keep pushing his case.

MS: I’m always very hopeful that we’ll be able to do something. And I try to continue that hope until somebody shuts my hope down. So as long as I don’t get the door shut on me, I’m going to continue to hope and we’re going to continue to try to push forward as if, all right, we think this is coming.

DG: When we come back, Maryland and Mike get their answer. 

BREAK

DG: Welcome back. The Trump administration, it waited until almost the last minute before it revealed exactly how much each state would get.

Mehmet Oz: Today’s the day! Fifty states are going to find out exactly how much money they’re getting from the Rural Health Transformation Fund.

DG: That is Mehmet Oz, one of the administration’s top health officials, on Facebook, on December 29. It’s two days before the deadline Congress gave the White House to hand out the money.

Mehmet Oz: This massive 50 $billion that the president and Congress are giving to our governors, and every state applied, and every state’s going to get money, but how much money, you’ll find out today.

DG: When the news broke, we called Elizabeth Kromm, the Maryland official who pulled together the state’s bid for the money. 

At the low end, she expected $100 million a year. 

The high, $200 million, that seemed out of reach.

Elizabeth got the news at home as she was helping her daughters with some field hockey drills.

EK: I was being the official timer. So that’s when I got the text, as they were saying, can you time me again? I was like, hold on, hold on. They were like, “oh, is this the thing? Is this the thing you were working on?” I’m like, yeah. And they’re like, “did you get, did you get 100 million?” I was like, no, I got 168 million. 

DG: That amount means Maryland has about 85% of funding for its proposed projects. 

EK: I think we accomplished our goal. We set out to capture as much as we could in a very strong program that would actually move the needle for what we know are incredibly sticky issues in the rural parts of Maryland when it comes to health. So this is really good.

DG: Good, because Elizabeth will have to make fewer cuts than she had initially feared. 

Still, Maryland needs to pare back, somewhere. 

So, she and her staff spent the first few weeks of 2026 trying figure it out.

Tradeoffs reporter Melanie Evans and I caught up with Elizabeth in the middle of January to see what they’d decided.

Like so much of America at that point, Elizabeth had some kind of bug. She was losing her voice.

EK: Do I sound okay to you?

ME: No, I you definitely sound like you’ve lost your voice. I don’t know if it’s like, if it actually hurts to speak, so you just kind of… 

EK: It doesn’t hurt to speak.

ME: Okay.

EK: Yeah. I’m fine.

DG: Under the weather or not, when it comes to the rural health fund, Elizabeth is feeling pretty good these days, even if she had to make some budget cuts. 

Deciding where to trim represented another policy puzzle for Elizabeth to solve.

Again, tapping into her capacity to think strategically, she came up with several ideas that made sense and minimized the hit to Maryland.

EK: I can give you one example: telehealth. 

DG: In its application, Maryland proposed spending $13 million to identify gaps in telehealth and to plug those holes. 

With the smaller budget, though, the state opted to first focus on finding the gaps, and delay the fixes. 

EK: We reduced that sort of bucket to really focus on the needs assessment. So it came down a fair bit, but we knew everyone was okay with that because we know you first have to assess and figure out what’s the scope of the problem before you can start addressing it.

DG: Maryland had three big, overarching goals in its proposal. Each got cut back a bit. 

The first: More people in health jobs. 

EK: The revised workforce budget is 91% of what we proposed.

DG: The second, find more ways to get people medical care.

EK: The sustainable access piece is 82% of what we proposed.

DG: And finally, food. Get more people to eat fresh, locally grown food. 

EK: The food pillar, or eating for health, is about 87% of what we proposed.

DG: Sustainable access, that is the pillar that includes community paramedics – the folks Mike Salvage wants to bring to the mountains of Allegany County. 

Elizabeth says getting people the care they need, that is one of the state’s top priorities.

EK: You don’t often get the dollars to bring care to people in this way. Sometimes you only get one shot at something like this. And so you want to make sure that you’re being true to what we set out as our overall vision of really trying to make the most out of each dollar that we do receive through this fund.

DG: Maryland doesn’t get the final say in what to cut. The Trump administration must sign off on Elizabeth’s revised budget by the end of February.

After that, the state will move quickly to open up competition for state grants, one Mike hopes to win.

So Mike will know, very soon, how much money for projects like his will start flowing.

MS: We’re just kind of in that holding pattern of waiting to pull the trigger. Once we get the up or down on this, then we can really start making some moves

DG: As we interviewed people for this story, inside and outside Maryland, we heard a lot of optimism that this money could do more than buy stuff. It could change stuff. 

Hemi Tewarson (HT): If everything worked exactly as we all wanted it to, we’d see meaningful change.

DG: That’s Hemi Tewarson, executive director of the National Academy for State Health Policy, a nonprofit where policymakers can learn and trade ideas. 

Hemi’s most ‘glass half full’ take,  this money may, finally, fix a few things that have long been broken.

HT: So, I hope some of these planned uses of the funding, are going to meet the intended goals. I hope many of them will. 

DG: But here’s the ‘but.’

While this money helps finally shine a bright light on rural health needs – issues typically ignored – it’s limited. 

HT: The funding is only for five years. So that’s a short amount of time to truly transform a system that’s been underfunded and has a number of challenges for many, many years.

DG: And then there’s the reality that millions of people are expected to lose health insurance under new Republican policies.

Those people will rack up debt at rural hospitals and clinics, which will find it harder to break even. Other policies will squeeze federal dollars that flow to state Medicaid programs. 

Total lost revenue is projected to be nearly three times the size of the new rural fund, adding strain on rural healthcare from already tight state budgets and changes to the Affordable Care Act. 

HT: These dollars can’t make up for all of that.

DG: Back in Maryland, Elizabeth knows this. 

Across the country, she and her peers, they are trying to strike this balance.

How do they make it all work, this huge windfall for rural health, and also this huge hit, looming on the horizon? 

Elizabeth response to this moment: she’s decided to focus on the work in front of her. 

EK: This is money that was not expected. I mean, one could take a different view, more cynical, of there’s been so much taken away, right, that this is a drop in the bucket to what we had before.

I’m going to take this for what it is. This is a great opportunity. And if we do not make the most of every dollar coming to us through whatever way, shape or form to drive to what we know are the things that are going to improve the health of Marylanders, then shame on us. 

DG: None of this, the new money, the cuts ahead, is happening in a vacuum. 

Maryland is wobbling on a recession. 

The Trump administration has scaled back public health funding, most of which flows directly to states and counties.

Meena Seshamani (MS): I mean, I wish there were one word to describe like how from challenge comes opportunity. Is there a word for that?

DG: That is Meena Seshamani.

She’s Elizabeth’s boss, and the health secretary for Maryland. 

It’s Meena’s job to keep up with federal changes and keep Maryland’s services going. Addiction treatment. Vaccines. Safety net insurance.

That’s been a big part of the job for all state health policymakers in the last year, keep up and keep going.

Maryland is adapting to a new relationship with federal agencies, Meena told us, one where the state relies less on Washington for health policy or steady funding. 

MS: I mean, these are really sobering times. There is less predictability, there is more uncertainty. There have been funding cuts, and, it has meant that we have to come back to where are our strengths.

DG: The exercise of applying for this rural money has been instructive, Meena says. 

MS: I spoke at the Rural Maryland Council. I had someone come up to me from western Maryland who said to me, put me in coach. I had a farmer come up to me from the eastern shore who said, we are ready. We can ramp up our food supply. 

DG: Meena’s boss, Maryland’s governor, he’s a Democrat. 

Western Maryland, the Eastern Shore, they vote Republican. But in that moment, she said, they had a shared goal. 

MS: That is what, in the middle of all of the uncertainty, the swirl, the chaos, the crisis, whatever term you want to use, that is where the opportunity presents itself.

DG: It’s these connections, across Maryland’s communities, that are the state’s strength, says Meena.

MS: I think what we can all agree on is that we want people to be healthy. It comes back to what I instill in my kids. There is a commonality for us that I think we always have to tap into, especially in tough times.

DG: This point of agreement, this shared desire for people to be healthy, this is where Meena sees a path forward through the uncertainty with Washington. 

I’m DG, this is Tradeoffs.