The Foundation that Binds and Sustains Rural North Carolina

In 2018, Dr. Tom Irons and I authored an issue brief commemorating the 45th Anniversary of the North Carolina Office of Rural Health, titled “Looking Back but Leaning Forward: New Opportunities and Challenges for North Carolina’s Rural Communities.” At that time, rural North Carolina was grappling with the aftermath of Hurricane Dorian. Since then, rural communities across the state have continued to face both opportunity and hardship—from the emergence of COVID-19 in 2020 to the long-awaited adoption of Medicaid expansion to the devastating impact of Hurricane Helene on 27 counties in Western North Carolina.

The North Carolina Institute of Medicine’s (NCIOM) 2014 Rural Health Action Plan remains an important touchstone for evaluating progress in rural health.^1,2 The plan outlined key priorities: strengthening small business and entrepreneurship, ensuring high-quality early childhood environments, promoting healthy eating and active living, increasing access to integrated mental health and substance use treatment, educating rural residents on insurance and safety-net resources, and recruiting and retaining health professionals in underserved areas. The 2018 NCMJ issue revisited these goals, with updates to the Rural Health Plan from Dr. Adam Zolotor. Readers are encouraged to revisit that report to more fully assess advancements and opportunities for transformation in rural health.³

North Carolina’s rural landscape is rich in beauty, heritage, and culture. Today presents a rare moment to reflect on “all things rural,” celebrating the communities and people who define these places. While it is essential to examine the needs and challenges rural communities continue to face, it is equally crucial to recognize the longstanding programs and infrastructure that have sustained rural North Carolina for decades. The state has the second-highest rural population in the nation and ranks among the top 5 states for total veteran population. This deep rural legacy has been shaped by visionary efforts, including the establishment of the nation’s first Office of Rural Health in 1973, the founding of the University of North Carolina (UNC) Cecil G. Sheps Center for Health Services Research, the creation of Area Health Education Centers (AHEC), the NCIOM, and the NC Rural Center’s decades of leadership in supporting entrepreneurship and community-led development.

Defining “rural” remains complex. As Susie Gurzenda and Mark Holmes explain in “Measuring Rural in North Carolina,” definitions matter. They affect data collection, resource allocation, program design, and service delivery. With 100 counties stretched across more than 500 miles, North Carolina’s diversity demands thoughtful partnership and planning grounded in respect for local culture, geography, and values.

The Rural Health Transformation Program (RHTP) emerged from federal concern that national legislation would disproportionately affect rural communities. Under a cooperative agreement with the Centers for Medicare & Medicaid Services (CMS), North Carolina received $213 million per year for 5 years—equating to roughly $72 per rural resident.⁴ States with smaller rural populations received more per capita due to how the legislation was structured.

Substantial reductions in Medicaid funding for rural hospitals and providers compound these challenges: North Carolina hospitals alone are projected to lose more than $3.7 billion over 10 years, not including additional cuts to rural clinicians.

Carrie Cochran from the National Rural Health Association outlines these federal changes in “Federal Funding Changes and Anticipated Impacts on Rural Hospitals: North Carolina at a Crossroads.”⁵ Yet even amid these challenges, North Carolina’s longstanding commitment to rural communities positions the state to “make hay while the sun shines.” The RHTP offers historic opportunities to strengthen rural care networks, expand primary and preventive care, integrate behavioral health and substance use services, modernize digital health infrastructure, develop innovative workforce models, and promote financial sustainability for rural providers.^6,7 RHTP Director Maggie Woods and colleagues describe these efforts in “Transforming Rural Health in North Carolina”.⁸

In 2018, the Aspen Institute’s Community Strategies Group released a report outlining Rural Development Hubs—or Hubs for short⁹:

"Rural Development Hubs are main players advancing an asset-based, wealth-building, approach to rural community and economic development in this country.

They are the most visible actors in rural America designing and implementing efforts that simultaneously:

• Increase and improve the assets that are fundamental to current and future prosperity: individual, intellectual, social, cultural, built, natural, political and financial capital.

• Increase the local ownership and control of those assets.

• Always include low-income people, places and firms in the design of their efforts—and in the benefits.

In short, Hubs offer a framework for NC’s consideration including critical ingredients in a region’s system that either advance or impede prosperity—the integrated range of social, economic, health and environmental conditions needed for people and places to thrive."¹⁰

Chris Estes and colleagues (unpublished manuscript) are building the NC Rural Center’s programs and leadership using the framework generated from the Rural Hub model, the Thrive Rural Framework.⁹ The Thrive Rural Framework “is grounded in the relationships and connections that underlie rural development: people, governments, and systems all working together and in parallel to achieve greater rural prosperity for all.”⁹ The Framework offers North Carolina’s diverse communities a strategy to navigate opportunities and challenges across partners in economic development, education, health care, and other sectors essential to transformation and rural prosperity.

Workforce development remains foundational. Hawes and colleagues highlight the value of rural residency programs, which improve recruitment, reduce wait times, expand service lines, and stimulate economic development.¹¹ The UNC System’s Rural Health Care Workforce Initiative, supported by the North Carolina General Assembly, leverages RHTP funds to build workforce pipelines across behavioral health, allied health, and other critical areas. The Governor’s Council on Workforce and Apprenticeships complements this strategy by ensuring access to career pathways that support thriving families and communities. The North Carolina Medical Society’s Community Practitioner Program continues to provide support to rural providers and their practices. Walker and colleagues discuss the program’s progress since it was established in 2006.¹²

Rural health is an ecosystem influenced by housing, transportation, food access, and other factors affecting health.¹³ North Carolina’s Healthy Opportunities Pilots (HOP)—the nation’s first comprehensive Medicaid initiative to fund non-medical services—have demonstrated reductions in health care spending, improved quality of life, and strengthened rural economies. As North Carolina Division of Health Benefits Deputy Secretary for Medicaid Melanie Bush notes, “HOP isn’t just about lowering health care costs, it is also about keeping dollars local, building on community strengths and making sure North Carolinians have the resources they need to stay healthy.”¹⁴ Jones and colleagues highlight this success in “The Living Infrastructure of Food is Medicine.”¹⁵

Digital access is another essential component of rural prosperity. The Division of Broadband and Digital Opportunity, established in 2021, aims to ensure statewide access to high-speed internet and digital literacy. The Division’s mission is to drive economic and workforce development by enabling all North Carolinians to fully participate in the digital economy through expanding access to high-speed internet, digital devices and digital literacy across the state.^16–18 Advances in interoperability, discussed by Oputa and colleagues, and emerging technologies such as artificial intelligence, explored by Greenblatt and colleagues, will further shape future rural care delivery.^19,20

RHTP investments also expand behavioral health, EMS, and community paramedicine. As Kimberly Clement notes, EMS providers often have unparalleled insight into the social conditions affecting rural patients.²¹ A recent $10 million RHTP investment supports mobile integrated health in 39 counties, strengthening local EMS agencies and improving community-based care.²²

Addressing behavioral health needs also requires leveraging opioid settlement funding. Harris and Edwards describe Rowan County’s comprehensive program as an evidence-based approach that saves lives, prevents infectious disease transmission, and strengthens connections to treatment and recovery.²³

Collaborative Practice Agreements between pharmacists and primary care providers can extend access to care in rural communities. Syed and colleagues describe the opportunity to increase these agreements using recent legislative changes in North Carolina Session Law 2025-37 (House Bill 67) and the current work underway in Roanoke Chowan and MAHEC.²⁴

Child care access remains a major barrier to rural employment and family stability. Leanne Martin’s work underscores the far-reaching consequences of inadequate child care for rural families and communities.

Finally, rural health must include support for veterans. Following passage of the 2022 Sergeant First Class Heath Robinson Honoring our Promise to Address Comprehensive Toxics Act (PACT Act), the North Carolina Institute of Medicine launched the Task Force on Veterans’ Health to improve access, coordination, and workforce readiness.²⁵ Cherry Kilby’s “The Quiet Crisis: A Call for Community-Embedded Solutions for Rural Veterans” highlights transportation and care gaps that uniquely affect rural veterans.²⁶

Finally, it is important to recognize the resources that help us discover new, informed, and innovative ways to serve and partner in rural North Carolina. Colleen Briggs highlights the powerful intersection of philanthropy, long-term impact, and sustainability.²⁷ Close engagement with philanthropic partners is essential for amplifying successes, understanding challenges, and sharing lessons learned.

Our federal partners have also played a vital role. The Federal Office of Rural Health Policy within the Health Resources and Services Administration (HRSA) has supported innovative efforts aimed at the unique environmental and institutional factors that contribute to financial instability in rural hospitals, workforce recruitment and retention challenges, and other barriers to healthcare access in rural communities. These resources informed the RHTP, and, combined with state, philanthropic, and local investments, expand what is possible.

Additionally, the CDC Office of Rural Health was established in January 2023 following congressional funding in the fiscal year 2023 Omnibus Appropriations bill.²⁸ The office focuses on rural populations and the drivers of health and disease, and it supports efforts by sharing national and state-level data.

The road ahead holds promise if we can partner and collectively weave these opportunities together. Borrowing from our 2018 commentary: rural North Carolina thrives because of the grit, resourcefulness, and deep engagement of its residents. This issue of the NCMJ is dedicated to those leaders, providers, and community members who continually strive to improve conditions where they live. Our sustainability lies in “the foundation that binds us”—decades of shared commitment to rural communities and an enduring willingness to adapt. Perhaps now is the time to revisit and update our Rural Health Action Plan, ensuring that North Carolina continues to lead in rural innovation, resilience, and prosperity.

Acknowledgments

The author refined language in this brief with the assistance of Microsoft 365 Copilot.

Declaration of Interests

The author has no conflicts of interests to share.

Correspondence

Address correspondence to Margaret L. Sauer, 2009 Mail Service Center, Raleigh, NC 27699-2009 (maggie.sauer@dhhs.nc.gov).