By San Lee · Updated October 24, 2026
For most of 2026, following the Rural Health Transformation Program has felt a little like assembling a puzzle while the pieces were still being manufactured.
States had plans. CMS had approved initiatives. Funding had been awarded. Then RFAs, RFPs, grants, contracts, subawards and implementation announcements began appearing, often under names that did not match the original state plans.
Now the picture is becoming much clearer. CMS has begun publishing a much richer national view of Year 1: state award amounts, State Policy Action commitments, initiative stages, obligated funds, state snapshots and, most recently, a 58-page Planned State Initiatives, Budget Period 1 report.
The new CMS data is enormously useful. But after comparing it against what Rural Care Journey has been tracking every day across the states, one thing becomes clear:
The federal view tells us what the program is supposed to become. The state-level implementation trail tells us what it is actually becoming. And there is still a significant distance between the two.
When RHTP launched, CMS described five strategic goals: healthier rural populations, sustainable access, workforce development, innovative care models and technology innovation. The new Planned State Initiatives dataset gives those broad goals much more definition. Across the states, CMS now identifies activity such as:
(These counts are the states CMS names in each focus area. For four of them, the deck's own headline totals run one or two higher: the deck disagrees with itself on 13 of 43 focus areas.)
That tells us something important about RHTP. This is not simply a rural hospital stabilization program. States are using the program to redesign how care gets delivered: who delivers it, where it happens, what technology connects it, how patients move through it, and increasingly, how that care might eventually be paid for.
The pattern is much broader than replacing equipment or issuing grants. It is an attempt to build a new rural-care operating model.
CMS's first obligated-funds report covers state-reported activity through July 31, 2026. CMS explicitly warns that it is not a full view of state progress and says the data will be refreshed after the November 30 quarterly reports. That warning matters.
The report reflects roughly $4 billion of the $10 billion in first-year awards as having been obligated nationally by July 31. But the variation among states is enormous.
California had already reported $219.1 million put to work from its $233.6 million award. Georgia reported its full $218.9 million award committed. Meanwhile, New York reported zero dollars obligated as of July 31, and West Virginia also reported zero.
That does not necessarily mean those states were doing nothing. It shows why timing matters. New York, for example, subsequently had a $76 million RHTP investment announced by CMS on September 4 for regional coordination, technology-enhanced primary care and workforce development.
Alaska illustrates the problem even more clearly. The CMS Year 1 financial snapshot showed only about $11.5 million of Alaska's $272.2 million Budget Period 1 award put to work as of July 31. Yet on October 22, the Alaska Department of Health announced nearly $249 million awarded to 254 projects, completing the state's Year 1 funding cycle.
Nothing is wrong with either figure. They describe different moments. And that is precisely the problem anyone trying to understand RHTP now faces.
A federal report can be accurate and already be behind the implementation market.
Michigan recently made its full CMS-accepted Year 1 Annual Report public. It is fascinating because it shows how much work can occur before traditional outcome measures begin moving.
Michigan reported approximately $26.0 million allocated to its partnership initiative, $44.7 million to workforce, $48.8 million to interoperability and $41.7 million to care closer to home. There were letters of intent, grant opportunities, partnerships and implementation preparation.
Yet as of July 31, several of those initiatives still reported: “0 individuals served, implementation activities not yet started.”
That should not be interpreted simply as failure. It illustrates the sequencing of transformation. Before patients appear in an outcome metric, somebody has to establish governance, design the program, approve budgets, build partnerships, procure technology, award grants, integrate systems, recruit people and establish measurement.
CMS's checkpoint model actually recognizes this. Stage 0 covers planning. Stage 1 covers project preparation and launch. Stage 2 moves into early implementation, including continuing activities, achieving a post-launch milestone, establishing metric methodology and submitting an updated project plan.
The challenge is that outsiders often collapse all of those phases into one word: “funded.”
But funded is not the same as obligated. Obligated is not the same as awarded to a provider. Awarded is not the same as implemented. And implemented is not the same as producing measurable patient outcomes. That distinction will become increasingly important in Year 2.
Look at Veterans' Health in CMS's new dataset. CMS identifies six states with RHTP activity related to veterans.
Michigan, Alabama and Nevada appear under behavioral health and CCBHC-related services. Nebraska, Nevada, Texas and Wisconsin appear under VA-rural provider integration and EHR coordination. Nebraska's plan is particularly specific: integrating VA External Provider Scheduling with rural EHR infrastructure to improve scheduling and reimbursement for rural providers caring for veterans.
Now compare the plan with implementation. As of October 24, RCJ had identified dedicated veterans-health solicitations in Nevada, such as Nevada Rural Veterans Health Transformation.
But in Alabama, Michigan, Nebraska, Texas and Wisconsin, CMS identified planned veterans-health activity while RCJ had not yet found a dedicated solicitation corresponding to it.
That does not prove that nothing is happening in those states. Some work may be performed through existing contracts, direct awards, interagency arrangements or broader solicitations. But it gives us something valuable: a place to watch. And this is where RCJ's role begins to differ from CMS's.
When we compared CMS's newly published information against RCJ, we found some things we needed to fix ourselves.
CMS now identifies 322 official state initiatives. RCJ's initiative taxonomy had been reconstructed from state narratives and documents, so only 69 of those official names matched directly. We corrected that.
CMS also publishes exact award amounts, initiative stages and 19 State Policy Action categories in its State Data Maps. RCJ has now incorporated those into state pages, comparisons and the public API.
But the comparison also uncovered inconsistencies in CMS's own new focus-area deck. For 13 of 43 focus areas, the headline total, map or named-state lists do not fully agree. The Veterans' Health section itself provides an example: the overview indicates five states for VA-rural provider integration, while the detailed page names four: Nebraska, Nevada, Texas and Wisconsin.
These are relatively small discrepancies. The bigger finding is more consequential.
Across CMS's focus-area/state combinations, RCJ found 753 of 1,553 planned state focus areas with no corresponding solicitation yet (live figure as of October 24). And according to the CMS stage information captured by RCJ on October 23, none of the 322 initiatives had moved beyond Stage 2.
In other words: a substantial portion of the RHTP opportunity market may still be ahead of us.
CMS Planned Initiatives vs. RCJ
Every CMS focus area by state, split by whether a solicitation has appeared, with the live opportunities behind each one.
Budget Period 2 begins October 31, 2026. Year 1 was largely about converting plans into programs. Year 2 should increasingly be about converting programs into evidence.
CMS has made clear that future state funding is not automatically identical to Year 1. In its post-award FAQ, CMS says states may budget around an average of $200 million per subsequent year, and that state budgets will go up or down depending on each state's ability to meet the program checkpoints CMS has set.
CMS also recalculates State Policy Actions and initiative-based factors each budget period, while the underlying data-driven factors remain fixed.
And GAO notes that CMS plans to allot up to $40 billion of the remaining funds over the next four years based on states' satisfactory progress, and may withhold, reduce or recover funding when award terms are not met.
That changes the incentive structure. In Year 1, having a compelling initiative mattered. In Year 2, states increasingly need to demonstrate that the initiative moved. That means:
governance → procurement → award → implementation → milestone → measurement → sustainability.
My expectation is that Year 2 will produce several changes.
For states, I would make the implementation trail as transparent as the plan. Every initiative should eventually have a simple public chain:
CMS initiative → state program → funding opportunity → recipient → implementation status → metric → outcome.
For providers and community organizations, I would stop treating RHTP as a collection of isolated grant notices. Start with the state's approved initiative and ask where that initiative currently sits in the CMS checkpoint model. That tells you much more about what the state is likely to need next.
And for vendors, the biggest mistake may be waiting for the perfect RFP. The most interesting signal may actually be the opposite: CMS says a state plans something, but no opportunity has appeared yet. That gap is where partnerships can form, requirements can be understood and implementation models can be prepared before procurement begins.
CMS's new transparency is good for everyone following RHTP. It also changes what RCJ needs to do.
The goal should not be to recreate CMS's database. CMS should be the authoritative source for official awards, initiatives, policy commitments and checkpoint status. RCJ's value is connecting that official layer to the fragmented implementation layer underneath it:
Plan → opportunity → applicant → award → organization → vendor → implementation → outcome.
That is why we are integrating CMS's official initiative names and stages while continuing to monitor thousands of state documents, procurements, awards and implementation activities.
The question we increasingly want RCJ to answer is not “What did the state say it would do?” CMS is now answering that increasingly well. The more useful question is: “What happened next?”
Year 1 gave rural America a $10 billion starting point. Year 2 is where we begin finding out whether those plans can become functioning systems of care. And that may be the most important transition in the Rural Health Transformation Program so far.
Related Rural Care Journey resources