A Rural Health Microcosm

North Carolina reflects the landscape of rural healthcare across the country, and UNC Health is stepping in to help seal the cracks.

Rural healthcare is under strain. Now, the Rural Health Transformation Program (RHTP) aims to blunt the impact of deep Medicaid cuts—especially in North Carolina, a state with nearly 80 rural counties and one of the highest Medicaid burdens in the country. Federal dollars cover 73% of its Medicaid spending, making it a microcosm of the challenges facing rural healthcare nationwide, says UNC Health CFO William Bryant.

A Small Step Forward

While UNC Health isn’t solely a rural provider, the academic system serves all 100 counties in the state with 17 hospitals, 20 hospital campuses, and over 900 clinics and affiliated locations. 

Bryant expressed skepticism that the federal infusion will meaningfully reshape North Carolina’s healthcare landscape, particularly for rural providers. He notes that when spread statewide, the funding amounts to roughly $2 million per county per year—insufficient, in his view, to offset looming Medicaid funding losses or address the scale of rural healthcare needs.

Those anticipated cuts, he argued, “dwarf the rural transformation funds,” limiting any real effect on referral patterns or provider financial stability. While he praises the state’s intentional push to use the dollars to encourage partnerships across providers and community organizations, he says the money is not concentrated enough to be truly impactful, with some funds flowing to non-provider organizations rather than direct patient care.

“Helpful but not transformative is a good way of describing it,” he said. “Much of it will remain to be seen, but it should evolve over time, next year should be better than this year and the following year. Hopefully we won't go back and redistribute funds to things that were not effective or impactful,” he says.

Lending A Neighborly Hand

Bryant says UNC Health began factoring the fragility of rural providers into its financial planning several years ago, anticipating that recent funding gains would not be permanent. While rural hospitals and clinics in North Carolina have seen improved financial stability over the past five to seven years—driven by Medicaid expansion and directed payment programs—he emphasizes that those gains are temporary. As a result, UNC Health has intentionally moved early to strengthen its balance sheet and redesign its strategy around long-term support for rural care delivery.

“Over the course of the last several years we've seen significant investment in stabilization of rural providers across the state of North Carolina,” he says. “I would say that the current state here is probably as good or better than it's ever been in my career, and that's not to say that it's good, but it's improved significantly with the infusion of investment over the course of the last several years through these programs.”

But Bryant cautions that this stability is unlikely to last as reimbursement cuts, Medicaid disenrollment, and the sunset of programs like Healthcare Access and Stabilization Program (HASP) take effect.

“We've made a very purposeful effort to deepen our relationship with the largely rural managed entities,” he says.

That strategy includes deepening relationships with owned, managed, and affiliated rural hospitals and practices; expanding durable models such as FQHCs and rural care centers; and generating margin in urban growth markets to help offset future rural shortfalls. The system is also preparing for the likelihood that some independent rural providers will struggle or close, positioning UNC Health to play “a larger and larger role” in stabilizing access through capital planning, infrastructure investment, and partnerships with the state and other systems.

A Hurricane Of Effort

Hurricane Helene did not change the organization’s rural health strategy, but it sharpened and accelerated it.

“Helene definitely reiterated for us the need to make the investments and infrastructure,” he says.

The storm exposed infrastructure vulnerabilities in Western North Carolina, including unreliable broadband, cellular service, and even water access at Mission Hospital, highlighting gaps in healthcare resilience just as demand for care surged.

The system expanded virtual care to reach patients unable to travel and drew on prior hurricane response experience to stabilize services. The experience reinforced the need for long-term investment in rural access and infrastructure, directly informing capital planning decisions such as filing a certificate of need for a new hospital in South Buncombe County.

For Bryant, Helene underscored that North Carolina reflects broader national challenges in rural healthcare: aging infrastructure, limited connectivity, capacity constraints, and the growing importance of resilience as extreme weather events become more unpredictable.

The Virtual Bridge

Virtual care has become a central tool in that effort. UNC Health has expanded hospital-at-home, behavioral health, and telehealth services to extend specialty access into communities that cannot sustain full-time providers and to better connect rural patients with urban tertiary centers and reduce pressure on inpatient capacity. 

“Telehealth and tighter integration help break down the barriers that have historically disrupted continuity of care between rural and urban settings,” he says.

At the same time, Bryant notes that Medicare reimbursement uncertainty complicates long-term planning, even as demand grows.

Use of these tools accelerated during Hurricane Helene and has continued to grow, reinforcing their importance for rural access and care continuity.

Bryant also described a mix of vertical and horizontal partnerships designed to improve care coordination, including vendor relationships, joint ventures, and the UNC Health Alliance, which connects thousands of rural providers through a clinically integrated network. These efforts are aimed at reducing unnecessary patient migration to urban centers and smoothing transitions when higher-acuity care is needed.

Building the Pipeline

Workforce remains another shared rural challenge. Bryant pointed to persistent shortages across nearly every clinical role and outlined UNC Health’s broad training footprint. Through the state’s largest medical school, satellite campuses, and nursing and pharmacy programs, UNC Health is working to strengthen rural pipelines, with a focus on deeper partnerships with community colleges to train providers locally and keep them in their home communities. He highlighted Wake Tech’s collaboration with WakeMed on a simulation hospital as a leading example and suggested similar models could be scaled statewide.

Together, these financial, clinical, and workforce strategies position UNC Health as a stabilizing force in a state that mirrors national rural pressures—aging infrastructure, thin margins, workforce shortages, and growing reliance on virtual and integrated care to sustain access.

Bryant also pointed to the long-term consequences of underinvestment in infrastructure, noting that many rural hospitals trace their origins to Hill-Burton–era funding from decades ago and are now aging out. He argued that sustaining a rural safety net will require a broader rethinking of insurance markets, payment structures across all payers, and how capital and operating costs are supported, potentially with technology and AI helping to improve efficiency, but not substituting for fundamental reform.

As he put it, “you’re not going to be able to fix the system if you only fix a part of the system.”