Are we willing to lose rural America?

OPINION:

The question may sound dramatic, but it deserves serious consideration: Are we willing to accept a future in which rural America becomes increasingly unaffordable for the families who built it?

Across the country, rising costs are making it harder for working families to stay in the communities they call home. While the national affordability debate focuses heavily on urban challenges, rural America faces distinct burdens that receive far less attention. Food costs are higher, healthcare access is limited and essential services are farther away. Yet many federal policies continue to be built around urban assumptions rather than rural realities.

The result is a growing gap between what rural Americans need and what the federal government delivers.

As the representative for Hawai’i’s largely rural Second Congressional District, I see these challenges every day. The communities I represent are separated by oceans and mountains, but their concerns mirror those expressed in farming communities across the Midwest, small towns in the South, and remote regions throughout the West.

Families are struggling to keep up with the rising cost of groceries, and rural healthcare providers are struggling to keep their doors open. But federal formulas too often fail to account for the higher costs of serving geographically isolated communities, and federal investments miss the mark in delivering resources to support them. These issues are symptoms of the same underlying problem: federal policies and programs that do not adequately account for rural realities.

Food affordability offers a clear example. While rising grocery prices affect households nationwide, rural communities face additional costs driven by transportation, limited competition and supply chain challenges. In Hawai’i, families living on islands such as Moloka’i and Lna’i routinely pay significantly more for groceries than residents in urban Honolulu. Yet Supplemental Nutrition Assistance Program (SNAP) benefits are calculated using price data from Honolulu, effectively treating incredibly different food markets exactly the same.

Families facing the highest food costs should not receive assistance based on the lowest-cost market in the state. That is why I introduced the Feeding Rural Families Act, legislation modeled after policies already used in Alaska to allow SNAP benefits better reflect actual grocery costs in rural Hawai’i. While the bill addresses a challenge specific to my state, the broader principle applies nationwide: nutrition assistance should reflect the true cost of feeding a family where that family lives.

Healthcare presents a similar challenge. Rural providers operate with workforce shortages, higher operating costs, smaller patient populations and significant geographic barriers. Yet reimbursement systems often fail to account for those realities. I introduced the PATCH Act to improve how Medicare reimbursement rates reflect the actual cost of care in Hawai’i, an issue that extends well beyond our state.

Across rural America, hospitals and clinics are expected to deliver high-quality care under conditions fundamentally different from those faced by large urban health systems. Today, nearly half of rural hospitals nationwide operate with negative margins, and hundreds remain at risk of closure. Impending Medicaid cuts have also intensified concerns in communities where hospitals depend heavily on those reimbursements to maintain services. In Hawai’i alone, several rural hospitals could face serious financial strain and close altogether.

When a rural hospital closes, the effects extend far beyond healthcare. Communities lose jobs, businesses become less likely to invest and families lose access to emergency care. The closure of a rural hospital is often a warning sign of broader economic decline.

To help rural hospitals modernize and meet community needs, I introduced the Rural Hospital Revitalization Act. This bill would provide interest-free, USDA-backed financing to upgrade facilities, expand services, and meet long-term infrastructure needs. Rural communities deserve the same healthcare investment opportunities as larger urban systems.

Food affordability and healthcare access are deeply connected. Without reliable healthcare, patients miss out on timely preventive care, diagnosis and treatment. The result is sicker people, higher costs, and greater financial strain on families. Securing both affordable food and quality healthcare is essential to the health and economic stability of rural America.

Rural Americans are not asking for special treatment. They are asking for a level playing field and the same opportunities as everyone else. A reimbursement formula that reflects the true cost of providing care is not a subsidy. A nutrition program that reflects actual grocery prices is not a special benefit. Both ensure that federal policies account for rural realities.

Rural America remains central to our nation’s food production, energy development, military recruitment and economic resilience.

If we are serious about sustaining the communities that feed, fuel, and sustain this nation, we must act now before they reach their breaking point. We cannot continue to treat rural America as a problem to be managed, but rather the foundation of this country that we cannot afford to lose.

• U.S. Rep. Jill Tokuda represents Hawai’i’s Second Congressional District, which includes suburban and rural parts of O’ahu, the islands of Hawai’i, Kaua’i, Maui, Lana’i, Moloka’i, Ni’ihau, Kaho’olawe, and the Northwestern Hawaiian Islands. She serves on the House Committee on Armed Services, the Select Committee on the Chinese Communist Party, and as Ranking Member on the Subcommittee on Conservation, Research, and Biotechnology on the Committee on Agriculture. She is a founding member and Co-Chair of the Bipartisan Rural Health Caucus, as well as the Co-Founder and Co-Chair of the Congressional Air Medical Caucus.