The 2028 Crisis Is Coming: What Every Hospital Leader Needs to Understand Now

The One Big Beautiful Bill Act will reduce Medicaid and CHIP funding by $1.02 trillion over the next decade, with cuts taking effect in 2028. The $50 billion Rural Health Transformation fund goes only to rural facilities, leaving urban safety-net systems exposed, but both face the same convergence of pressures, and the window to act on facts is narrowing.

As this comes to fruition, it is crucial to understand different perspectives on what is driving distress.

How Risk Presents Differently

From Medicaid erosion to workforce shortages, coverage losses, and regulatory uncertainty, each presents unique risk profiles.

Rural hospitals face thin volume bases where a single service line loss can be existential. Workforce scarcity drives premium labor costs; distance to alternative care concentrates community risk, and $137 billion in rural Medicaid cuts are arriving despite the transformation fund — with limited commercial volume to cross-subsidize.

Urban safety-net systems face high Medicaid and self-pay concentration with Disproportionate Share Hospital (DSH) and 340B exposure under active policy threats. Exchange losses quietly convert insured patients to self-pay; social determinants intensify uncompensated care in already-underserved communities, and no dedicated federal relief exists outside the rural carve-out. Ultimately, this highlights the same convergence, but different pressure points.

Where the Money Is — and Why Most Hospitals Aren't Ready to Access It

Congress created the $50 billion Rural Health Transformation Program to fund hospital transformation across 10 categories:

1. Evidence-based prevention and chronic disease management

2. Provider payments for healthcare items and services

3. Consumer-facing tech for chronic disease prevention and management

4. IT advances and cybersecurity, including assistance, software, hardware

5. Advanced tech training, including remote monitoring, robotics, AI

6. Clinical workforce recruiting and retention (5-year minimum)

7. Right-sizing delivery across preventive through post-acute

Opioid, SUD, and mental health services

8. Value-based and alternative payment models

9. Other uses promoting sustainable rural access, per the Administrator

States have started opening applications, but accessing funds requires operational readiness, fundable narratives, financial projections, and compliance infrastructure. For hospitals under financial pressure that compete with maintaining access to care, stabilization must come first.

Who Is Eligible for Rural Health Transformation Program?

• Critical Access Hospitals (CAH)
• Rural Health Clinics (RHC)
• Federally Qualified Health Centers (FQHC)
• Sole Community Hospitals
• Rural Emergency Hospitals (REH)
• Tribal Facilities
• Behavioral Health Providers

Why This Series

Our team is dedicated to providing administrators and practices with actionable insights to successfully prepare for what is to come. Over the coming weeks, you can discover insights into the hospital’s financial crisis, distress warning signs, impactful operational levers, how to use technology, grant management, and more to help you establish a hospital that thrives, not just survives.

Start with the Facts, Not the Spiral

Organizations should start by stress-testing their exposure against the 2028 timeline. EisnerAmper’s Healthcare Advisory team conducts facility-specific rapid assessments, typically two to four weeks, benchmarked against national data. This enables leadership to act on facts, not just under pressure. Our team works with rural and urban hospitals, navigating financial uncertainty. Learn more about how our team helps you, contact our team today.