On April 1, 2026 — National Public Health Week — David Kustoff and Alabama Democrat Terri Sewell announced a bill to keep rural hospitals from closing.

"Access to health care should not depend on a person's ZIP code," Kustoff said. "Many rural hospitals are held back by outdated payment policies that fail to account for the challenges they face."

The background section of that same press release lays out the crisis: "over 40 percent of rural hospitals are operating at a loss, with more than 400 at risk of closure."

Those numbers come from the Chartis Center for Rural Health's 2026 rural health study, published in February. Kustoff's office quoted the parts about the country. Here are the parts about Tennessee.

Tennessee is now the worst state in the country on this measure

Chartis rates rural hospitals for how likely they are to close. In its 2026 analysis:

• Tennessee has the highest percentage of rural hospitals vulnerable to closure of any state — 61%. That is up from 44% a year earlier. Only South Dakota saw a comparable jump.
• Twenty-seven Tennessee rural hospitals are on the vulnerable list, the third-most in the nation behind Texas and Kansas.
• Tennessee has lost inpatient care at 18 rural hospitals since 2010 — second only to Texas, a state four times its size.
• 43% of Tennessee's rural hospitals that used to offer chemotherapy no longer do. 33% stopped offering general surgery.

Chartis is blunt about the cause. In the ten states that refused to expand Medicaid under the Affordable Care Act — Tennessee is one — 52.2% of rural hospitals operate in the red. In states that expanded, it's 34.9%. That is a 17-point gap that tracks one policy choice.

And the report is equally blunt about what's coming. The $50 billion Rural Health Transformation fund, it says, "won't offset the nearly $140 billion in expected losses from Medicaid-related cuts stemming from the One Big Beautiful Bill Act (H.R. 1)." Those cuts take effect in 2027.

He voted for it

On July 3, 2025, the House passed H.R. 1. Kustoff voted yes.

Writing in the Tennessee Lookout that August, Ren Brabenec pulled together what the law does to the state: between the Medicaid and Affordable Care Act changes, at least 110,000 Tennesseans are expected to lose health coverage, with an estimated $7 billion cut from TennCare over the next decade and at least nine rural Tennessee hospitals "on the chopping block." Tennessee, the piece noted, already had the highest number of rural hospital closures per capita in the country. Nationally, the same law is expected to cut federal Medicaid spending by more than $900 billion over a decade.

This was not a vote Kustoff cast from the back bench. He sits on the Ways and Means Committee, and within it on the Subcommittees on Tax and Health — the panel with jurisdiction over Medicare. He was in the room where it was written.

The rescue money comes with a catch, and Tennessee may not get all of it

The $50 billion rural health fund inside H.R. 1 is what Republicans point to when they're asked about rural hospitals. Tennessee's slice for the first year was about $207 million.

Except the money is conditional. As Tennessee Lookout reported in March 2026, the Centers for Medicare & Medicaid Services can claw back part of that award if the state legislature doesn't pass a list of policy changes Tennessee promised in its application — including repealing the state's Certificate of Need law, which the Tennessee Hospital Association has resisted for years. State officials estimated the clawback at about $8.4 million of the first year plus $10 million in future years if the bills fail, and warned that "substantially more could be at impact."

Republican state Sen. Bo Watson put it this way: "There are a number of these pieces of legislation that probably are not going to pass, so we don't want to commit dollars to projects … on something that is going to get clawed back."

And the money can't be spent on the things a struggling hospital actually needs. Under the program's rules, funds cannot go to building construction, clinician salaries, loan repayment, hospital operating deficits, historical debt, or raising reimbursement rates.

Three Congresses of rural health bills. Zero laws.

Kustoff's rural health record is long, and that is exactly the problem.

He introduced the Rural Health Innovation Act in 2019, again in 2023, and again in 2025. He introduced the Rural America Health Corps Act in 2023 and again in 2025. He introduced the RPM Access Act in 2025. He introduced the Save Struggling Hospitals Act in 2026.

Not one of them has become law. The 2025 Rural Health Innovation Act was referred to the Energy and Commerce Committee in February 2025 and has not moved since. The Save Struggling Hospitals Act was referred to his own committee and has not moved either.

The Save Struggling Hospitals Act is also not new money. It restores a Medicare wage-index adjustment that existed from fiscal 2020 through 2024 and was then dropped — a formula fix that shifts dollars toward hospitals in low-wage areas. It is a reshuffle of the Medicare pie, not an addition to it.

So the scoreboard on rural health, nine years into his time in Congress, looks like this. Every bill Kustoff wrote to help rural hospitals: still sitting in committee. The one health law he actually voted onto the president's desk: takes $7 billion out of TennCare and more than $900 billion out of Medicaid nationally.

This is a pattern, not a coincidence

Kustoff is not the only Republican running this play. Mississippi's Cindy Hyde-Smith voted for the same law, then put out three rural hospital rescue bills in five months while 24 Mississippi rural hospitals were rated vulnerable to closure.

The bills are real. The press releases are real. The quotes about ZIP codes are sincere-sounding. What they are not is a substitute for the vote.

A rural hospital in West Tennessee does not stay open because a congressman introduced a Medicare wage-index bill that sat in committee. It stays open or it doesn't based on whether the people walking through the door have insurance. Kustoff voted to take that insurance away from at least 110,000 people in his state, and then went looking for a formula to blame.

Tennessee is now first in the nation in the share of its rural hospitals at risk of closing. That happened on his watch, on his committee, with his vote.

Sources

During National Public Health Week, Reps. Sewell and Kustoff Introduce the Bipartisan Save Struggling Hospitals Act, Office of Rep. Terri Sewell, April 1, 2026. Rural hospital data: 2026 Rural Health State of the State, Chartis Center for Rural Health, February 10, 2026. Photo: Tennessee Lookout / Getty Images.