The Origins of Public Health Finance in America

Public health finance in the United States is not a system that was designed. It is a system that accumulated — through political compromise, economic crisis, ideological conflict, and institutional inertia — across a century of contested decisions about what the government owes its citizens, what the market can provide, and who bears the cost when both fail.

Understanding how we got here is not historical decoration. It is the prerequisite to understanding why RHTP exists, why Medicaid is being cut, why rural hospitals are closing, and why GrantBridges operates at the precise fault line where these forces collide. Every operational decision in grants administration — every compliance requirement, every spending cap, every expenditure deadline — is a downstream expression of political choices made decades or centuries earlier about the role of government in healthcare.

This document traces those choices, the intellectual traditions that explain them, and what they mean for the current moment.

Before the Safety Net: Healthcare as Private Good (Pre-1930s)

For most of American history, healthcare was a private transaction. Physicians were independent practitioners. Hospitals were charitable or religious institutions, not government entities. Public health existed — quarantine powers, sanitation infrastructure, vaccination campaigns — but the idea that the government had an obligation to finance individual healthcare delivery did not.

This was not an oversight. It was a philosophical position with deep roots in American political economy. The framers of the Constitution did not enumerate healthcare as a federal responsibility. The Commerce Clause and the General Welfare Clause would eventually be stretched to accommodate it, but the original constitutional architecture placed healthcare — like education, like housing, like most social services — in the domain of states, localities, charities, and private markets.

Kenneth Arrow’s seminal 1963 paper, “Uncertainty and the Welfare Economics of Medical Care” (American Economic Review), provided the theoretical explanation for why this arrangement fails. Arrow demonstrated that healthcare markets are fundamentally different from competitive markets: the asymmetry of information between physician and patient, the uncertainty of illness, the barriers to entry created by licensure, and the moral obligations embedded in the physician-patient relationship all prevent healthcare from functioning as a normal commodity market. Arrow’s paper is the intellectual foundation for the claim that healthcare requires non-market intervention — not as a political preference but as an economic necessity derived from the structural properties of the good itself.

The consequences were predictable and unevenly distributed. Wealthy Americans purchased healthcare. Middle-class Americans managed with a combination of charity care, mutual aid societies, and fraternal organizations that provided rudimentary insurance. Poor Americans, rural Americans, and Black Americans received little or nothing. In 1900, life expectancy at birth was 47 years. In rural areas, maternal mortality, infectious disease mortality, and childhood mortality were catastrophically higher than in cities — not because rural people were sicker by constitution, but because the market for healthcare delivery does not naturally extend to low-density, low-income populations. The unit economics don’t work. They have never worked. They will not work without subsidy.

This is the foundational fact of rural health finance, and it is Arrow’s point made geographic: the private market cannot sustain healthcare delivery in communities where the population is too small, too poor, or too dispersed to generate the revenue that providers need to operate. Every public health finance program for rural America — from the Hill-Burton Act to Medicare’s Critical Access Hospital designation to RHTP — is an attempt to solve a problem that the market structurally cannot solve. The debate is never about whether subsidy is needed. It is about what form the subsidy takes, who controls it, and how long it lasts.

The New Deal and the Architecture of Entitlement (1930s–1960s)

The Great Depression shattered the assumption that private markets and private charity could sustain social welfare. By 1933, 25% of the workforce was unemployed. Banks had failed. Charitable institutions were overwhelmed. The political legitimacy of the laissez-faire model collapsed, and Franklin Roosevelt’s New Deal constructed the first comprehensive federal social safety net.

The Social Security Act of 1935 is the architectural foundation of American social welfare. It created old-age insurance (Social Security), unemployment insurance, and Aid to Dependent Children (later AFDC, later TANF). It also created federal grants-in-aid to states for public health, maternal and child health, and services for crippled children — the first systematic federal investment in health services delivery.

Theda Skocpol’s Protecting Soldiers and Mothers (1992) and Social Policy in the United States (1995) documented how the New Deal established the institutional template that would govern American social policy for the next sixty years. Three principles emerged:

Principle 1: The federal government has a legitimate role in financing social welfare. This was contested before 1933 and remains contested today, but the New Deal established it as operational reality. Federal taxation would fund federal programs that provided benefits to individuals and communities that the market could not serve. Jacob Hacker’s The Divided Welfare State (2002) traces how this principle was immediately and permanently qualified by the decision to channel much of the welfare state through private institutions (employer-sponsored insurance, private pensions) rather than direct government provision — a choice that would shape every subsequent healthcare financing debate.

Principle 2: Entitlement is the mechanism. An entitlement is a legal right to a benefit, defined by statute, available to anyone who meets the eligibility criteria. Social Security is an entitlement: if you paid in, you draw out. Medicaid would become an entitlement: if you’re poor enough, you’re covered. Entitlements are expensive precisely because they are open-ended — the government pays whatever the eligible population costs. But they are also the strongest form of social commitment, because they cannot be reduced by annual appropriation decisions. Paul Pierson’s Dismantling the Welfare State? (1994) demonstrated why this matters: entitlements create constituencies — beneficiaries, providers, administrators — whose political mobilization makes retrenchment difficult. To reduce an entitlement, you must overcome the political resistance of everyone who benefits from it.

Principle 3: Federal-state partnership is the delivery mechanism. The federal government funds, the states administer. This partnership model — born from the political necessity of getting legislation through a Congress that included Southern Democrats opposed to federal control over state social services — would become the structural template for Medicaid, CHIP, block grants, and eventually RHTP. Martha Derthick’s work on federal-state relations, particularly Keeping the Compound Republic (2001), shows how this partnership creates permanent tension: federal standards for equity and accountability versus state flexibility and administrative capacity.

The Hill-Burton Act of 1946 extended this architecture specifically to healthcare infrastructure. Federal grants funded hospital construction in underserved areas, with the requirement that recipient hospitals provide free or reduced-cost care to the community. Hill-Burton built or renovated 6,800 healthcare facilities in its first 25 years. Many of today’s rural hospitals exist because of Hill-Burton funding in the 1950s and 1960s. The buildings are still standing. The communities they serve are still underserved. The financial model that sustained them — a combination of charity care obligations, cost-plus reimbursement, and community support — has been eroding for decades.

Hill-Burton is the first instance of the pattern that RHTP repeats: time-limited federal investment in healthcare infrastructure with the expectation that the investment creates self-sustaining capacity. The historical record — documented extensively by the National Academy for State Health Policy and in Thomas Ricketts’ work on rural health services research — shows that infrastructure investment without ongoing revenue support produces buildings, not sustainability.

Medicare, Medicaid, and the Great Society (1965)

The creation of Medicare and Medicaid in 1965 was the most consequential act of healthcare finance legislation in American history. Theodore Marmor’s The Politics of Medicare (1973, updated 2000) remains the definitive political history. Jonathan Oberlander’s The Political Life of Medicare (2003) extended the analysis to show how Medicare’s political durability shapes — and constrains — every subsequent health policy debate.

The 1965 legislation did three things simultaneously:

It made the federal government the largest purchaser of healthcare services in the world. Medicare (Title XVIII of the Social Security Act) provides health insurance for Americans 65 and older and for certain disabled populations. Medicaid (Title XIX) provides health insurance for low-income Americans, jointly funded by federal and state governments. Together, they currently account for approximately 37% of all healthcare spending in the United States — over $1.5 trillion annually.

It created a two-tier system with profoundly different political durability. This is Pierson’s retrenchment theory made visible. Medicare is a universal entitlement for the elderly — a politically powerful constituency that votes, donates, and organizes. Cutting Medicare is political suicide. Medicaid is a means-tested entitlement for the poor — a politically weak constituency with low voter turnout and no organized lobbying power. Cutting Medicaid is politically feasible, which is why it is being cut now. Colleen Grogan and Eric Patashnik’s work on Medicaid politics demonstrates that this differential vulnerability was not accidental — it was embedded in the program’s design. The structural difference between these two programs — both created in the same legislation, both entitlements, both federally funded — is not economic. It is political. The beneficiaries of Medicare have political power. The beneficiaries of Medicaid do not.

It embedded private industry in the delivery system. Paul Starr’s The Social Transformation of American Medicine (1982) — the Pulitzer Prize-winning history of American healthcare — documented how this embedding was a deliberate political compromise. Unlike the British National Health Service (created in 1948 as a government-owned, government-operated system), Medicare and Medicaid preserved private ownership of hospitals, physician practices, and insurance administration. The government pays, but the private sector delivers. Organized medicine (the AMA) vigorously opposed government-owned healthcare delivery, and the Johnson administration purchased their acquiescence by guaranteeing that Medicare would reimburse providers generously, preserve fee-for-service practice, and not interfere with medical decision-making.

The consequences of this compromise echo through every dimension of contemporary healthcare finance. Provider reimbursement rates are set by political negotiation (the Medicare Physician Fee Schedule, hospital prospective payment, Medicaid state plan rates), not by market forces. Private insurance benchmarks against Medicare rates. Provider profitability is a function of payer mix — the ratio of commercial (profitable), Medicare (approximately break-even), Medicaid (below cost), and uninsured (pure loss) patients. Rural providers, with higher Medicaid shares and lower commercial volumes, are structurally disadvantaged in this model. They always have been.

The Managed Care Revolution and Market Ideology (1980s–2000s)

The Reagan era introduced a competing philosophy: the market, not the government, should organize healthcare. Alain Enthoven, a Stanford economist and former Deputy Assistant Secretary of Defense, became the intellectual architect of “managed competition” — the idea that structured market competition among health plans could achieve efficiency without direct government provision. Enthoven’s Health Plan: The Practical Solution to the Soaring Cost of Medical Care (1980) provided the theoretical framework that shaped three decades of health policy, from the HMO Act through the ACA marketplace design.

The practical instruments of this revolution were:

Prospective Payment and DRGs (1983). Medicare shifted from cost-plus reimbursement (paying hospitals whatever they spent, plus a margin) to prospective payment (paying hospitals a fixed amount per diagnosis, regardless of what they spent). This was the most significant single change in healthcare finance since Medicare’s creation. It transformed hospitals from cost centers reimbursed for activity into businesses that profit or lose based on efficiency. The Diagnosis-Related Group (DRG) system created financial incentives to reduce length of stay, minimize resource use, and increase throughput. It also created incentives to upcode, cherry-pick profitable cases, and avoid complex patients whose costs exceeded the payment. The system produced both efficiency gains and new forms of gaming — exactly as mechanism design theory would predict. This is the origin of the volume-over-value problem that value-based care attempts to solve.

Managed care and HMOs. The HMO Act of 1973 planted the seed, but managed care exploded in the 1990s. The core mechanism: instead of paying providers for each service (fee-for-service), pay a fixed amount per patient per month (capitation) and let the provider manage within that budget. Managed care reduced cost growth, improved some preventive care metrics, and provoked enormous backlash from patients and providers who experienced it as rationing. The managed care backlash of the late 1990s — driven by stories of denied claims, restricted networks, and profit-driven coverage decisions — is the direct ancestor of contemporary distrust of insurance companies and the political appeal of “keeping your doctor.” Mark Peterson’s analysis in the Journal of Health Politics, Policy and Law traces how this backlash constrained every subsequent attempt at structural reform.

Medicaid managed care. States, seeking to control Medicaid cost growth, shifted Medicaid beneficiaries from fee-for-service into managed care organizations (MCOs). Today, over 70% of Medicaid beneficiaries are enrolled in managed care. The MCOs receive a per-member-per-month capitation payment from the state and manage care delivery. This created a new layer of private intermediaries between public money and patient care — with administrative costs, profit extraction, and coverage decisions that operate largely out of public view. The dollars-to-provider ratio that the GrantBridges Intermediary Tax article measures for RHTP is structurally identical to the question Medicaid managed care has faced for decades: how much of the public dollar reaches the patient?

The ACA: Expanding the Insurance Model (2010)

The Affordable Care Act represented the fullest expression of the bipartisan consensus that had governed health policy since Enthoven: expand coverage through insurance, not through direct government provision. Lawrence Jacobs and Theda Skocpol’s Health Care Reform and American Politics (2012) documented the political dynamics: the ACA expanded Medicaid eligibility to 138% of the federal poverty level (in states that chose to expand), created insurance marketplaces with subsidized premiums, mandated essential health benefits, prohibited pre-existing condition exclusions, and imposed the individual mandate.

The ACA’s Medicaid expansion was the largest single expansion of the social safety net since the original Medicaid legislation. Forty states and DC eventually adopted it. An estimated 21 million people gained Medicaid coverage. For rural communities, the expansion was transformative: Medicaid became the primary payer for many rural hospitals that had previously relied on a precarious mix of Medicare, self-pay, and charity care. Rural hospitals in expansion states saw uncompensated care drop by 30–50% and operating margins stabilize. The research of Richard Lindrooth, George Pink, and the Chartis Center for Rural Health has documented this rural revenue stabilization extensively.

This is why the current Medicaid cuts are existential for rural healthcare. The ACA made rural hospitals financially dependent on Medicaid expansion revenue. This is Pfeffer and Salancik’s resource dependence theory in real time: the ACA created a new resource dependency, and the withdrawal of that resource threatens organizational survival. Rolling back that expansion — through eligibility restrictions, work requirements, enrollment procedural barriers, or outright funding cuts — removes the revenue base that keeps these hospitals open. The $1.02 trillion Medicaid cut in the One Big Beautiful Bill Act is not an abstract policy change. It is a structural defunding of the revenue source that sustains rural healthcare delivery in 40 states.

The Private Sector in Public Healthcare: A Structural Feature, Not a Bug

A recurring pattern in American health finance is the embedding of private industry in publicly financed systems. Hacker’s The Divided Welfare State provides the most complete theoretical treatment: Americans are willing to fund healthcare through taxation (Medicare enjoys 80%+ public approval), but they resist government operation of healthcare delivery (single-payer proposals consistently fail politically). The result is a divided welfare state where public money flows through private channels — and the private channels extract value at every stage.

Insurance. Medicare Advantage (private insurers administering Medicare benefits for a capitated fee) now enrolls over 50% of Medicare beneficiaries. Medicaid managed care is administered by private MCOs. ACA marketplace plans are private insurance products subsidized by public money. The insurance industry has become the administrative intermediary for public health finance — taking a percentage of every public dollar that passes through it. The work of Miriam Laugesen (Fixing Medical Prices, 2016) details how the pricing mechanisms within this public-private hybrid are neither market-determined nor publicly accountable, but emerge from opaque negotiations between political actors, industry lobbyists, and administrative agencies.

Providers. Hospitals, physician groups, and clinics are overwhelmingly privately owned (nonprofit or for-profit). Community Health Centers (FQHCs) are nonprofit but operate as independent organizations receiving federal grants. Tribal health organizations operate under P.L. 93-638 as sovereign entities contracting with the federal government. Burton Weisbrod’s The Nonprofit Economy (1988) provides the theoretical framework for understanding why so many healthcare providers are nonprofit: the nonprofit form is a response to market failure in trust goods — services where the consumer cannot evaluate quality and relies on the provider’s mission orientation as a proxy for trustworthiness.

Research and development. NIH funds approximately $47 billion annually in biomedical research, the majority conducted at private universities and increasingly translated into products by private pharmaceutical and device companies. The Bayh-Dole Act of 1980 allowed universities to patent discoveries made with federal funding, creating the pipeline through which public investment in basic research generates private profit in commercial products.

Consulting and technical assistance. An entire industry — grant writers, compliance consultants, EHR vendors, population health analytics firms — exists to help organizations navigate the complexity of public health finance. GrantBridges is part of this ecosystem. The complexity of the system creates the market for the tools that manage it.

This public-private hybrid has consequences. It means that every dollar of public health investment passes through multiple private hands before reaching a patient. It means that the efficiency of the system is a function of how many intermediaries extract value along the way. It means that the political economy of healthcare is dominated by private interests (insurers, hospital systems, pharmaceutical companies, physicians) that depend on public revenue but resist public control. And it means that any attempt to simplify the system — single-payer, direct government provision, block grants — threatens the economic interests of the intermediaries who profit from its complexity.

The Current Moment: Dismantling and Rebuilding Simultaneously

The One Big Beautiful Bill Act of 2025 represents the most significant restructuring of American health finance since the ACA. It does two things that are politically coherent but operationally contradictory:

It cuts Medicaid by $1.02 trillion over ten years. This is accomplished through enrollment restrictions (work requirements, more frequent eligibility redeterminations, elimination of presumptive eligibility), federal matching rate reductions, and caps on per-beneficiary spending growth. The effect is to remove millions of people — disproportionately in rural communities, disproportionately low-income, disproportionately people of color — from the insurance coverage that the ACA extended to them. For rural providers, this means the return of uncompensated care, the collapse of the Medicaid revenue base, and accelerated hospital closures.

It creates RHTP at $50 billion over five years. The Rural Health Transformation Program is a time-limited, capacity-building grant program designed to strengthen rural healthcare infrastructure, workforce, and technology. It is explicitly not an entitlement. It is a competitive grant program with an expenditure deadline, administered through states, with spending category restrictions and compliance requirements.

These two actions are not contradictory from the perspective of the political coalition that enacted them. They are two halves of a coherent project. Pierson’s work on policy feedback and institutional change provides the theoretical framework: the Medicaid cuts dismantle the institutional arrangements that create dependence on government insurance, while RHTP creates new institutional arrangements oriented toward capacity and self-sufficiency. This is not incremental reform. It is institutional replacement — the deliberate substitution of one policy regime for another.

The thesis: Rural healthcare should not depend on government entitlements. The Medicaid expansion made rural providers financially dependent on government insurance payments — a dependency that (in this view) distorts markets, discourages self-sufficiency, and creates permanent reliance on federal largesse. RHTP provides a one-time investment to build the infrastructure, workforce, and capacity that rural communities need to sustain healthcare delivery without ongoing government subsidy. The $50 billion is not a replacement for $1.02 trillion in Medicaid. It is transition funding — seed capital for a post-entitlement model of rural healthcare.

The implicit expectation: After RHTP, these organizations will operate as businesses. They will have the infrastructure (buildings, technology, systems), the workforce (recruited, trained, retained through RHTP investment), and the administrative capacity (grants management, compliance, financial controls) to bill commercial payers, negotiate rates, manage revenue cycles, and sustain operations on market revenue. The government will have provided the initial investment. The market will provide the ongoing revenue.

The structural problem: This thesis requires rural communities to have a commercial payer base sufficient to sustain provider operations. Most do not. Arrow’s 1963 insight returns: the fundamental market failures in healthcare — information asymmetry, uncertainty, moral hazard — are amplified in rural settings by low population density, high fixed costs, unfavorable payer mix, and geographic isolation. A Critical Access Hospital in a county of 8,000 people with 40% Medicaid, 35% Medicare, 15% commercial, and 10% uninsured cannot sustain operations on commercial revenue alone. The commercial payer base is too small. It will always be too small. RHTP can build the building, train the nurses, install the EMR, and modernize the billing system. It cannot create the population density or the commercial insurance enrollment that market-based revenue requires.

This is the Medicaid Offset Paradox that the GrantBridges article describes, scaled to the level of national policy. The $50 billion investment builds capacity. The $1.02 trillion cut removes the revenue that makes the capacity financially viable. The net effect, for many rural communities, will be negative: better infrastructure in closed hospitals.

What This Means for GrantBridges

GrantBridges sits at the exact junction of these forces. Its customers are the organizations navigating this transition — tribal health programs, community behavioral health centers, federally qualified health centers — that depend on public financing and are being told to become self-sustaining. The compliance infrastructure that GrantBridges builds is not just administrative tooling. It is the mechanism through which these organizations demonstrate that they can manage public investment responsibly — the prerequisite to receiving it, and eventually the prerequisite to not needing it.

The survey platform, the data products, the published research — all of it maps onto this political economy:

The Readiness Survey measures whether organizations have the infrastructure to receive RHTP funding. It is implicitly measuring whether they are ready for the transition from entitlement to capacity.

The Compliance Burden Survey measures whether the compliance architecture of RHTP is proportional to its purpose. It is implicitly measuring whether the government’s monitoring of the transition is itself undermining the transition.

The Application Complexity Index measures whether the access ramp to RHTP is designed for the organizations it claims to serve. It is implicitly measuring whether the political rhetoric of “investing in rural health” matches the operational reality of who can actually access the investment.

The Workforce Pipeline Report measures whether RHTP’s workforce investment produces workers who stay in rural communities. It is implicitly measuring whether the one-time investment model can solve a structural labor market problem.

None of these are neutral research instruments. They are accountability tools for a political project that claims to strengthen rural healthcare while simultaneously removing the revenue base that sustains it. The data they produce will either validate the thesis (rural organizations can become self-sustaining with one-time investment) or refute it (they cannot, because the structural economics haven’t changed). Either finding is consequential. Either finding is publishable. Either finding positions GrantBridges as the organization that measured what everyone else debated.

The Philosophical Stakes

The deeper question beneath all of this is one that Americans have never resolved and are not resolving now: Is healthcare a public good or a private commodity?

If it is a public good — like national defense, public roads, or clean water — then the government has an obligation to ensure its provision regardless of market conditions, and the appropriate financing mechanism is taxation and entitlement. The New Deal, Medicare, Medicaid, the ACA, and the FQHC program all embody this answer.

If it is a private commodity — like housing, food, or transportation — then the market should provide it, government intervention should be temporary and targeted, and the goal of public investment should be to create the conditions for market self-sufficiency. RHTP, as currently designed, embodies this answer.

The American system has never chosen. It operates both answers simultaneously. Medicare (public good for the elderly) coexists with employer-sponsored insurance (private commodity for the employed). Medicaid (public good for the poor) coexists with commercial insurance markets (private commodity for everyone else). FQHCs (publicly funded safety-net providers) coexist with for-profit hospital chains (private delivery organizations). Deborah Stone’s The Samaritan’s Dilemma (2008) and her earlier work on the politics of policy design explore how this ambiguity is not a failure of political will but a reflection of genuine value pluralism in American political culture.

The One Big Beautiful Bill Act is the most explicit assertion in decades that the private commodity answer should prevail — at least for the populations served by Medicaid. The Medicaid cuts are a contraction of the public good model. RHTP is the bridge to the private commodity model. Whether the bridge reaches the other side is the empirical question that GrantBridges is uniquely positioned to measure.

This is not a political position. It is a structural analysis. The data products that GrantBridges produces — readiness scores, compliance burden indices, workforce pipeline metrics, application complexity grades — are the instruments that measure whether the bridge is load-bearing. If the data shows that rural providers can transition to self-sufficiency with RHTP investment, the political project is validated. If the data shows they cannot, the political project produces a healthcare access crisis in communities that were already underserved.

Either way, the measurement matters. That is why the survey platform exists. That is why the data architecture is designed for longitudinal tracking. That is why every entity in the database is a point on a trend line that will eventually tell us whether this moment in American health finance was a transition or a collapse.

Intellectual Debts

This document draws on the following primary works:

• Arrow, K. (1963). “Uncertainty and the Welfare Economics of Medical Care.” American Economic Review 53(5). The foundational economic argument for why healthcare markets fail.
• Starr, P. (1982). The Social Transformation of American Medicine. The political and economic history of American healthcare institutions.
• Enthoven, A. (1980). Health Plan: The Practical Solution to the Soaring Cost of Medical Care. The intellectual architecture of managed competition.
• Weisbrod, B. (1988). The Nonprofit Economy. The theory of nonprofit organizations as responses to market failure in trust goods.
• Skocpol, T. (1992). Protecting Soldiers and Mothers: The Political Origins of Social Policy in the United States. The institutional origins of American social policy.
• Pierson, P. (1994). Dismantling the Welfare State? Reagan, Thatcher, and the Politics of Retrenchment. The politics of welfare state retrenchment and the role of policy feedback.
• Marmor, T. (2000). The Politics of Medicare (2nd ed.). The definitive political history of Medicare’s creation and evolution.
• Derthick, M. (2001). Keeping the Compound Republic: Essays on American Federalism. Federal-state relations and the politics of intergovernmental programs.
• Hacker, J. (2002). The Divided Welfare State: The Battle over Public and Private Social Benefits in the United States. The public-private architecture of American social policy.
• Oberlander, J. (2003). The Political Life of Medicare. How Medicare’s political durability shapes health policy.
• Grogan, C. & Patashnik, E. (2003). “Between Welfare Medicine and Mainstream Entitlement.” Journal of Health Politics, Policy and Law 28(5). The political vulnerability of Medicaid.
• Stone, D. (2008). The Samaritan’s Dilemma: Should Government Help Your Neighbor? Value pluralism and the politics of social provision.
• Jacobs, L. & Skocpol, T. (2012). Health Care Reform and American Politics. The political dynamics of the ACA.
• Laugesen, M. (2016). Fixing Medical Prices: How Physicians Are Paid. The opaque pricing mechanisms of public-private healthcare finance.
• Lindrooth, R., Perraillon, M., Hardy, R., & Tung, G. (2018). “Understanding the Relationship Between Medicaid Expansion and Hospital Closures.” Health Affairs 37(1). The empirical relationship between Medicaid revenue and rural hospital viability.