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In 2001, the Institute of Medicine (IOM) called for transformation of the United States health care system to make it safe, effective, patient-centered, timely, efficient, and equitable.1 The journey toward these six aims in public policy and the private sector is underway, but fundamental challenges detailed by the IOM remain. Patients are injured at alarming rates, wide variation in care exists across geographies, patients complain of insensitive and/or inaccessible health care providers, health care costs are nearly twice that in other developed countries, and nearly 50 million Americans lack health insurance. As a result, our health care is often fragmented, uncoordinated, and excessively costly. In fact, the United States health care system has been called a “non-system.” The rural health care landscape is additionally challenged by independent and autonomous providers often struggling to survive financially, burdensome geographic separations in health care services, and incompatible information technologies. As a result, resources are wasted, patients are harmed, and rural communities are neglected.

Despite persistent rural challenges, public policies during the past 30 years have helped build and stabilize rural health care services. New payments have increased revenue for physicians practicing in shortage areas, rural hospitals certified as Critical Access Hospitals (very small hospitals in isolated places), Sole Community Hospitals (larger hospitals also in isolated areas), and Rural Health Clinics (primary care clinics staffed by nurse practitioners and/or physician assistants). New programs continue to provide technical assistance and grants to rural hospitals (Medicare Rural Hospital Flexibility Program), fund installation of telemedicine equipment, and promote rural health professions education.

These successes have required political capital and developmental resources to support a system that delivers discrete and uncoordinated health care services, provided by specific professionals and institutions, each paid on a per-service basis. Yet, progressive work by the Institute of Medicine (especially the Rural Health Committee document Quality Through Collaboration: The Future of Rural Health Care), the Commonwealth Commission on a High Performance Healthcare System, and other organizations suggest more effective strategies to improve and sustain the health of rural people...