September 2025 in review: Shutdown looms, rural fund opens, visa fee hits
- Posted by Greg Wahlstrom, MBA, HCM
- Posted in Blog
Hospitals ended the month facing a funding deadline, a $50 billion rural program with a November application window, and a steep new cost to recruit foreign-trained clinicians.
September set up the fall agenda for hospital leaders. Congress drifted toward an October 1 funding deadline with several hospital priorities unresolved, CMS opened the application process for the largest rural health investment in years, and a White House immigration action raised the cost of a recruiting channel many systems depend on.
A shutdown deadline with hospital priorities attached
As the month closed, a stopgap spending deal had not materialized. Hospital groups were pressing for more time on Medicare telehealth flexibilities, the acute hospital care at home waiver and enhanced low-volume hospital payments, all of which were scheduled to lapse with the fiscal year. A scheduled $8 billion reduction in Medicaid disproportionate share hospital payments was also set to begin, and bipartisan members of the House urged leadership to stop it.
The larger fight centered on the enhanced ACA premium tax credits, which expire at year end. KFF estimated that subsidized marketplace enrollees would see their annual premium payments rise from an average of $888 to $1,904, an increase of about 114%, if the credits lapse. For hospitals, that points to more uninsured patients and more uncompensated care in 2026.
CMS opens the $50 billion Rural Health Transformation Program
On September 15, CMS released the funding opportunity for the Rural Health Transformation Program created by this summer’s reconciliation law. The program will distribute $10 billion a year for five years beginning in fiscal 2026. Half will be split equally among approved states; the other half will be awarded based on state metrics and the strength of each application. States must apply by November 5, and CMS plans to announce awards by December 31.
Funding flows to states, not directly to hospitals. Rural providers that want a role need to be in conversation with their state health agencies now, while plans covering prevention, workforce, care models and technology are being written.
A $100,000 fee on new H-1B petitions
A September 19 presidential proclamation set a $100,000 fee on new H-1B petitions. AHA asked the administration to exempt health care personnel, noting that roughly 17,000 H-1B approvals in fiscal 2024 were for medicine and health occupations, about half of them physicians and surgeons. Systems that rely on international recruitment, particularly rural and safety-net hospitals, face a sharp jump in hiring costs while the policy stands.
- Finance: model coverage losses and DSH reductions in 2026 budgets.
- Strategy: engage state officials on rural transformation plans.
- Workforce: inventory pending and planned H-1B hires.
Executive takeaway: Build 2026 budgets that assume higher uninsured volume and lower DSH funding, and get rural facilities into your state's transformation planning before the November 5 application deadline.
Sources
- CMS Launches Landmark $50 Billion Rural Health Transformation Program (CMS, Sept. 15, 2025)
- Congressional healthcare spending showdown (HFMA, Sept. 30, 2025)
- ACA Marketplace Premium Payments Would More than Double on Average Next Year if Enhanced Premium Tax Credits Expire (KFF, Sept. 30, 2025)
- AHA urges administration to make health care personnel exempt from H-1B visa changes (AHA, Sept. 29, 2025)
- Bipartisan letter urges House leadership to halt Medicaid DSH cuts (AHA, Sept. 17, 2025)
