Elizabeth Kromm spent the final months of last year locked in a $50 billion competition.
The prize: a windfall to make progress on longstanding barriers to health that lead rural Americans to live sicker and die younger than their metropolitan counterparts.
Kromm is a top health official in Maryland. She had to convince the Trump administration that her plan to improve rural health was better than the ideas being cooked up in the other 49 states.
“There’s a game to be played,” Kromm said, “and we have to figure out how to play it and then how to win it.”
The White House pitted states against each other to determine which would get the most money from a $50 billion fund Republicans in Congress created last summer for new technology, physician recruiting and other health care investments across rural America.
“This is a competition,” said Mehmet Oz, a physician and top Trump administration health official. “America loves a competition.”
Lawmakers tucked the money into their sweeping domestic policy bill under pressure from senators in rural states who feared the $1 trillion in cuts to Medicaid and the Affordable Care Act also included in the bill would hit their hospitals hard.
Rural communities are expected to lose $137 billion in federal funding over the next decade — nearly three times the size of the new fund.
The chance to get any new money from Washington set off a sprint by Kromm and her counterparts across the country. They had 52 days to pull together their proposals.
The breakneck pace and the looming cuts posed a unique challenge for state officials.
Tradeoffs followed Kromm for seven weeks as she and her team navigated hard choice after hard choice as they rushed to pull their application together last fall. Kromm’s experience is a glimpse of how states are adapting to the big, fast-moving changes to federal policy that have become a hallmark of this Trump administration and Republican-controlled Congress.
This account is taken from meetings Kromm held with state staff and interviews with Kromm, state and local policymakers, and Maryland residents.
So many ideas, so little time
As soon as the Trump administration laid out the ground rules in September, Kromm began to strategize.
Some things were out of her control. The White House said more money would flow to the most rural states, and Maryland stacked up poorly.
Kromm’s best option to increase Maryland’s funding was to pitch projects in line with ideas the White House really liked: increasing the number of medical workers in rural areas and tackling chronic disease through technology and lifestyle changes.
She hastily arranged 17 public meetings over roughly two weeks across the state’s rural counties to get input from county officials, hospitals, doctors and residents.
Hospitals pushed hard to get money to flow to them, but the administration encouraged state leaders like Kromm to think more broadly.
Mike Salvadge, the emergency services chief in western Maryland’s Alleghany County saw a chance to launch a new community paramedics program. The workers, he said, could help people manage their chronic diseases and save his ambulances for true emergencies.
Along Maryland’s eastern shore, residents lobbied for more specialists, to make it easier to get appointments for cancer screening.
Kromm knew she’d have to choose just a few projects to request funding for — and they had to be strong bets. The Trump administration’s Oz said federal health officials will evaluate states’ performance each year, docking money from states that fall short of promised targets.
“The folks who don’t deliver what they promised, they might get some money taken away from them to give to the guys who are doing a great job,” Oz said in December.
Kromm had to pass over projects that required too much time to vet. One idea left on the cutting room floor: increase transportation across rural Maryland — something Kromm believes is much needed to improve health outcomes.
“If you are not able to actually … physically get to the care you need, that’s a problem,” she said. “That was a hard decision to kind of just stop that conversation.
Maryland’s big swing
By late October, Kromm and her team had landed on their three big priorities: get more people into health care jobs, expand ways rural Marylanders can get medical care, and feed people more locally grown food.
Kromm was particularly excited about the state’s plans for food. It was a chance to align the Trump administration’s interest in improving people’s diets with something Kromm knew could help tackle diabetes and heart disease, two conditions that are more common in rural Maryland than the rest of the state.
But states are prohibited from buying people food with this pot of money.
Kromm planned to ask the White House for $88 million over the state’s five-year, $1 billion budget request, to help the state’s farmers and rural grocers expand the supply of locally grown fresh produce.
“I need more Maryland food in Maryland bodies,” she said. “How am I going to get that? I have a lot of Maryland farmers.”
Maryland would use the funds to buy freezers and refrigerated trucks to keep food fresh longer and reduce waste. The state would also stand up groups to broker sales between small farms and large health care buyers.
Farmer Levi Lantz said hospitals, insurers and nonprofits in his area are increasingly looking for ways to get fresh food to patients and low-income families.
“There’s more and more people that say, ‘Hey, I have money, I want to get it out to the people that need it,’” Lantz said.
Lantz worked with other farmers in northwestern Maryland last summer to fill produce boxes for 400 local hospital patients. Additional funding, local agricultural leaders said, would help them sustain and expand their efforts.
Kromm hopes that investing in farmers such as Lantz will improve the health of rural Marylanders like Bonita Baer and her family.
Baer lives about 45 minutes east of Lantz’s farm in a town of roughly 1,000 people. With the help of federal food assistance programs, Baer makes a tight food budget stretch to feed her four boys — ages three to 14 — and her husband, who was recently diagnosed with diabetes.
Some weeks, Baer turns to a local food pantry to get by. The stress of making sure there’s enough food on the table takes a toll.
When the shelves start to run bare, “I get anxious and very jittery,” she said. “I can’t sleep, I can’t focus. Everything’s out of whack.
Her children love fresh vegetables — especially zucchini — but fresh is more expensive. Last summer, Baer got a box of locally grown food, subsidized by a grant. She would jump at the chance again, she said.
“We’re in scary times,” Baer said. “Prices don’t go down and checks don’t go up.”
An answer and more hard choices
Making so many high-stakes decisions in such a short period of time left Kromm exhausted by the time her team sent in their application to federal officials in early November.
For the next seven weeks, she waited. States had been told by the White House to pitch a $200 million a year budget, but she knew she’d get less. Kromm was confident she’d get at least $100 million for the first year, and she hoped for $120 million.
She got her answer just a few days before New Year’s. Kromm was helping her daughters run field hockey drills.
“They were like, ‘Did you get $100 million?’” Kromm said. “I was like, ‘No, I got $168 million.’”
It was less than most states, but more than Kromm expected.
“This is very good,” she said the day the award was announced. “I think we accomplished our goal.”
But there were still more hard choices to make. Kromm now had to cut back Maryland’s $200 million budget to match the smaller award.
Rather than scrap any single initiative, Kromm opted to keep all of the state’s proposals, but cut many of them by up to 30%.
Food projects got a smaller haircut, she said. Telehealth took a bigger hit, with some work delayed until next year. Mobile health — which includes community paramedics — held onto nearly all its funding.
The Trump administration must sign off on Kromm’s revised budget by the end of February.
Kromm’s next challenge will be figuring out how to quickly stand up all the approved programs. The administration will be evaluating states’ progress and giving out the next round of funding this fall.
Kromm is aware of the consequences of looming federal health cuts: fewer people with insurance, less money going to hospitals, more preventable illness. But she’s focused on the work in front of her.
“If we do not make the most of every dollar coming to us,” Kromm said, “through whatever way, shape or form to drive to what we know are the things that are going to improve the health of Marylanders, then shame on us.”
Jennifer Weingart contributed to this story.
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