BIG SANDY, Mont. \u2014 The emergency department at Big Sandy Medical Center is one room with a single curtain between two beds.<\/p>\n
It\u2019s one of the many parts of the 25-bed rural hospital that need updating, former CEO Ron Wiens said.<\/p>\n
He said the hospital, an essential service in its namesake town of nearly 800 residents in the state\u2019s sprawling north-central high plains, needs at least $1 million for deferred maintenance, including a failing HVAC system. But the facility has struggled to make payroll each month and can\u2019t afford to make all the fixes, Wiens said.<\/p>\n
Built by farmers and ranchers in 1965, Big Sandy Medical Center began with nine beds. Today, a similar community effort \u2014 donations and grants to plug financial holes each year \u2014 keeps it afloat.<\/p>\n
Wiens, who recently left his position at the hospital, said he wishes Big Sandy could get funding from Montana\u2019s share of the $50 billion federal Rural Health Transformation Program to renovate the hospital and direct payments to help secure its future. The state received more than $233 million in its first-year award.<\/p>\n
But the hospital may not get the kind of help he sought.<\/p>\n
That\u2019s because the five-year program focuses on new, creative ways to improve access to rural health care, not on directly funding services and renovations. And Montana is one of at least 10 states whose leaders say projects launched under the federal program could lead rural hospitals to cut services so they can continue to afford to offer emergency and other essential care.<\/p>\n Congressional Republicans created the fund as a last-minute sweetener to their One Big Beautiful Bill Act, signed into law last summer. The funding was intended to offset disproportionate fallout anticipated in rural communities from the law, which is expected to slash Medicaid spending by nearly $1 trillion over 10 years.<\/p>\n Montana\u2019s application includes programs to make it easier for rural residents to get medical care and live a healthy lifestyle. For example, it says funding can be used to start community gardens, train paramedics to make home visits, open school-based clinics, or bring mobile clinics to rural areas.<\/p>\n The application also says rural Montana hospitals can receive payments for implementing recommendations, \u201cincluding right-sizing select inpatient services\u201d to match demand. In some cases, it says, right-sizing might mean \u201cdownsizing.\u201d The state says hospitals will have input and recommendations will be specific to each facility.<\/p>\n \u201cThat\u2019s what has all the hospitals on pins and needles, words like restructuring, reducing inpatient beds. Everybody is going, \u2018What is this going to look like?\u2019\u201d Wiens said.<\/p>\n The Montana Department of Public Health and Human Services declined to answer questions about how it will carry out its right-sizing efforts.<\/p>\n \t\t\tEmail Sign-Up A Lifeline of Care<\/strong><\/p>\n Big Sandy cattle rancher Shane Chauvet doesn\u2019t want any services cut.<\/p>\n He credits Big Sandy Medical Center with saving his life after a flying piece of metal nearly cut off his arm during a windstorm a few years back.<\/p>\n \u201cI looked over, saw it coming, and whack!\u201d Chauvet recalled.<\/p>\n His wife drove him to the hospital, where they frantically pounded on the ER door while Chauvet\u2019s blood pooled on the ground.<\/p>\n Because of the storm, staffers worked on Chauvet with no power and no ability to summon a helicopter. He was then taken by ambulance 80 miles through intense rain and hail to a larger hospital.<\/p>\n Chauvet understands the state\u2019s plan doesn\u2019t call for eliminating emergency care, but he worries that reducing other services would set off a downward spiral for the hospital and his town.<\/p>\n In Oklahoma, realigning clinical services could mean \u201cshutting down service lines,\u201d according to its application to the federal program. And in Wyoming, any facility that receives funding must agree to \u201creduce unprofitable, duplicative or nonessential service lines,\u201d according to its rural health law.<\/p>\n Monique McBride, business operations administrator at the Wyoming Department of Health, said the department interprets right-sizing as helping rural hospitals provide essential services \u2014 such as emergency departments, ambulance services, and labor and delivery units \u2014 while maintaining long-term, financial stability.<\/p>\n \u201cThis might involve limiting some elective procedures that could be done at lower cost in higher-volume facilities. The main distinction here is time-sensitive emergencies vs. \u2018shoppable\u2019 services,\u201d she said.<\/p>\n A New Lease on Life?<\/strong><\/p>\n Seven of the 10 states \u2014 Nebraska, North Dakota, Tennessee, Kansas, Nevada, South Carolina, and Washington \u2014 where rural hospital service cuts are on the table say they\u2019ll help pay for hospitals to convert to Rural Emergency Hospitals. The recently created federal designation requires hospitals to halt inpatient services and offers enhanced payments to help them maintain emergency and outpatient care.<\/p>\n At least 15 additional states wrote that they\u2019ll use the federal funding to right-size, evaluate, or adjust services \u2014 which could mean adding or taking away services, or transitioning them to a telehealth or outpatient setting.<\/p>\n Brock Slabach, chief operations officer of the National Rural Health Association, said, \u201cThere\u2019s a proper concern from rural hospital administrators that this funding is not going to where it was intended.\u201d<\/p>\n He said cutting services that lose money could backfire in the long run. For example, he said, halting labor and delivery care might drive more people out of small towns, further reducing hospitals\u2019 patient numbers and revenue.<\/p>\n The type of hospital services that states will assess matters, said Tony Shih, a senior adviser at the Commonwealth Fund, a nonprofit focused on making health care more equitable.<\/p>\n \u201cIf the end result is that high-margin services are taken away from local hospitals with nothing given back in return, it can be financially harmful,\u201d he said.<\/p>\n Shih noted that states\u2019 plans to add more outpatient care could prove beneficial for patients. It\u2019ll take time to know which states help stabilize rural hospitals, he said.<\/p>\n Rural hospital leaders say they know which changes would keep their facilities open and that states shouldn\u2019t suggest or mandate service cuts and other changes on their behalf.<\/p>\n Josh Hannes, who oversees rural health policy at the Colorado Hospital Association, said \u201ctop-down\u201d directives won\u2019t work.<\/p>\n He said the association\u2019s members believe they can find efficiencies and are eager to collaborate. But \u201ca state agency shouldn\u2019t be making those determinations,\u201d he said.<\/p>\n Hannes said members are worried Colorado\u2019s plan to classify rural health facilities as a \u201chub, spoke, or telehealth node\u201d will compel service reductions. The classification will help determine \u201cwhich services are sustainable locally and which are best provided regionally or through telehealth,\u201d according to its program application.<\/p>\n Spokespeople for the Colorado and Oklahoma health departments said no facility will be forced to end services. But Oklahoma spokesperson Rachel Klein said some facilities might choose to do so as part of a broader effort to make sure they\u2019re meeting community needs while remaining financially stable.<\/p>\n \u201cA hospital might shift certain services to a nearby regional provider with higher patient volume and specialized staff while expanding other local services,\u201d such as primary, outpatient, or community-based care, she said.<\/p>\n Wiens and Darrell Messersmith, CEO of Dahl Memorial Hospital in the southeastern Montana town of Ekalaka, said they worry the only way hospitals will get their share of funding is to cut services or become Rural Emergency Hospitals that don\u2019t offer inpatient services.<\/p>\n \u201cI would hate to see things shift toward a pack-and-ship facility,\u201d Messersmith said. \u201cRight now, we function quite well as an inpatient facility.\u201d<\/p>\n Not all Montana health leaders are worried.<\/p>\n Ed Buttrey, president and CEO of the Montana Hospital Association, said he thinks his state\u2019s plan could help rural hospitals become financially sustainable and survive Medicaid cuts. Buttrey is also a Republican state lawmaker.<\/p>\n Chauvet, the Big Sandy rancher, said his perspective on whether remote towns like his should have a hospital is forever changed because of his accident.<\/p>\n \u201cI always would say, \u2018Oh, they\u2019re nice to have,\u2019 but now I look at the hospital and say, \u2018That\u2019s essential to our community,\u2019\u201d he said.<\/p>\n![\"A](\"https:\/\/kffhealthnews.org\/wp-content\/uploads\/sites\/2\/2026\/04\/RHT-04-resized.jpg\")
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