Federal Regional Commissions and Authorities (FRCAs): Health-Related Programs
Congressional research reportJun 15, 2026
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Federal Regional Commissions and
Authorities (FRCAs): Health-Related
Programs
June 15, 2026
Congressional Research Service
https://crsreports.congress.gov
R48993
SUMMARY
Federal Regional Commissions and Authorities
(FRCAs): Health-Related Programs
Congress has maintained a long-standing interest in improving the health status of rural
populations, particularly through increasing access to health services and health workforce
training. Federal regional commissions and authorities (FRCAs) are state-federal partnerships
that use congressionally-provided appropriations for economic development grants and related
activities. FRCAs tend to be rural relative to the overall United States’ population. There are
eleven FRCAs (see map below); as of the date of publication, six are active.
R48993
June 15, 2026
Julie M. Lawhorn
Analyst in Economic
Development Policy
Elayne J. Heisler
Specialist in Health
Services
FRCAs have used a range of program authorities to help economically distressed regions to
address health-related concerns. For instance, FRCAs can provide grants for health care facility
development, health care workforce development, substance use disorder treatment, and health
care business technical assistance. In addition, some FRCAs oversee health advisory councils and J-1 visa waivers for foreign
physicians who provide medical services in communities with shortages of health providers. Under P.L. 118-272, enacted in
FY2025, Congress expanded FRCA authorities, including authorities for health care demonstration projects. In recent years,
Congress has directed other federal agencies to partner with or provide funding to FRCAs for various health care initiatives.
Regions of the Federal Regional Commissions and Authorities (FRCAs)
(by county, parish, or borough)
Source: CRS analysis of authorizing commission and authorities legislation and Esri Data and Maps.
Notes: There are no FRCAs in Hawaii. The Northwest Regional Commission is not included in the map above. P.L. 119-74
provided funding for this commission in Washington, Oregon, Idaho, and Montana, but did not provide further geographic
information.
Efforts to improve individual and community health outcomes and expand health care access may align with a region’s
economic development objectives. Health care facilities and related businesses are often employers and may be a region’s
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Federal Regional Commissions and Authorities (FRCAs): Health-Related Policies
largest source of jobs. They may also contribute to state and local economic development through their direct and indirect
spending and may induce other jobs in their regions. Health resources and health care institutions also contribute to public
health, and are amenities that workers and businesses may consider in their location and investment decisions.
FRCAs use community-driven approaches, convene cross-sector partnerships, and are statutorily authorized to facilitate
projects informed by state and local priorities, some of which may also address individual and community health. For
instance, FRCAs may support workforce development efforts, which are often designed to enhance regional employment
opportunities, and employment is generally correlated with improved individual and community health. Employment is
associated with lower mortality in certain circumstances and conditions, and employment may also affect the health of the
larger community because of the relationship between employment opportunities, insurance status, health care access, and the
financial viability of health providers. FRCAs may also provide a regionally-oriented framework for addressing certain
factors that contribute to health. Health care funding often flows to states, but individuals may access health care in ways that
cross state boundaries. FRCAs, most of which have multistate regions, may be able to work on the complicated issue of
health care access using their experience in administering regional, multistate projects and collaborating with multiple levels
of government entities, including regional development organizations.
Congress may wish to evaluate how FRCAs’ health-related programs are implemented and how they may further the FRCAs’
and FRCA members’ economic development goals. Congress may also wish to evaluate whether these programs may serve
as a way to expand the reach of federal funding in different or complementary ways or if there are areas of overlapping
activity. Congress may consider options to change, integrate, or otherwise coordinate FRCAs’ health-related activities with
other federal funding programs. Recognizing the role of state and local decisions in health outcomes, policymakers could
direct FRCAs to administer economic development programs that are tailored to specific health challenges or opportunities
while continuing to integrate state and local input and priorities. Should Congress be supportive of expanded FRCA roles,
Congress may wish to build on the existing state and local partnerships that are central to the FRCAs’ structural, governance,
and operational framework. Finally, Congress may wish to evaluate existing FRCA health activities and their partnerships
with other federal, regional, state, and local entities.
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Federal Regional Commissions and Authorities (FRCAs): Health-Related Policies
Contents
Introduction ..................................................................................................................................... 1
Why Health Is Considered a Regional Economic Development Issue............................................ 3
Employment and Health ............................................................................................................ 5
Health Care Industry Employment ............................................................................................ 7
Health Care Spending and Regional Economic Effects ............................................................ 9
Talent Attraction, Human Capital, and Place-Making .............................................................11
Negative Impacts of Certain Health Care Challenges ............................................................. 13
Overview of FRCAs ...................................................................................................................... 16
FRCAs’ Health-Related Activities................................................................................................. 19
Health in FRCA Strategic Plans and Investment Priorities ..................................................... 20
Examples of Health Related FRCA Grant Programs .............................................................. 21
Addressing Specific Health Conditions: The Example of Substance Use Disorder
(SUD) ................................................................................................................................... 23
Other FRCA Health Activities and Partnerships ..................................................................... 24
J-1 Visa Waiver Program for Physician Recruitment ........................................................ 25
Selected FRCA-Federal Partnerships................................................................................ 27
Health Research and Evaluation Activities ....................................................................... 28
Advisory Councils ............................................................................................................ 28
Selected FRCA Features, Roles, and Activities ............................................................................. 29
Links to Regional, State, and Local Organizations and Convenor Roles ............................... 29
FRCAs’ Capacity for Regional and Multistate Projects .......................................................... 30
FRCAs’ Program and Funding Flexibilities ............................................................................ 31
Recent Legislation and Policy Proposals Involving FRCAs and Health ....................................... 32
Considerations for Congress.......................................................................................................... 33
FRCA-Federal and Other Partnership Activities ..................................................................... 34
Pilot Programs to Address Nonmedical Determinants of Health ............................................ 35
Research and Evaluation ......................................................................................................... 36
Concluding Remarks ..................................................................................................................... 36
Figures
Figure 1. U.S. Employment by Selected Industry, 1990-2025 ........................................................ 8
Figure 2. Economic Impacts Associated with Health Care Spending ........................................... 10
Figure 3. Health Care Provider Shortage Areas, by FRCA Region ............................................... 14
Figure 4. Regions of the Federal Regional Commissions and Authorities (FRCAs) .................... 16
Figure 5. ARC’s Recovery Ecosystem Model for Substance Abuse Disorder .............................. 24
Tables
Table 1. Statutory Citations for Operating Authorizations ............................................................ 17
Table 2. State, Local, and Regional Health and Health Care Strategies and
Selected FRCA Project Examples .............................................................................................. 22
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Table 3. Summary of FRCAs’ J-1 Visa Programs ......................................................................... 26
Table A-1. Percent of FRCA Regions’ Population in Rural Areas, 2020 ...................................... 38
Appendixes
Appendix A. FRCAs and Rurality ................................................................................................. 38
Appendix B. Selected References on the Relationship Between Health and Economic
Well-Being ................................................................................................................................. 39
Contacts
Author Information........................................................................................................................ 42
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Introduction
Policymakers have linked health and economic development for decades (see textbox on “ARC’s
Health Demonstration Health Projects”). Efforts to improve health outcomes and expand health
care access often align with economic development objectives for several reasons.1 Resilient
regional economies—with economic development and employment opportunities—are
increasingly viewed as complementary to individual and community health. Social and economic
policies, including economic development efforts (e.g., entrepreneurship, workforce training), are
often designed to address certain factors, employment opportunities, and living conditions that—
along with other determinants—contribute to individual and community health. Such factors are
referred to broadly as social determinants of health (i.e., the conditions in which people are born,
grow, work, live, worship, and age) and are separate from medical interventions that tend to occur
in a clinical setting.2 Individual health is also generally correlated with socioeconomic status;
higher income and wealth levels are associated with greater life expectancy and improved health
outcomes.3
Health care, as an industry, may also drive economic development. Health care facilities and
related businesses are employers and may be a community’s largest source of jobs.4 They may
also contribute to state and local economic development through their direct and indirect
spending and may induce other jobs in their regions. Additionally, for-profit (investor-owned)
hospitals may provide regional revenue by paying state and local taxes.5 Nonprofit hospitals are
required to meet a “community benefit” standard to qualify for tax exemptions; these include
community building activities that are designed to improve the health of the population that the
hospital serves.6 In addition to jobs, revenue, and other economic impacts, health resources and
1
For examples of state perspectives on rural economic development and health care, see National Governors
Association (NGA), “Governors and States Are Advancing Equitable Rural Economic Development and Healthcare,”
summary of roundtable events, April 12, 2023, https://www.nga.org/meetings/governors-and-states-are-advancingequitable-rural-economic-development-and-healthcare. For an example of private sector perspectives, see Nashville
Healthcare Council, “Intersection of Economic Development and Health: Insights from Crucial Conversations,” March
5, 2025, https://healthcarecouncil.com/intersection-of-economic-development-and-health-insights-from-crucialconversations/. For an example of philanthropic perspectives, see Georgia Health Policy Center, “Reimagining Rural
Health: Landscape Analysis,” April 2025, pp. 39-40, https://www.gih.org/wp-content/uploads/2026/01/ReimaginingRural-Health-Landscape-Analysis.pdf.
2 Centers for Disease Control (CDC), “Social Determinants of Health (SDOH),” https://www.cdc.gov/about/priorities/
why-is-addressing-sdoh-important.html.
3 For a summary of recent research on life expectancy and income, see “The Growing Gap in Life Expectancy by
Income: Recent Evidence,” in CRS Report R44846, The Growing Gap in Life Expectancy by Income: Recent Evidence
and Implications for the Social Security Retirement Age, by Katelin P. Isaacs et al.
4 News analysis of job growth in 2025-2026 has pointed to healthcare-related jobs as a significant driver of economic
growth. See, for example, Abha Bhattarai and Luis Melgar, “If Not for This One Industry, the U.S. Labor Market
Would Look a Lot Worse,” The Washington Post, February 14, 2026, https://www.washingtonpost.com/business/2026/
02/14/health-care-industry-fuels-employment/; and Lydia DePillis,“Healthcare Has Become the Lifeblood of the Labor
Market,” New York Times, March 6, 2026, https://www.nytimes.com/2026/03/06/business/economy/health-care-hiringlabor-market.html.
5 In 2025, the share of hospitals that were for-profit (compared to nonprofit or government-run) was approximately
17—24% of all hospitals. See KFF (formerly the Kaiser Family Foundation), “The Hospital Industry—Hospital
Characteristics,” https://www.kff.org/health-costs/key-facts-about-hospitals/?entry=the-hospital-industry-hospitalcharacteristics; and Christopher M. Whaley, “Reassessing the Value of Nonprofit Hospital Tax Exemptions:
Community Benefit or Missed Opportunity?” Testimony for the U.S. Congress, House Committee on Ways and
Means, Subcommittee on Oversight, September 16, 2025, p. 5, https://waysandmeans.house.gov/wp-content/uploads/
2025/09/Whaley_Ways-and-Means-Nonprofit-Hospitals-.pdf.
6 Nonprofit hospitals are required to provide certain community benefits (e.g., free or reduced-cost care) and to meet
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health care institutions contribute to public health, and—as amenities—contribute to an area’s
quality of place. Workers, retirees, and businesses generally consider proximity to and quality of
amenities in location decisions.7 In some regions, health care institutions also lead or facilitate
community development, education, and innovation roles and provide telehealth and other
services.8
For decades, Congress has authorized federal regional commissions and authorities (FRCAs) to
address economic and social disparities in designated regions of the United States. FRCAs are
quasi-governmental partnerships between the federal government and the constituent state or
states of the given authority or commission. FRCAs are federally chartered, receive congressional
appropriations for their administration and activities, and include an appointed federal
representative.9 FRCAs may award grants to further their economic goals. In addition to grantmaking activities, FRCAs may partner with federal agencies on targeted health initiatives,
convene public and private sector stakeholders, serve as Interested Government Agencies for J-1
visa waivers for physician recruitment (see “J-1 Visa Waiver Program for Physician
Recruitment”), and coordinate research on health or health care challenges and opportunities
(e.g., access to health care, workforce training).
Most FRCA regions also face health and health care challenges, which may impact economic
development, health outcomes, and business location decisions in their regions.10 Generally
speaking for most FRCAs, over a third of the population lives in rural areas, exceeding the
national average of 20% (see Appendix A). Federal policies have long recognized the health
challenges that rural areas face—through targeted grants and technical assistance supported by
the Federal Office of Rural Health Policy and through payments in federal health programs that
target rural hospitals, among other efforts.11
This report summarizes research on the relationships between economic development and health
as context for discussing health and health care programs facilitated by federal economic
development policy—with an emphasis on the six active FRCAs. FRCAs address economic
development as well as health and health care priorities as key components of their overall
other requirements (e.g., to implement financial assistance and emergency medical care policies) in order to maintain
their tax-exempt status. Nonprofit hospitals must also meet the general requirements applicable to all 501(c)(3)
organizations. For additional information, see CRS Report R48027, Legal Requirements for Section 501(c)(3)
Hospitals, by Edward C. Liu.
7 James F. Oehmke et al., “Can Healthcare Services Attract Retirees and Contribute to the Economic Sustainability of
Rural Places?” Northeastern Agricultural and Resource Economics Association Agricultural and Resource Economics
Review, vol. 36, no. 1 (April 2007), pp. 1-12, https://doi.org/10.22004/ag.econ.10155; and Jeffrey Dorfman and Anne
Mandich “Senior Migration: Spatial Considerations of Amenity and Health Access Drivers,” Journal of Regional
Science, vol. 56, no. 1 (August. 2016), pp. 96-133, https://doi.org/10.1111/jors.12209.
8 National Association of Development Organizations (NADO), Building Healthier Rural Communities: Economic
Development Districts Address Social Determinants of Health, August 2025, p. 13, https://www.nado.org/wp-content/
uploads/2025/08/Social-Determinants-of-Health_v6.pdf.
9 The appointment of a federal co-chair, unless otherwise provided, is essential for most federal regional commissions
and authorities’ (FRCAs’) operations. With the exception of the Denali Commission, a federal co-chair is a
presidentially nominated and Senate-confirmed position.
10 Elizabeth Weeks, “Medicalization of Rural Poverty: Challenges for Access,” Journal of Law, Medicine & Ethics,
vol. 46, iss. 3 (September 2018), p. 653, https://journals.sagepub.com/doi/10.1177/1073110518804219; and Shannon
Monnat and Khary Rigg, “The Opioid Crisis in Rural and Small Town America,” Carsey Research, University of New
Hampshire, June 19, 2018, https://carsey.unh.edu/publication/opioid-crisis-rural-small-town-america. See also Anne
Case and Angus Deaton, Deaths of Despair and the Future of Capitalism (Princeton University Press: 2020).
11 U.S. Department of Health and Human Services (HHS), Health Resources and Services Administration (HRSA),
Federal Office of Rural Health Policy (FORHP), https://www.hrsa.gov/rural-health and CRS Infographic IG10095,
Medicare Payment for Rural or Geographically Isolated Hospitals, 2026, by Marco A. Villagrana.
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missions to improve the economic conditions of the areas they serve. As such, Congress may
consider examining, changing, or expanding the role of FRCAs in advancing health and health
care objectives. It may also consider how FRCA activities complement or duplicate existing
efforts undertaken by the Department of Health and Human Services (HHS), which is the lead
federal health agency. This report considers some of the possible advantages of strong population
health and health care resources on regional economic development, as well as the impacts of
health care shortages and health-related challenges in place-making, workforce development, and
business attraction. Congress may consider the federal role in addressing these challenges, as well
as the value of a community- or state-led approach. This report summarizes research and program
evaluations carried out by epidemiologists, health economists, social scientists, and policy
analysts, where available. There is a vast literature on these topics and this report’s review is not
exhaustive. Appendix B provides additional sources that CRS consulted when developing its
analysis.
This report focuses on the health-related initiatives carried out by place-based economic
development entities and does not cover general economic policies, though these too may benefit
an individual’s health.12 This report does not provide a comprehensive analysis of socioeconomic
disparities, health care workforce shortages, or rural hospital closures in FRCA regions.13
Why Health Is Considered a Regional Economic
Development Issue
Health is multidimensional. Broadly, community and individual health conditions are linked
with—and affected by—economic conditions and opportunities in a particular place.14 Also,
economic development policies are often place-based and focused on improving economic
mobility, employment opportunities, conditions for private investment, as well as the quality of
services and amenities in a specific place or region.15 Place-based economic development
considerations include, among other things, a community’s health resources, human capital, and
12 For perspective on the relationships of economic policies on health, see Elizabeth Rigby, “Economic Policy: An
Important (but Overlooked) Piece of ‘Health in All Policies,’” Washington, DC: Institute of Medicine, 2013,
https://nam.edu/perspectives/economic-policy-an-important-but-overlooked-piece-of-health-in-all-policies/.
13 For additional information on rural hospital closures, see CRS Report R47526, Closed, Converted, Merged, and New
Hospitals with Medicare Rural Designations: January 2018-November 2022, coordinated by Marco A. Villagrana.
14 Manuel Pastor and Rachel Morello-Frosch, “Integrating Public Health and Community Development to Tackle
Neighborhood Distress and Promote Well-Being,” Health Affairs, vol. 33, no. 11 (November 2014), https://doi.org/
10.1377/hlthaff.2014.0640.
15 The definition of “economic development” often varies depending on the priorities, economy, and values of the
communities involved. Generally, economic development includes two definitions: first, a general usage; and second, a
more specific description of its application in a public policy context. For the former, economic development can be
interpreted as the promotion of certain economic ends through site selection by companies, business expansion and
development, and public spending (or tax incentives) that support these activities, particularly as they may relate to job
creation. In a more public policy-specific context, the definition of economic development may include policy
interventions that may support or shape economic activity. Broadly, policy options for economic development typically
fall along a continuum between economic growth and social welfare. Growth-oriented policies tend to focus on
maximizing top-line macroeconomic performance, whereas social welfare policies often emphasize ameliorating
inequality and poverty. The U.S. Economic Development Administration (EDA) defines economic development as
“creating the conditions for economic growth and improved quality of life by expanding the capacity of individuals,
businesses, and communities to maximize the use of their talents and skills to support innovation, job creation, and
private investment.” See EDA, “Economic Development Glossary,” https://www.eda.gov/about/economicdevelopment-glossary.
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health care employers and workforce, as well as its overall population health.16 For instance,
positive community health indicators are generally associated with strong regional economic
conditions and vice versa.17 Elevated mortality rates of certain conditions such as substance use
disorder are associated with areas experiencing economic distress, including certain FRCA
regions.18 Economic development policies to expand employment opportunities, for example,
may align with health policies because employment is correlated with positive individual- and
community-level health outcomes.19 It is important to consider that, while certain aspects of a
community’s economic and population-level health are intertwined, the relationships are
multifaceted, and effects vary by population, location, context, and other factors.20
Just as community health outcomes are impacted by many factors, multiple non-medical factors
also affect individual health. Certain economic and social factors may influence individual health
including health behaviors, socioeconomic factors, and physical and environmental conditions.21
Some of these factors may be referred to as social determinants of health (see text box).
Social Determinants of Health
Factors that affect individual and population health are known as determinants of health. Determinants of individual
health are varied and multifaceted. The U.S. Department of Health and Human Services (HHS) defines social
determinants of health (SDOH), as “the conditions in which people are born, grow, live, work and age, and
people’s access to power, money and resources.” When weighing all of the factors that may impact an individual’s
health, HHS has found that the SDOH contribute approximately 50% to health outcomes. These determinants
include factors “such as housing, food and nutrition, transportation, social and economic mobility, education, and
environmental conditions.” In addition to clinical care and SDOH, other factors that contribute to health
outcomes include genetics and health behaviors.
Sources: CRS Infographic IG10083, Public Health Prevention and the Determinants of Health, by Johnathan H. Duff et
al.; Centers for Disease Control (CDC), “Social Determinants of Health (SDOH),” https://www.cdc.gov/about/
priorities/why-is-addressing-sdoh-important.html; U.S. Department of Health and Human Services (HHS), “Social
Determinants of Health,” https://odphp.health.gov/healthypeople/priority-areas/social-determinants-health; and
Amelia Whitman et al., “Addressing Social Determinants of Health: Examples of Successful Evidence-Based
Strategies and Current Federal Efforts,” 2022, p. 2, https://aspe.hhs.gov/reports/sdoh-evidence-review.
16 For additional information, see CRS In Focus IF12409, What Is Place-Based Economic Development?, by Adam G.
Levin. For a review of changing approaches to economic development, see Steven S. Deller, “Are We at an Inflection
Point in Community Economic Development? The 4th Wave,” Economic Development Quarterly, vol. 39, iss. 4 (May
28, 2025), https://doi.org/10.1177/08912424251339139.
17 Steven H. Wolf et al., “How Are Income and Wealth Linked to Health and Longevity?” April 2015, pp. 6, 11-12,
https://www.urban.org/sites/default/files/publication/49116/2000178-How-are-Income-and-Wealth-Linked-to-Healthand-Longevity.pdf; and Atheendar S. Venkataramani et al., “Economic Influences on Population Health in the United
States: Toward Policymaking Driven by Data and Evidence,” PLOS Medicine, vol. 17, iss. 9 (September 2, 2020)
https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1003319. See also “Impact of Health on
Economic Growth” in Alison F. Davis et al., The Program Evaluation of the ARC’s Health Projects, 2004-2010,
prepared for ARC, pp. 6-10, https://www.arc.gov/wp-content/uploads/2020/06/
ProgramEvaluationofARCsHealthProjects2004-2010.pdf.
18 For instance, deaths by suicide, drug use, and alcohol abuse are commonly referred to as “deaths of despair.” See
Anne Case and Angus Deaton, Deaths of Despair and the Future of Capitalism (Princeton University Press: 2020); and
Andrew Goodman-Bacon, “‘Deaths of Despair’ and Economic Opportunity,” Federal Reserve Bank of Minneapolis,
February 24, 2023, https://www.minneapolisfed.org/article/2023/deaths-of-despair-and-economic-opportunity.
19 See the “Economic Stability” section in HHS, Office of Disease Prevention and Health Promotion (ODPHP), “Social
Determinants of Health Literature Summaries,” https://odphp.health.gov/healthypeople/priority-areas/socialdeterminants-health/literature-summaries.
20 Andrew Goodman-Bacon, “‘Deaths of Despair’ and Economic Opportunity,” Federal Reserve Bank of Minneapolis,
February 24, 2023, https://www.minneapolisfed.org/article/2023/deaths-of-despair-and-economic-opportunity.
21 Carlyn M. Hood et al., “County Health Rankings: Relationships Between Determinant Factors and Health
Outcomes,” American Journal of Preventive Medicine, vol. 50, no. 2 (February 2016), pp. 129–135;
https://www.sciencedirect.com/science/article/abs/pii/S0749379715005140.
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The cumulative impact of living in places with limited financial and educational resources or
under persistent poverty conditions is linked to health in complex ways. Economic Research
Service researchers have observed that, “the cumulative effect of being poor may lead to poor
health, limited education, and other negative outcomes.”22 An HHS summary of the literature on
poverty notes that
Unmet social needs, environmental factors, and barriers to accessing health care contribute
to worse health outcomes for people with lower incomes. For example, people with limited
finances may have more difficulty obtaining health insurance or paying for expensive
procedures and medications. In addition, neighborhood factors, such as limited access to
healthy foods and higher instances of violence, can affect health by influencing health
behaviors and stress.23
The following sections summarize select health-related opportunities and challenges and how
they may be linked with regional economic development and growth. They also provide context
for FRCA investments in health. Additional information on FRCAs is provided later in the report.
The challenges and opportunities discussed below do not uniformly apply to all FRCA regions,
but are generally relevant to many of the FRCAs’ economic development priorities and activities,
and particularly for rural areas in FRCA regions (see Appendix A).
Employment and Health
Employment and health are linked.24 For instance, employment is associated with lower mortality
in certain circumstances and conditions.25 Unemployment is generally correlated with negative
health consequences, particularly for mental health.26 Authors of a 2018 review of research found
that, rather than a bidirectional causal relationship (i.e., employment causes improved health and
vice versa), the relationships between employment and health are correlational and complex and
depend on social contexts, such as the nature of jobs that workers occupy.27
Employment and health are often directly linked because jobs provide income and other benefits
that support health.28 Depending on the rate of compensation, having a job enables individuals to
22 U.S. Department of Agriculture (USDA), Economic Research Services (ERS), “Rural Poverty & Well-Being,”
updated January 14, 2025, https://www.ers.usda.gov/topics/rural-economy-population/rural-poverty-well-being.
23 As part of developing national population health goals, HHS’s Office of Disease Prevention and Health Promotion
(ODPHP), reviews the literature on various health priority areas. For more information, see HHS ODPHP, “Poverty,”
https://odphp.health.gov/healthypeople/priority-areas/social-determinants-health/literature-summaries/poverty.
24 For a summary of the literature on the association between health and employment, see Jerome M. Adams,
“Improving Individual and Community Health Through Better Employment Opportunities,” Health Affairs Blog, May
8, 2018, https://www.healthaffairs.org/content/forefront/improving-individual-and-community-health-through-betteremployment-opportunities; and HHS, “Employment,” https://odphp.health.gov/healthypeople/priority-areas/socialdeterminants-health/literature-summaries/employment.
25 An analysis of health and economic literature noted that in the United States, minimum-and medium-skilled workers
had higher mortality, compared to higher income workers, if they were unemployed—likely because they had “less
access to support services.” See Steven H. Wolf et al., “How Are Income and Wealth Linked to Health and
Longevity?” April 2015, p. 11, https://www.urban.org/research/publication/how-are-income-and-wealth-linked-healthand-longevity.
26 HHS, ODPHP, “Employment,” https://odphp.health.gov/healthypeople/priority-areas/social-determinants-health/
literature-summaries/employment.
27 Larisa Antonisse and Rachel Garfield, “The Relationship Between Work and Health: Findings from a Literature
Review,” KFF Issue Brief, August 2018, pp. 5-6, https://files.kff.org/attachment/Issue-Brief-The-RelationshipBetween-Work-and-Health-Findings-from-a-Literature%20Review.
28 Research supports positive correlational relationships between health and income. Experts continue to examine
potential causal relationships between income and health and related effects. For a summary of select studies, see
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pay for housing, food, and health care, which contribute to health. Jobs may provide benefits such
as health insurance. They may also provide other benefits such as retirement funding and paid
leave, which may also facilitate health and well-being. Jobs may also be a source of structure,
social connection, and meaning, which benefit individual health.29 The nature and quality of the
job may affect how employment influences individual health. Certain jobs with low security, high
stress, or long hours may negatively impact health.30
One of the mechanisms through which employment may affect health is through health insurance
coverage. The predominant method of health insurance coverage in the United States is
employer-sponsored insurance.31 Thus employment status is directly linked to the ability to access
health services as some health providers require health insurance as a condition of seeing a
patient. Being uninsured generally reduces access to care and increases out of pocket costs for
care.32 Individuals with concerns about cost may be less likely to seek necessary care.33 General
access to health care in a given geographic area may also be influenced by the insurance coverage
of the population of that area. In general, a medical facility’s payer mix—its percentage of
patients with private health insurance—affect the facility’s financial health.34 Facilities that serve
more people with private health insurance and fewer people who are uninsured are less likely to
experience financial distress, and financial distress is associated with health facility closures.35
Thus, employment generally both improves individual health, but may also affect the health of
the larger community because of the relationship between employment, insurance status, health
care access, and the financial viability of health providers.
Health also affects employment and is correlated with income levels. Physical and mental health
conditions impact individuals’ ability to learn and work, which, in turn, affects their productivity,
earnings, and quality of life. When individuals are healthy, they are generally able to obtain and
keep jobs.36 When individuals are in poor health, they have a higher risk of job loss or
Angus Deaton, “Health, Inequality, and Economic Development,” Journal of Economic Literature, vol. XLI (March
2003), https://www.princeton.edu/~deaton/downloads/Health_Inequality_and_Economic_Development.pdf.
29 HHS, ODPHP, “Employment,” https://odphp.health.gov/sites/default/files/2023-05/
SDOH%20Infographic_Employment.pdf.
30 Jerome M. Adams, “Improving Individual and Community Health Through Better Employment Opportunities,” May
8, 2018, https://www.healthaffairs.org/content/forefront/improving-individual-and-community-health-through-betteremployment-opportunities. There are exceptions to the correlation between unemployment and poor health
consequences. See Sarah A. Burgard and Katherine Y. Lin, “Bad Jobs, Bad Health? How Work and Working
Conditions Contribute to Health Disparities,” The American Behavioral Scientist, vol. 57, no. 8 (August 2013), pp. 1011, https://journals.sagepub.com/doi/10.1177/0002764213487347.
31 CRS In Focus IF10830, U.S. Health Care Coverage and Spending, by Ryan J. Rosso and Sylvia L. Bryan.
32 Jennifer Tolbert et al., “The Uninsured Population and Health Coverage,” KFF, Health Policy 101, Washington, DC,
October 8, 2025, https://www.kff.org/uninsured/health-policy-101-the-uninsured-population-and-health-coverage/?
entry=table-of-contents-introduction.
33 Shameek Rakshit, “Access & Affordability: How Does Cost Affect Access to Healthcare?,” Peterson KFF Health
System Tracker, Washington, DC, March 10, 2026, https://www.healthsystemtracker.org/chart-collection/cost-affectaccess-care/#Percent%20of%20adults%20who%20reported%20barriers%20to%20accessing%20healthcare,%202024.
34 Matthew Manary et al., “Payer Mix & Financial Health Drive Hospital Quality: Implications for Value-Based
Reimbursement Policies,” Behavioral Science & Policy, Spring 2015, pp. 78-84, https://journals.sagepub.com/doi/
10.1177/237946151500100110.
35 George M. Holmes et al., “Predicting Financial Distress and Closure in Rural Hospitals,” The Journal of Rural
Health, vol. 33, no. 3 (Summer 2017), pp. 239-249, https://onlinelibrary.wiley.com/doi/abs/10.1111/jrh.12187?
msockid=12085c83de2365cf2bf44bfbdf846454.
36 Jerome M. Adams, “The Value of Worker Well-Being,” Public Health Reports, vol. 134, iss. 6 (2019), pp. 83-586,
https://journals.sagepub.com/doi/10.1177/0033354919878434.
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unemployment.37 At the aggregate level, when workers are healthy, they are also able to be
productive and thereby contribute to gross domestic product (GDP).38 In the United States, higher
incomes are correlated with longer life expectancy.39 In a 2016 study researchers analyzed 1.4
billion tax records for individuals for every year from 1999 through 2014 and observed that
longer life expectancies were generally associated with higher income levels.40
Relationships between education and individual health are also multifaceted. A considerable body
of research has identified the relationship between health and education. However, researchers do
not have a single theory or explanation for the relationships between education and health.
Numerous studies point to the overall positive impact that education has on individual health
outcomes. Adults with higher levels of education generally have better health.41 Education that
leads to better jobs and higher income is one of several likely pathways that contribute to
improved health. In other words, greater educational attainment may improve individual
economic outcomes, which may, in turn, improve health through better access to health services,42
better access to healthy food, among other benefits.43
Health Care Industry Employment
Health care and health-related businesses and institutions can be a major source of employment
and may generate other beneficial economic activity in certain regions. Health care employment
is often considered in regional economic development strategies for several reasons: (1) the
industry’s often high share of overall employment; (2) the industry’s growth trend and resilience;
and (3) the nature of health care wages, which tend to be higher than average than other
industries.
37 For a summary of the literature on health and employment, see Larisa Antonisse and Rachel Garfield, “The
Relationship Between Work and Health: Findings from a Literature Review,” KFF Issue Brief, August 2018, pp. 2-3,
https://files.kff.org/attachment/Issue-Brief-The-Relationship-Between-Work-and-Health-Findings-from-aLiterature%20Review.
38 David E. Bloom et al., “The Effect of Health on Economic Growth: a Production Function Approach,” World
Development, vol. 32, iss. 1 (2014), pp. 1-13, https://doi.org/10.1016/j.worlddev.2003.07.002.
39 For a summary of recent research, see “The Growing Gap in Life Expectancy by Income: Recent Evidence,” in CRS
Report R44846, The Growing Gap in Life Expectancy by Income: Recent Evidence and Implications for the Social
Security Retirement Age, by Katelin P. Isaacs et al.
40 Raj Chetty et al., “The Association Between Income and Life Expectancy in the United States, 20012014,” JAMA, vol. 315, no. 16 (April 26, 2016), pp. 1751, 1762, https://jamanetwork.com/journals/jama/fullarticle/
2513561.
41 For a summary of the relationship between education and health, see David M. Cutler and Adriana Lleras-Muney,
“Education and Health,” in Robert F. Schoeni, et. al, eds., Making Americans Healthier (Russell Sage Foundation
Press, 2008), pp. 29-60; and See Steven H. Wolf et al., “How Are Income and Wealth Linked to Health and
Longevity?” April 2015, p. 1, https://www.urban.org/research/publication/how-are-income-and-wealth-linked-healthand-longevity.
42 Access to health care is impacted by the availability of health care services in a particular place, as well as the
affordability of health care, including insurance coverage and other factors. See Agency for Healthcare Research and
Quality, “Access to Healthcare and Disparities in Access,” 2021 National Healthcare Quality and Disparities Report,
December 2021, https://www.ncbi.nlm.nih.gov/books/NBK578537/.
43 Research findings suggest that education facilitates better-paying jobs, which supports wealth creation, and income
and/or wealth can be used to improve health. See Anna Zajacova and Elizabeth M. Lawrence, “The Relationship
Between Education and Health: Reducing Disparities Through a Contextual Approach,” Annual Review of Public
Health, vol. 39 (April 1, 2018), pp. 273-289, https://www.annualreviews.org/content/journals/10.1146/annurevpublhealth-031816-044628.
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For several decades, health care has been one of largest industries in the United States.44
Beginning in 2009, employment in health care surpassed employment in manufacturing, and in
2018, employment in health care surpassed employment in retail (see Figure 1).45
Figure 1. U.S. Employment by Selected Industry, 1990-2025
Source: CRS with data from the following U.S. Bureau of Labor Statistics (BLS) Current Employment Statistics
(CES) data series IDs: CES2000000001 (construction), CES6562000101 (health services), CES7000000001
(leisure, hospitality), CES3000000001 (manufacturing), CES6000000001 (professional and business services), and
CES4200000001 (retail). Retrieved February 20, 2026, from https://data.bls.gov/PDQWeb/ce.
Notes: Data are seasonally adjusted. Each line corresponds to a major industry, by North American Industry
Classification System (NAICS) industry codes. This figure displays Health Services (NAICS 62 [621, 622, 623])
and does not include Social Assistance (NAICS 624). For additional information about NAICS 62, see
https://www.bls.gov/iag/tgs/iag62.htm. Periods of economic recession are shaded in gray.
44 For a comparison of employment by industry sectors in 2014 and 2024, see U.S. Bureau of Labor Statistics (BLS),
“Employment by Major Industry Sector,” https://www.bls.gov/emp/tables/employment-by-major-industry-sector.htm.
For data on employment and earnings for the past six months, see BLS, “Employment and Earnings Table B-1a,”
https://www.bls.gov/web/empsit/ceseeb1a.htm. See also Lydia DePillis and Christine Zhang, “How Healthcare Remade
the U.S. Economy,” New York Times, July 3, 2025, https://www.nytimes.com/interactive/2025/07/03/business/
economy/healthcare-jobs.html; and Kristen Stiegler et al., “Healthcare Employment Projections, 2019–2029: An
Analysis of Bureau of Labor Statistics Projections by Setting and by Occupation,” Rensselaer, NY: Center for Health
Workforce Studies, School of Public Health, SUNY Albany; August 2021, https://www.chwsny.org/wp-content/
uploads/2021/08/Health-Care-Employment-Projections-2019%E2%80%932029.pdf.
45 CRS calculations based on the industry’s annual average employment using BLS Current Employment Statistics
(CES) data series. See also Joshua D. Gottlieb et al., “Rise of Healthcare Jobs,” National Bureau of Economic Research
(NBER) Working Paper No. 33583, March 2025, https://www.gottlieb.ca/papers/HealthCareJobs.pdf. For a comparison
of average annual job growth by industry for selected periods (January 2014-July 2024), see Figure 10 in CRS Report
R48468, Recent Wages Trends and Issues, by Sarah A. Donovan.
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Health care employment is also an important share of all employment in rural areas.46 Since 2001,
health care and social assistance has been one of the top four industries in rural areas in terms of
employment.47 In addition, a Federal Reserve analysis noted that health care is one of the
industries with the most significant employment gains in nonmetro areas in recent years.48
Health care jobs appear to be resilient to economic downturns. Analysts observe that health sector
jobs—with some exceptions—are typically “recession-proof” because many health services,
unlike other purchases, cannot be delayed. 49
Lastly, jobs in the health care industry generally have wages that are higher than the median
annual wages for jobs in other industries.50 Health care workers include a wide range of positions
and training requirements. While median wages for health care practitioners and technical
occupations (e.g., dental hygienists, physicians and surgeons, registered nurses) are generally
higher than the national median wage, median wages are lower than the national median wage for
health care support occupations (e.g., home health and personal care aides, medical
transcriptionists, and occupational therapy assistants).51
Health Care Spending and Regional Economic Effects
Health care spending is a significant and growing portion of U.S. gross domestic product
(GDP).52 At the subnational level, health care spending is often an important economic factor in
46 James C. Davis, “Rural Job Growth Has Shifted Toward High-Skill Workers Since 2001,” January 17, 2023, USDA,
ERS, https://www.ers.usda.gov/data-products/charts-of-note/chart-detail?chartId=105587; and Anne M. Mandich and
Jeffrey H. Dorfman, “The Wage and Job Impacts of Hospitals on Local Labor Markets,” Economic Development
Quarterly, vol. 31, iss. 2 (February 1, 2017), https://doi.org/10.1177/0891242417691609.
47
James C. Davis et al., “Rural America at a Glance: 2022 Edition,” USDA, ERS, Economic Information Bulletin
Number 246, November 2022, pp. 8-10, https://ers.usda.gov/sites/default/files/_laserfiche/publications/105155/EIB246.pdf?v=13453.
48 Andrew Dumont, “Changes in the U.S. Economy and Rural-Urban Employment Disparities,” FEDS Notes
(Washington: Board of Governors of the Federal Reserve System, January 19, 2024), https://doi.org/10.17016/23807172.3428. See also James C. Davis et al., “Rural America at a Glance: 2022 Edition,” USDA, ERS, Economic
Information Bulletin Number 246, November 2022, p. 12, https://ers.usda.gov/sites/default/files/_laserfiche/
publications/105155/EIB-246.pdf?v=13453.
49 In 2020, the COVID-19 recession impacted job growth in most employment industries—including health care.
During the COVID-19 recession, health care jobs dropped significantly between January and April 2020 compared to
jobs from the same period in the prior year. See Imani Telesford et al., “What Are the Recent Trends in Health Sector
Employment?” Peterson Center on Healthcare and KFF, March 27, 2024, https://www.healthsystemtracker.org/chartcollection/what-are-the-recent-trends-health-sector-employment/; Joshua D. Gottlieb et al., “Rise of Healthcare Jobs,”
NBER Working Paper No. 33583, March 2025, p. 2, https://www.gottlieb.ca/papers/HealthCareJobs.pdf; and Anne M.
Mandich and Jeffrey H. Dorfman, “The Wage and Job Impacts of Hospitals on Local Labor Markets,” Economic
Development Quarterly, vol. 31, iss. 2 (February 1, 2017), p. 144, https://doi.org/10.1177/0891242417691609 (Original
work published 2017).
50 According to the BLS, “The median annual wage for healthcare practitioners and technical occupations (such as
dental hygienists, physicians and surgeons, and registered nurses) was $83,090 in May 2024, which was higher than the
median annual wage for all occupations of $49,500.” See BLS, “Healthcare Occupations,” https://www.bls.gov/ooh/
healthcare/; and Joshua D. Gottlieb et al., “Rise of Healthcare Jobs,” NBER Working Paper No. 33583, March 2025, p.
8, https://www.gottlieb.ca/papers/HealthCareJobs.pdf.
51 BLS, “Healthcare Occupations,” https://www.bls.gov/ooh/healthcare/.
52 Health care spending comprised 5% of gross domestic product (GDP) in the 1950s and was approximately 18% of
GDP in 2024. See U.S. Centers for Medicare & Medicaid Services, “National Health Expenditures (NHE) Fact Sheet,”
updated January 14, 2026, https://www.cms.gov/data-research/statistics-trends-and-reports/national-health-expendituredata/nhe-fact-sheet; and Aaron C. Catlin and Cathy A. Cowan, “History of Health Spending in the United States, 19602013,” November 19, 2015, https://www.cms.gov/research-statistics-data-and-systems/statistics-trends-and-reports/
nationalhealthexpenddata/downloads/historicalnhepaper.pdf.
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local and regional economies where health care businesses contribute to direct, indirect, and
induced economic impacts (see Figure 2). Direct impacts include wages (employment) and
operations expenses. The indirect impacts include business spending on local suppliers’ goods
and services, which may spin off additional jobs. Induced impacts occur when workers (and their
households) spend money in the region.53
Figure 2. Economic Impacts Associated with Health Care Spending
Source: CRS. Figure based on examples of economic impact analysis provided in Federal Reserve Bank of
Philadelphia, Rural Economic Development Summit: Health Ecosystems and Workforce Pipelines (presentation), June 3,
2025, https://www.philadelphiafed.org/calendar-of-events/rural-economic-development-summit-healthecosystems-and-workforce-pipelines; Patrick T. Harker et al., “Anchor Impact: Understanding the Role of Higher
Education and Hospitals in Regional Economies,” Federal Reserve Bank of Philadelphia, September 2022,
https://www.philadelphiafed.org/-/media/FRBP/Assets/Community-Development/Reports/anchor-economyreport-92022.pdf; and Patricia Oslund et al., ”The Importance of the Health Care Sector to the Barber County
Economy,” Institute for Policy & Social Research, University of Kansas, May 2025.
Direct, indirect, and induced economic impacts, when present, vary by geography (e.g., location,
degree of economic distress and/or rurality), type of businesses (e.g., inpatient facilities,
outpatient facilities), and other factors and considerations, which may affect the degree or scale of
their impacts.54
53 Cristina Miller et al., “Employment Spillover Effects of Rural Inpatient Healthcare Facilities,” ERR-241, USDA
ERS, December 2017, p. 10, https://ers.usda.gov/sites/default/files/_laserfiche/publications/86254/ERR-241.pdf?v=
88835.
54 Researchers and economic development practitioners estimate local job (employment) multiplier effects as a means
of measuring the economic impacts associated with an employment or output shift (e.g., a particular investment, policy
or industry shift, development project) on the broader regional or local economy. Researchers use a range of
approaches or models for estimating the impacts (e.g, input-output, econometric), which generally account for the size
(continued...)
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Anchor Institutions: Eds and Meds
In many regions, health care facilities, along with educational institutions (“eds and meds”), are considered key
drivers of regional economic activity. Eds and meds are referred to as anchor institutions due to their direct
impacts on local and regional economies as employers and purchasers of goods and services. Anchor institutions
may provide indirect and induced effects when other companies do business with the institutions and when
employees spend earnings.
There are risks to having a regional economy that is primarily focused on health care—or on any other singular
industry. Analysts note that potential economic and community benefits associated with anchor institutions may
be impacted by disruptions caused by pandemics (e.g., COVID-19), technology (e.g., telehealth), demographic
shifts (e.g., declining populations), or public policy changes (e.g., insurance coverage). These changes are relevant
to regions with eds and meds as anchor institutions because the business practices of these entities often involve a
significant volume of transfer payments from the government and/or insurance industry. Policy changes that seek
to constrain health care spending may be particularly challenging to areas with health care anchor institutions. For
example, some hospitals are planning to reduce or cut services because of concerns about reductions in federal
health payments included in the FY2025 Reconciliation Law (P.L. 119-21).
Sources; Andrew Cass, “32 Hospitals Closing Departments or Ending Services,” May 1, 2026, Becker’s Hospital
Review, https://www.beckershospitalreview.com/finance/32-hospitals-closing-departments-or-ending-services;
Patrick T. Harker et al. “Anchor Impact: Understanding the Role of Higher Education and Hospitals in Regional
Economies,” Federal Reserve Bank of Philadelphia, September 2022, p.3, https://www.philadelphiafed.org/-/media/
FRBP/Assets/Community-Development/Reports/anchor-economy-report-92022.pdf; and CRS Report R48633,
Health Provisions in P.L. 119-21, the FY2025 Reconciliation Law, coordinated by Alison Mitchell.
Talent Attraction, Human Capital, and Place-Making
Strong regional economies feature amenities that help attract and retain businesses, workers, and
residents.55 For certain businesses, locating their facilities in areas with access to health care
amenities may help recruit and retain employees.56 Businesses generally benefit from lower costs
and higher productivity by having a healthy workforce.57 The quality of health care services and
and type of the labor market, labor supply conditions, and industry factors, among other considerations. The effects
may be positive or negative. When positive, the multiplier effect is occasionally referred to as an indicator of “spinoff”
jobs that may be created when a job is created in a particular area. See Timothy J. Bartik and Nathan Sotherland,
“Realistic Local Job Multipliers,” W.E. Upjohn Institute Policy Brief, April 2019, https://research.upjohn.org/cgi/
viewcontent.cgi?article=1007&context=up_policybriefs.
A 2017 analysis by the USDA ERS described the multiplier in the inpatient health care context as
the total number of jobs in the county in all industries that result from the addition of one inpatient
healthcare job. A multiplier equal to 1 implies that there is only a direct impact of that healthcare
job. A multiplier greater than one implies that the inpatient healthcare job generated additional jobs
in the county in other industries.
The report noted that a county’s degree of rurality influenced whether there were positive multiplier effects from rural
inpatient health care facilities (e.g., hospitals, nursing homes, other residential care facilities). The study found that
rural inpatient health care facilities have direct employment effects (i.e., jobs associated with the facility) and estimated
a likely positive multiplier effect for facilities in larger, less remote rural areas or “micropolitan” areas, but did not find
such an effect in more remote or “noncore” areas. See Cristina Miller et al., “Employment Spillover Effects of Rural
Inpatient Healthcare Facilities,” USDA, ERS, ERR-241, December 2017, pp. iv, 24-25.
55 Rural Health Information Hub, “Community Vitality and Rural Healthcare,” https://www.ruralhealthinfo.org/topics/
community-vitality-and-rural-healthcare.
56 Anne M. Mandich and Jeffrey H. Dorfman, “The Wage and Job Impacts of Hospitals on Local Labor
Markets,” Economic Development Quarterly, vol. 31, iss. 2 (February 1, 2017), p. 146, https://doi.org/10.1177/
0891242417691609; “Exploring Strategies to Improve Health and Equity in Rural Communities,” NORC Walsh Center
for Rural Health Analysis, February 2018, p. 33, https://www.norc.org/content/dam/norc-org/pdfs/
Rural%20Assets%20Final%20Report%20Feb%2018.pdf; and Rural Health Information Hub, “Community Vitality and
Rural Healthcare,” https://www.ruralhealthinfo.org/topics/community-vitality-and-rural-healthcare.
57 David E. Bloom et al., “The Effect of Health on Economic Growth: a Production Function Approach,” World
Development, vol. 32, iss. 1 (2014), pp. 1-13, https://doi.org/10.1016/j.worlddev.2003.07.002.
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the proximity to health care facilities also factor into worker and retiree location decisions—
including remote workers’ location decisions.58 The effects of community health and health care
resources on in-migration (i.e., people relocating to the area) appear to correlate in reverse as
well. Regions experiencing high rates of economic distress and diseases of despair, including
opioid and substance use disorders (SUD), may have health and health care challenges that limit
private investment, economic development, and growth.59
In addition to targeted strategies to attract human capital, economic development practitioners
increasingly focus on place-making strategies designed to enhance an area’s suite of public and
private amenities, which, in turn, contribute to an overall enhanced quality of place.60 In doing so,
economic developers emphasize “attracting and retaining people,” rather than—or in addition
to—focusing solely on attracting and retaining businesses and private investment.61 According to
this perspective, factors that contribute to an area’s quality of place may include healthy
individuals, health care access, various amenities, and resilient regional economies—which are
mutually reinforcing.62 Creating quality places may attract businesses, which may increase an
area’s tax base and population. A community with residents with insurance coverage may be
better positioned to support health care businesses. Stakeholder groups have identified a similar
relationship between health care industry and economic development in certain communities—
noting the reliance of financially sustainable health care systems on the “overarching economic
prosperity and revitalization of rural communities.”63
58 Health care access has been linked with senior and retiree location decisions—see James F. Oehmke et al., “Can
Healthcare Services Attract Retirees and Contribute to the Economic Sustainability of Rural Places?” Northeastern
Agricultural and Resource Economics Association Agricultural and Resource Economics Review, vol. 36, no. 1 (April
2007), pp. 1-12, https://doi.org/10.22004/ag.econ.10155; and Jeffrey Dorfman and Anne Mandich, “Senior Migration:
Spatial Considerations of Amenity and Health Access Drivers,” Journal of Regional Science, vol. 56, no. 1 (August.
2016), pp. 96-133, https://doi.org/10.1111/jors.12209.
For a description of health care as a consumptive and productive amenity for rural areas, see “Local Amenity Effects”
in Cristina Miller, John Pender, and Thomas Hertz, “Employment Spillover Effects of Rural Inpatient Healthcare
Facilities,” ERR-241, USDA ERS, December 2017, p. 12, https://ers.usda.gov/sites/default/files/_laserfiche/
publications/86254/ERR-241.pdf?v=88835.
59 Bokyung Kim et al., “The Opioid Crisis and the Role of Employers,” Stanford Institute for Economic Policy
Research Policy Brief, January 2024, https://drive.google.com/file/d/1gTYv-GiSaQ_3ovmUbc1pNPe96EpVsVjD/
view; and Julia Paris et al., “The Economic Impact of the Opioid Epidemic,” The Brookings Institution, April 17, 2023,
https://www.brookings.edu/articles/the-economic-impact-of-the-opioid-epidemic.
60 John C. Austin et al., “Improving Quality of Life—Not Just Business—Is the Best Path to Midwestern
Rejuvenation,” the Brookings Institution, January 26, 2022, https://www.brookings.edu/articles/improving-quality-oflife-not-just-business-is-the-best-path-to-midwestern-rejuvenation/; Manuel Pastor and Rachel Morello-Frosch,
“Integrating Public Health and Community Development to Tackle Neighborhood Distress and Promote Well-Being,”
Health Affairs, vol. 33, no. 11 (November 2014), https://www.healthaffairs.org/doi/10.1377/hlthaff.2014.0640; and
National Association of Development Organizations (NADO), Building Healthier Rural Communities: Economic
Development Districts Address Social Determinants of Health, August 2025, p. 13, https://www.nado.org/wp-content/
uploads/2025/08/Social-Determinants-of-Health_v6.pdf.
61 Steven S. Deller, “Are We at an Inflection Point in Community Economic Development? The 4th Wave,” Economic
Development Quarterly, vol. 39, iss. 4 (May 28, 2025), https://doi.org/10.1177/08912424251339139.
62 Amanda Blanco and Jay Lindsay, “What Stops the Bleeding? Healthcare Gets Harder to Find in Northern New
England,” Federal Reserve Bank of Boston, https://www.bostonfed.org/news-and-events/news/2025/06/health-careaccess-health-care-deserts-primary-care-doctor-shortage-northern-new-england.aspx.
63 Robert Harrington et al., “Call to Action: Rural Health: A Presidential Advisory,” American Heart Association and
American Stroke Association, vol. 141, no. 10 (February 10, 2020), https://doi.org/10.1161/CIR.0000000000000753.
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Negative Impacts of Certain Health Care Challenges
The preceding sections of this report have discussed the ways that health care and related services
may contribute to a region’s economy. The inverse may also be true in certain communities and
circumstances, where a lack of health care access and the loss of health care providers
(particularly hospitals) can have broader impacts on where people and businesses choose to
locate.64
Health care shortages are particularly acute in rural areas with low population densities that lack
primary and specialty providers.65 The Health Resources and Services Administration (HRSA)
classifies areas as Health Professional Shortage Areas (HPSAs) annually, with areas reevaluated
every three years. HPSAs are geographic areas, populations, or facilities with a shortage of
primary, dental, or mental health care providers.66 As of March 31, 2026, over 101 million people
(approximately 30% of the U.S. population) reside in primary care HPSAs, and approximately
62% of primary care HPSAs are in rural areas.67 The Delta Regional Authority (DRA) reports that
approximately 91% of its counties are HPSAs, and a map of HPSAs by FRCA regions suggests a
concentration of these areas in the Delta region (see Figure 3).68 Living in areas with low access
to care means greater travel times to access health services and delayed or foregone care, which
can worsen existing health conditions.69
64 Multiple factors inform business site selection decisions and may vary by industry. According to a 2024 survey of
executive decisionmakers, for instance, quality of life was the second top factor in location decisions. See Jonathan
Morgan, “Perspectives on the Business Location and Site Selection Process,” November 7, 2025,
https://ced.sog.unc.edu/2025/11/07/perspectives-on-the-business-location-and-site-selection-process/; and Robert
Harrington et al., “Call to Action: Rural Health: A Presidential Advisory,” American Heart Association and American
Stroke Association, vol. 141, no. 10 (February 10, 2020), https://doi.org/10.1161/CIR.0000000000000753.
Additionally, analysts observe that certain business may base their location decisions on proximity or availability of an
emergency room since workers’ compensation rates are related to the distance from an emergency room and that “a
closure could generate increased business operating costs and another reason a business moves away or decides not to
expand.” See Brian Dabson and Victoria Faust, “Rural Development and Rural Health Practices: Trends and
Opportunities For Alignment,” Aspen Institute, pp. 2, 6, https://www.aspeninstitute.org/wp-content/uploads/2025/05/
TR-FP-1-Rural-ED-Rural-Health-FINAL2-Singles.pdf.
65 HHS, Health Resources and Services Administration (HRSA), “Designated Health Professional Shortage Areas
Statistics: Second Quarter of Fiscal Year 2026 Designated HPSA Quarterly Summary As of March 31, 2026;” CRS
calculations of total U.S. population obtained from U.S. Census Bureau; and Alyssa M. Hundrup, “Why Healthcare Is
Harder to Access in Rural America,” Government Accountability Office (GAO), 2023, https://www.gao.gov/blog/whyhealth-care-harder-access-rural-america; and Meagan Clawar et al., “Access to Care: Populations in Counties with No
FQHC, RHC, or Acute Care Hospital,” January 2018, https://www.shepscenter.unc.edu/wp-content/uploads/
dlm_uploads/2025/03/r-18_Access-to-Care-Pop-in-Counties-w-No-FQHC-RHC-or-Hospital.pdf.
66 HRSA, “What Is Shortage Designation?” https://bhw.hrsa.gov/workforce-shortage-areas/shortage-designation.
67 HRSA, “State of the Healthcare Workforce, 2025,” December 2025, p. 4, https://bhw.hrsa.gov/sites/default/files/
bureau-health-workforce/data-research/State-of-the-Primary-Care-Workforce-2025.pdf.
68 DRA, “Navigating the Currents of Opportunity: Regional Development Plan IV,” February 2023, p. 13,
https://dra.gov/wp-content/uploads/2023/03/APPROVED_DRA-RDP-IV_20230215.pdf.
69 Joint Economic Committee Democrats, “Addressing Rural Health Worker Shortages Will Improve Population Health
and Create Job Opportunities,” Issue Brief, January 2024, https://www.jec.senate.gov/public/_cache/files/80b460a562ab-4f5f-a259-86625dab021f/jec-issue-brief-on-rural-health-worker-shortages.pdf.
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Figure 3. Health Care Provider Shortage Areas, by FRCA Region
Source: CRS analysis of HPSA data obtained from the Health Resources and Services Administration (HRSA)
Data Warehouse, Shortage Area files obtained at https://data.hrsa.gov/data/download.
Notes: HRSA requires that individuals who receive a scholarship from the National Health Service Corps
program to fulfill their requirement to provide health services in a HPSA of greatest need. HRSA annually
designates the HPSA scores considered to be greatest need. For 2026, for primary care that score was 21 or
above. To examine the overlap between HPSAs and FRCA areas, CRS examined HPSAs that exceeded a score of
21 in 2026. See HRSA, “Review Site HPSA Score and Job Search Requirement for NHSC Scholars,”
https://nhsc.hrsa.gov/scholarships/requirements-compliance/jobs-and-site-search.
There are no FRCAs in Hawaii. The Northwest Regional Commission is not included in this map. P.L. 119-74
provided appropriations for “expenses necessary to establish a Northwest Regional Commission located in
Washington, Oregon, Idaho, and Montana.”
One related challenge that distressed areas may face is the closure of health facilities—
particularly hospitals and sole hospitals in rural areas.70 These closures—and the health policy
70 The Cecil G. Sheps Center for Health Services Research maintains a database of Rural Hospital Closures since 2005
at https://www.shepscenter.unc.edu/programs-projects/rural-health/rural-hospital-closures/. While rural hospital
closures have generally received more policy attention, non-rural hospitals have also closed in recent years. See, for
example, GAO, Urban Hospitals: Factors Contributing to Selected Hospital Closures and Related Changes in
Available Health Care Services, 25-106473, August 20, 2025, https://files.gao.gov/reports/GAO-25-106473/
index.html#_Toc206076142.
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strategies to avert closure—often tie closely to regional economic development strategies.71 Such
health and economic development interests may overlap for several reasons. Hospital closures
may affect access to health care and certain health outcomes,72 and may also affect worker and
business location decisions.73 As noted, hospitals provide jobs and have other economic impacts
(see Figure 2), and closures may decrease an area’s number and quality of employment
opportunities. Research findings vary as to whether, and to what extent, rural hospital closures
impact a given region’s long term economic growth and other measures.74 However, a 2024
summary of 21 studies on the impacts of rural hospital closures found that most of the studies
reviewed reported negative economic outcomes related to income, population, poverty, and
community economic growth.75 Stakeholder groups and analysts note that hospitals often have
roles in community development, neighborhood revitalization, workforce training, innovation,
telemedicine, and other aspects of regional economic development—particularly in rural areas—
which may be impacted by hospital closures as well.76 Some researchers have suggested that
focusing on broader community economic development conditions and opportunities could boost
rural economies and thus potentially contribute to sustaining health care systems and facilities.77
71 There are multiple factors/causes that contribute to a rural hospital closure, conversion, or merger. An analysis of
such factors is beyond the scope of this report.
72 The relationship between hospital closures and health is complex and the findings vary. The impact of closures on
health is beyond the scope of this report. For more information on this topic, see, for example, Carol A. Mills et al.,
“The Impact of Rural General Hospital Closures on Communities—A Systematic Review of the Literature,” The
Journal of Rural Health, vol. 40, iss. 2 (November 20, 2023), pp. 238-248, https://doi.org/10.1111/jrh.12810; Paula
Chatterjee, “Causes and Consequences of Rural Hospital Closures,” Journal of Hospital Medicine (2022), vol. 17, iss.
11, pp. 938-939, doi:10.1002/jhm.12973; GAO, “Rural Hospital Closures: Affected Residents had Reduced Access to
Healthcare Services,” GAO-21-93, January 21, 2021, p. 1, https://www.gao.gov/products/gao-21-93; Riley Sullivan,
“Declining Access to Health Care in Northern New England,” Federal Reserve Bank of Boston, April 10, 2019,
https://www.bostonfed.org/publications/new-england-public-policy-center-regional-briefs/2019/declining-access-tohealth-care-in-northern-new-england.aspx; and Sean McCarthy et al., “Impact of Rural Hospital Closures on HealthCare Access,” Journal of Surgical Research, vol. 258 (February 2021), pp. 170-178, DOI: 10.1016/j.jss.2020.08.055.
73 A 2017 summary of literature on rural hospital closures found that rural hospitals are attributed with providing highskill, high-wage jobs and serving as an amenity that supports business growth and incoming workers and residents. See
Anne M. Mandich and Jeffrey H. Dorfman, “The Wage and Job Impacts of Hospitals on Local Labor Markets,”
Economic Development Quarterly, vol. 31, iss. 2 (February 1, 2017), p. 146, https://doi.org/10.1177/
0891242417691609.
74 See, for examples, George M. Holmes et al., “The Effect of Rural Hospital Closures on Community Economic
Health,” Health Services Research, vol. 41, iss. 2 (2006), pp. 467-485, https://doi.org/10.1111/j.14756773.2005.00497.x; and Paula Chatterjee et al., “Changes in Economic Outcomes Before and After Rural Hospital
Closures in the United States: A Difference-in-Differences Study,” HRSA Health Services Research, vol. 57, iss. 5
(April 27, 2022), pp. 1020‐1028, https://pmc.ncbi.nlm.nih.gov/articles/PMC9441283/.
75 See Diane E. Alexander and Michael R. Richards, “Economic Consequences of Hospital Closures,” Journal of
Public Economics, vol. 221 (January 13, 2023), https://doi.org/10.3386/w29110.
76 Federal Reserve Bank of Philadelphia, Rural Economic Development Summit: Health Ecosystems and Workforce
Pipelines (presentation), June 3, 2025, https://www.philadelphiafed.org/calendar-of-events/rural-economicdevelopment-summit-health-ecosystems-and-workforce-pipelines; Brian Stermer, “‘Economic Development Is
Population Health’: A New Vision for Rural Hospital Leadership,” Rural Health Information Hub, April 24, 2024,
https://www.ruralhealthinfo.org/rural-monitor/economic-development; and Robert Harrington et al., “Call to Action:
Rural Health: A Presidential Advisory,” American Heart Association and American Stroke Association, vol. 141, no.
10 (February 10, 2020), https://doi.org/10.1161/CIR.0000000000000753.
77 A review of literature noted that
… efforts to reduce the risk of hospital closures may require a broader focus on local communities
and economies in order to be successful.[34] For example, existing rural economic development
efforts, which include state tax credits to encourage industries to enter rural markets or place-based
federal investments (e.g., “Empowerment Zones”), may play an important and complementary role
(continued...)
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Overview of FRCAs
Since 1965, Congress has established various FRCAs to address instances of economic distress in
geographically defined regions. FRCAs share similar structures and functions, but vary in terms
of appropriations, programs, staff sizes, and service regions (see Figure 4).
Figure 4. Regions of the Federal Regional Commissions and Authorities (FRCAs)
(by county, parish, or borough)
Source: Compiled by CRS using the jurisdictional data in the authorizing legislation of the various commissions
and authorities and Esri Data and Maps.
Note: There are no FRCAs in Hawaii. The Northwest Regional Commission is not included in the map above.
P.L. 119-74 provided funding for a “Northwest Regional Commission located in Washington, Oregon, Idaho, and
Montana” and did not identify specific sub-regions or counties within those states.
The authorized FRCAs are listed in Table 1. Six of the FRCAs are active as of the date of
publication.78
in reducing the risk of rural hospital closures.
See Paula Chatterjee et al., “Changes in Economic Outcomes Before and After Rural Hospital Closures in the United
States: A Difference-in-Differences Study,” HRSA Health Services Research, vol. 57, iss. 5 (April 27, 2022), pp. 1020‐
1028, https://pmc.ncbi.nlm.nih.gov/articles/PMC9441283/.
78 With the exception of the Denali Commission, a FRCA federal co-chair is a presidentially nominated and Senateconfirmed position. The appointment of a federal co-chair, unless otherwise provided, is essential for most FRCAs’
operations. For example, the Southeast Crescent Regional Commission (SCRC) consistently received appropriations
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Table 1. Statutory Citations for Operating Authorizations
(for active and inactive federal regional commissions and authorities [FRCAs])
Commission or
Authority
Year
Authorized
Operating Authorization of
the Commission or
Authority
FY2026
Appropriations
(P.L. 119-74)
(dollars in millions)
Active FRCAs
Appalachian Regional
Commission (ARC)
1965
40 U.S.C. §14301
$200.0
Delta Regional Authority
(DRA)
2000
7 U.S.C. §§2009aa-1 et seq.
$32.0
Denali Commission
1998
42 U.S.C. §3121 note
$18.0
Northern Border
Regional Commission
(NBRC)
2008
40 U.S.C. §§15301 et seq.
$42.0
Southwest Border
Regional Commission
(SBRC)
2008
40 U.S.C. §§15301 et seq.
$5.5
Southeast Crescent
Regional Commission
(SCRC)
2008
40 U.S.C. §§15301 et seq.
$20.0
Inactive FRCAs
Great Lakes Authority
(GLA)
2022
40 U.S.C. §§15301 et seq.
$5.0
Mid-Atlantic Regional
Commission (MARC)
2025
40 U.S.C. §§15301 et seq.
—
Northern Great Plains
Regional Authority
(NGPRA)
2002
7 U.S.C. §§2009bb-1 et seq.
—
Northwest Regional
Commission (NRC)
2026
40 U.S.C. §§15301 et seq. note*
Southern New England
Regional Commission
(SNERC)
2025
40 U.S.C. §§15301 et seq.
$1.0
—
Source: Compiled by CRS.
Notes: The table lists citations for authorizing statutes for the FRCAs. For more information, see CRS Report
RS20371, Overview of the Authorization-Appropriations Process, by Bill Heniff Jr.; and CRS Report R46497,
Authorizations and the Appropriations Process, by James V. Saturno, which includes a section on “The Relationship
of Appropriations to Authorizations.” A dash in the FY2026 appropriations column (“—”) indicates that no
appropriation was provided.
* In FY2026, P.L. 119-74 provided funding “for expenses necessary to establish a Northwest Regional
Commission located in Washington, Oregon, Idaho, and Montana,” and noted that the funding “shall be used to
carry out activities authorized for other regional Commissions by subtitle V of title 40, United States Code.”
each fiscal year beginning in FY2010, but was unable to begin its operations until a federal co-chair was appointed by
the President and confirmed by the Senate in December 2021, over 13 years after it was authorized. Appropriations for
this commission were made available until expended (i.e., no-year funds).
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The FRCAs are quasi-governmental partnerships between the federal government and the
constituent state or states of the given authority or commission. FRCAs are federally chartered,
receive congressional appropriations for their administration and activities, and include an
appointed federal representative in their respective leadership structures (the federal co-chair and
his/her alternate, as applicable). FRCAs’ state-federal partnership structure includes substantial
input and efforts at the sub-state level, and represents a unique federal approach to economic
development.
FRCAs use appropriations to provide economic development,79 infrastructure, workforce
development, and energy reliability and security grants in their respective regions. As noted
below, in recent years, in addition to annual appropriations for FRCA activities, Congress has
directed several federal agencies to provide funding to support rural health and rural economic
development activities in certain FRCA regions.80 In addition to grant programs, FRCAs also
undertake various partnerships and initiatives unique to their regions’ opportunities and
challenges (e.g., leadership academies, health advisory councils).81 FRCA programs and strategic
directions vary, but are generally designed to build economic resiliency or support economic
restructuring in economically distressed regions.82
The President’s FY2027 budget request proposed to terminate all but one (the ARC) of the
FRCAs.83 FRCAs have been previously proposed for elimination in presidential budgets, but have
continued to receive subsequent appropriations from Congress. For instance, in May 2025, the
President’s FY2026 budget request proposed closeout budgets for most of the FRCAs and the
79 The definition of “economic development” often varies depending on the priorities, economy, and values of the
communities involved. Generally, economic development includes two definitions: first, a general usage; and second, a
more specific description of its application in a public policy context. For the former, economic development can be
interpreted as the promotion of certain economic ends through site selection by companies, business expansion and
development, and public spending (or tax incentives) that support these activities, particularly as they may relate to job
creation. In a more public policy-specific context, the definition of economic development may include policy
interventions that may support or shape economic activity. Broadly, policy options for economic development typically
fall along a continuum between economic growth and social welfare. Growth-oriented policies tend to focus on
maximizing top-line macroeconomic performance, whereas social welfare policies often emphasize ameliorating
inequality and poverty.
80 In recent years, FRCA federal partners have included the United States Department of Agriculture, the Department
of Defense (DOD), the Department of Labor (DOL), the National Telecommunications and Information Administration
(NTIA), the Federal Highway Administration (FHWA), HHS HRSA, and others. The DOD is “using a secondary
Department of War designation,” under Executive Order 14347 dated September 5, 2025.
See https://www.federalregister.gov/documents/2025/09/10/2025-17508/restoring-the-united-states-department-of-war.
81 Most FRCAs support some form of infrastructure and/or business development and entrepreneurship activity in their
various grant programs. FRCAs may also administer programs or initiatives that are unique to their region. For
instance, the NBRC is the only FRCA that administers the Forest Economic Program, which is designed to support the
forest-based economy and the integration of new technology in the NBRC region. See NBRC, “FY2024 Annual
Report,” p. 13, https://www.nbrc.gov/userfiles/files/Annual%20Reports/NBRC-2024-Annual-Report-Webversion%20(1).pdf.
82 The FRCAs use annual designations of economic distress levels to prioritize their economic development activities in
their service areas. For additional information, see CRS Report R45997, Federal Regional Commissions and
Authorities: Structural Features and Function, by Julie M. Lawhorn.
83 U.S. Office of Management and Budget, “Technical Supplement to the 2026 Budget: Appendix,” May 30, 2025,
https://www.whitehouse.gov/wp-content/uploads/2025/05/appendix_fy2026.pdf; “Technical Supplement to the 2027
Budget: Appendix,” April 3, 2026, https://www.whitehouse.gov/wp-content/uploads/2026/04/appendix_fy2027.pdf;
and Energy and Water Development and Related Agencies Appropriations Act, 2026, appropriations tables,
Congressional Record, January 8, 2026, pp. H456-H470, https://www.congress.gov/119/crec/2026/01/08/172/5/CREC2026-01-08-bk3.pdf.
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enacted FY2026 appropriations measure continued funding for FRCA programs and
administrative expenses at 1% over FY2025 enacted levels.84
Eight of the authorized FRCAs received $1 million to $200 million each in annual appropriations
in FY2026 for their various activities.85 For an overview of the commissions, including legislative
and funding histories, see CRS Report R45997, Federal Regional Commissions and Authorities:
Structural Features and Function, by Julie M. Lawhorn.
FRCAs’ Health-Related Activities
In many FRCA regions, expanding health care access may also support economic development
and growth by creating employment opportunities and other economic impacts (see Figure 2).86
Health and FRCA policies have been linked since the ARC’s establishment (see text box).
ARC’s Health Demonstration Projects
The Appalachian Regional Development Act of 1965 (ARDA, P.L. 89-4), the Appalachian Regional Commission
(ARC)’s authorizing legislation, established a demonstration health system program (i.e., Section 202 of ARDA)
that focused on health center construction. A 1967 amendment to ARDA allowed funding to be used for
operations as well. In a committee hearing in 1974, the federal co-chair of the ARC observed
When the Commission was formed and the statute enacted which created the Appalachian Commission in 1965, the
Commission was directed to do something in the field of health because it was the feeling of the Congress that a fullscale economic development program could not be achieved in the absence of a healthy population. But there was
little understanding about the direct relationship of health and economic development. And so one of the particular
mandates of the Appalachian experiment was to investigate the extent to which there is such a relationship.
Since 1965, ARC’s authority to administer demonstration health projects has been amended or expanded by
Congress several times. In addition to the 1967 amendment to ARDA, a 1969 amendment extended the health
program to include demonstration facilities for nutrition, child care, and occupational diseases (e.g., black lung).
According to a history of the ARC, the House Committee on Public Works observed that the expansion of the
health program in 1969 was “the greatest contribution of the Appalachian program in building institutions,” and a
1986 study showed improvements in access to and number of doctors and medical staff in the ARC region. The
projects contributed to improved access to health care as measured by the number of people who had a thirty
minute drive to health care facilities in 332 of the ARC’s 397 county region at the time. (ARC’s region now covers
423 counties.) Critics of the early health programs, however, observed shortcomings in the implementation of the
ARC’s initial health programs. For instance, the demonstration program guidelines limited the type of health
services provided, and “did not demonstrate any new approaches to medical care.” Critics further noted that
ARC-supported health services were insufficiently coordinated and lacked follow-up care. They also noted the
slow implementation and alignment of the ARC black lung program, which may have impeded its effectiveness.
Several laws have since amended Section 202 of ARDA (see 40 U.S.C. §14502).
Sources: The Appalachian Regional Development Act of 1965 (ARDA), P.L. 89-4; ARC, “Annual Report of the
Appalachian Regional Commission for Fiscal Year 1968,” 91st Cong., 1st sess., House Document No. 91-59 (U.S.
Government Printing Office: Washington, DC, 1969); U.S. House of Representatives, Committee on Agriculture,
“Federal Health Policies in Rural Areas, Part 1,” October 1-3, 1974, 93rd Congress, 2nd sess.; David E. Whisnant,
Modernizing the Mountaineer (University of Tennessee Press, 1980), pp. 158-163; and Michael Bradshaw, in
Appalachian Regional Commission: Twenty-Five Years of Government Policy (Lexington, KY: University Press of
Kentucky, 1992), pp. 54, 96.
84 OMB, “Technical Supplement to the 2026 Budget: Appendix,” May 30, 2025, https://www.whitehouse.gov/wp-
content/uploads/2025/05/appendix_fy2026.pdf.
85 P.L. 119-74. The act also provided funding for a new regional commission, the Northwest Regional Commission, for
distressed areas in Idaho, Montana, Oregon, and Washington. As of the date of this report, the commission does not
have a federal co-chair and is not active.
86 For examples of this perspective, see ARC, “Strengthening the Future of Appalachia’s Healthcare Workforce,”
https://www.arc.gov/investment/strengthening-the-future-of-appalachias-healthcare-workforce/; and DRA, “DRA
Regional Development Plan IV,” February 2023, https://dra.gov/wp-content/uploads/2023/03/APPROVED_DRARDP-IV_20230215.pdf.
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Several FRCAs have authorities, similar to that of the ARC, under which they can provide
financial assistance for the development of health care facilities or related infrastructure; health
care workforce training; and similar health-related activities that facilitate regional economic
development and growth. Four FRCAs administer J-1 visa waiver programs (i.e., ARC, DRA,
NBRC, SCRC), which provides visa waivers for physicians who are willing to provide medical
services in distressed communities.
Recent FRCA grant programs and other health-related activities are highlighted in the subsections
below.
Health in FRCA Strategic Plans and Investment Priorities
Most FRCAs’ authorizing statutes require the development of region-wide plans and statespecific plans.
FRCAs develop regular strategic plans that outline key goals and grant priorities for the overall
region.87 The plans generally cover five-year periods and include four to seven priorities that are
established with input from state members. Some FRCAs’ plans include priorities that focus on
aspects of health or health care. For instance
•
•
•
one of the six priorities in ARC’s strategic plan is to “expand and strengthen
community systems (education, health care, housing, childcare, and others) that
help Appalachians obtain a job, stay on the job, and advance along a financially
sustaining career pathway”;88
one of the Denali Commission’s seven priorities is “other programs, such as
sanitation, health facilities, housing, and broadband”;89 and
one of the SCRC’s six priorities is to “improve health and support services access
and outcomes.”90
The FRCAs’ state-specific plans reflect the member states’ goals, objectives, and priorities, and
inform implementation activities based on the specific conditions of a particular region.91 States
may emphasize activities or industries, such as health care or infrastructure, in such plans. The
state of South Carolina, for instance, included “Improve Health and Support Public Service
Access and Outcomes” as one of its six goals for the 2023-2027 period.92
87 For additional information and links to FRCA strategic plans, see CRS In Focus IF11140, Federal Regional
Commissions and Authorities: Overview of Structure and Activities, by Julie M. Lawhorn.
88 ARC, “Performance & Accountability Report Fiscal Year 2024,” https://www.arc.gov/wp-content/uploads/2024/11/
FY-2024-Performance-and-Accountability-Report.pdf.
89 Denali Commission, “Strategic Plan,” https://denali.gov/strategic-plans/.
90 SCRC, “SCRC: Strategic Plan (2023–2027),” https://scrc.gov/sites/default/files/2025-07/
strategic_plan_updated_april_2025.pdf.
91 For ARC, see 40 U.S.C. §14322; for DRA, see 7 U.S.C. §2009aa–6; for NGPRA, see 7 U.S.C. §2009bb–6; and for
GLA, MARC, NBRC, SBRC, SCRC, and SNERC, see 40 U.S.C. §15502.
92 SCRC, “Economic and Infrastructure Development Strategic Plan,” pp. 20-21, https://scrc.gov/sites/default/files/
2024-05/sc_scrc-5-year-economic-and-infrastructure-development-strategic-plan-2023-2027-approved-document1.pdf.
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Examples of Health Related FRCA Grant Programs
FRCAs may also use grant programs to support health related activities such as health care
facility development and equipment, workforce development, business technical assistance, and
substance use disorder (SUD) treatment.
Since the establishment of the first FRCA in 1965 (i.e., ARC), policymakers have directed
ARC—and authorized other FRCAs—to award grants to build and equip health care
demonstration facilities.93 In 2022, for example, the ARC awarded a grant in eastern Kentucky to
provide equipment for two long-term acute care hospitals.94 The other active FRCAs also assist
with the development of health care demonstration facilities and equipment projects. The GLA,
MARC, NBRC, SBRC, SCRC, and SNERC are statutorily authorized to provide economic and
infrastructure grants—in addition to health demonstration projects—that fulfill a number of
purposes, including “to provide assistance to severely economically distressed and
underdeveloped areas of its region that lack financial resources for improving basic health care
and other public services.”95 In January 2026, the Denali Commission reported that it has
contributed to over 175 village health clinics and two regional hospitals (see text box).96
Rural Health Facility Construction and Environmental Health Grants:
Denali Commission Examples
Since it was established in 1998, the Denali Commission has provided grants to construct and equip rural health
care facilities and to address environmental health concerns. The Denali Commission continues to partner with
Alaska Native tribal communities, Native corporations, Native nonprofit entities, tribal governments, and other
groups on a range of energy, infrastructure, and health projects.
The Denali Commission’s statutory mission includes providing workforce and other economic development
assistance to distressed rural regions in Alaska. In 1999, P.L. 106-113 amended the Denali Commission Act and
established “demonstration health projects” as an authorized activity and authorized HHS to make grants to the
commission to that effect. For approximately a decade thereafter, the Denali Commission co-funded the
construction of rural primary care clinics, hospitals, behavioral health facilities, and rural emergency medical
services. Examples include hospitals in Nome and Barrow.
In recent years, the Denali Commission has focused on energy and bulk fuel and village infrastructure protection
programs—many of which address environmental health concerns pertaining to bulk fuel storage systems. The
infrastructure and bulk fuel grants are designed to address threats to “health, safety, and energy security” and
often involve partnerships with Alaska Native tribes, nonprofit Tribal health organizations, and federal agencies. In
2025, for example, the U.S. Environmental Protection Agency (EPA) transferred $100 million to the Denali
Commission for bulk fuel facility improvements. The Denali Commission used the funding for a grant to the Alaska
Native Tribal Health Consortium to assist ten rural communities with efforts to address environmental health and
other concerns.
Sources: Denali Commission, “Other Programs,” https://denali.gov/programs/other-programs/; “Energy,”
https://denali.gov/programs/energy/; “Programs,” https://denali.gov/programs/energy/; “Energy & Bulk Fuel Program
Fact Sheet,” https://x11.6e7.myftpupload.com/wp-content/uploads/2022/01/Energy-Bulk-Fuel-Program-FactSheet.pdf; and “Denali Commission Awards $100 Million to Address Urgent Fuel Infrastructure Needs in Rural
Alaska,” https://denali.gov/wp-content/uploads/2025/07/2025-07-17pressrelease_Final_v3.pdf.
93 In 1965, the ARC’s authorizing legislation established a comprehensive demonstration health system program that
focused on health center construction. See the Appalachian Regional Development Act (ARDA) of 1965, P.L. 89-4.
94 ARC, “POWER Award Summaries by State As of March 2022,” p. 5, https://www.arc.gov/wp-content/uploads/
2022/03/POWER-Award-Summaries-by-State-as-of-March-2022.pdf.
95 40 U.S.C. §15501(a), 40 U.S.C. §15902.
96 Denali Commission, “Testimony for the Record,” House Committee on Transportation and Infrastructure,
Subcommittee on Economic Development, Public Buildings, and Emergency Management, Smarter Spending,
Stronger Results: Reducing Duplication and Ensuring Effectiveness Through Economic Development Reforms,
119th Cong., 2nd sess. January 22, 2026, https://www.congress.gov/119/meeting/house/118896/witnesses/HHRG-119PW13-Wstate-FentonJ-20260122.pdf.
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Notes: The Denali Commission is required by law to create an annual work plan, which solicits project proposals,
guides activities, and informs a five-year strategic plan. Although the Denali Commission has recently referred to
them as “legacy programs,” one of several allocations in the FY2023 Work Plan was for “Health Facilities.”
FRCAs’ grant programs may also support health care workforce development by funding projects
designed to train physicians, nurses, dentists, counselors, or community health workers. These
projects are often carried out in partnership with community colleges, workforce investment
boards, and other partners. FRCAs may, for example, support state and local “grow your own”
efforts designed to train rural residents with the goal of having health care professionals stay in
rural areas.97 For instance, in 2025, DRA provided grants to fund a health care professional job
training program in southern Alabama, a medical laboratory science program designed to address
workforce challenges in medical laboratory sciences in south central Louisiana, and a medical
coding and billing pre-apprenticeship project in southeast Missouri.98
Grants for capacity and business technical assistance may also support expanded health care
access and employment objectives in FRCA regions. For example, in 2025, ARC provided grant
funded technical assistance for under-resourced health care systems and providers across 66
counties in two states. According to ARC, “the project was designed to retain and create health
care jobs—and facilitate the development of new payment approaches that both improve health
outcomes and reduce costs for providers, patients, and communities.”99 DRA, in collaboration
with HHS, provided technical assistance to rural health providers throughout the region, which
the DRA credits with supporting more than 73,000 jobs.100
Table 2 provides a summary of FRCA grants for health and health care strategies and project
examples, and additional examples of grants for SUD are in the section on “Addressing Specific
Health Conditions: The Example of Substance Use Disorder (SUD).”
Table 2. State, Local, and Regional Health and Health Care Strategies and
Selected FRCA Project Examples
Strategy
Health facility infrastructure
development and equipment
FRCA Project Examples
Constructing or renovating clinical facilities, including procuring high-tech
equipment for medical and dental screenings and services, and for education
and training purposes
Broadband planning or implementation projects to expand access to
telehealth services
Infrastructure investments that also promote resiliency, health, reduce
pollution and infrastructure investments in other forms, such as mobility or
transportation
97 NGA, “Governors and States Are Advancing Equitable Rural Economic Development and Healthcare,” April 12,
2023, https://www.nga.org/meetings/governors-and-states-are-advancing-equitable-rural-economic-development-andhealthcare/; and John Pender et al., “Linkages Between Rural Community Capitals and Health Care Provision: Findings
of a Survey of Small Rural Towns in Three U.S. Regions,” USDA ERS, EIB-251, p. 43, https://ers.usda.gov/sites/
default/files/_laserfiche/publications/106139/EIB-251.pdf?v=29727.
98 DRA, “Delta Regional Authority Invests $7 Million Toward 25 Workforce Development Projects,” July 10, 2025,
https://dra.gov/delta-regional-authority-invests-7-million-toward-25-workforce-development-projects/.
99 ARC, “Appalachian Rural Health Technical Assistance Center—Project Snapshot,” https://www.arc.gov/wp-content/
uploads/2025/03/2025.03-ARISE-Project-Snapshot-Rural-Health-Redesign-Center.pdf.
100 See House Committee on Transportation and Infrastructure, Subcommittee on Economic Development, Public
Buildings, and Emergency Management, Regional Commissions: A Review of Federal Economic Development
Program Effectiveness, 118th Cong., 1st sess., October 19, 2023, Serial No. 118–32, p. 21, https://www.congress.gov/
118/chrg/CHRG-118hhrg56927/CHRG-118hhrg56927.pdf.
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Strategy
FRCA Project Examples
Health care workforce
development and training
Establishing rural medical residency training sites
Implementing a dual-track training program involving a graduate nurse
residency and a virtual nursing training model
Conducting training for professionals and paraprofessionals working in the
prevention and treatment of opioid (and other substances) use disorders
Capacity and business technical
assistance
Business technical assistance for health care enterprises
Substance use disorder
workforce recovery
Funding program expenses for comprehensive support services for employers
and individuals in recovery across multiple counties (see Figure 5)
Source: CRS, using FRCA project examples.
Notes: As FRCAs vary in terms of programs, priorities, and governance structures, the examples are illustrative.
Not all project examples apply to all FRCAs.
Addressing Specific Health Conditions: The Example of Substance
Use Disorder (SUD)
Some FRCA regions have faced acute challenges with SUD-related conditions. For example, in
2024, Alaska—covered by the Denali Commission and West Virginia—covered by the ARC were
the two states with the highest drug overdose mortality rates.101
SUD negatively impacts individuals and communities in several ways. In addition to effects on
individual lives and families, the economic costs associated with SUD include health care costs
for treatment and other medical consequences, criminal justice expenses, and lost productivity.102
A 2023 review of the economic impacts of the opioid epidemic noted that SUD reduces labor
force participation and hinders economic growth due to “disability, incarceration, or death.”103
SUD affects individuals’ health and their capacity to obtain and maintain employment. Work is
often beneficial for people seeking recovery from SUD, but many continue to face hiring
challenges.104 Some employers have drug testing requirements that a significant portion of the
workforce may not be able to pass in some areas due to high rates of SUD, and many individuals
in SUD recovery face stigma that can affect hiring.105
101 Centers for Disease Control and Prevention, “Drug Overdose Mortality,” March 3, 2026, https://www.cdc.gov/nchs/
state-stats/deaths/drug-overdose.html.
102 Bokyung Kim et al., “The Opioid Crisis and the Role of Employers,” Stanford Institute for Economic Policy
Research Policy Brief, January 2024, https://drive.google.com/file/d/1gTYv-GiSaQ_3ovmUbc1pNPe96EpVsVjD/
view; and Julia Paris et al., “The Economic Impact of the Opioid Epidemic,” The Brookings Institution, April 17, 2023,
https://www.brookings.edu/articles/the-economic-impact-of-the-opioid-epidemic.
103 The report referenced a study that linked “43% of the decline in men’s labor force participation rate between 1999
and 2015, and 25% of the decline for women” to the opioid epidemic. See Julia Paris et al., “The Economic Impact of
the Opioid Epidemic,” The Brookings Institution, April 17, 2023, https://www.brookings.edu/articles/the-economicimpact-of-the-opioid-epidemic/; and U.S. Department of Justice, National Drug Intelligence Center, “The Economic
Impact of Illicit Drug Use on American Society,” 2011, http://www.justice.gov/archive/ndic/pubs44/44731/44731p.pdf.
104 See, for example, Stuart Rumrill and Malachy Bishop, “The Role of Employment Status, Change, and Satisfaction
for People Who Have Completed Substance Use Disorder Treatment,” WORK: A Journal of Prevention, Assessment &
Rehabilitation, vol. 74, no. 2 (January 9, 2023), https://journals.sagepub.com/doi/10.3233/WOR-236012.
105 Nancy M. Petry et al., “Engaging in Job-Related Activities Is Associated with Reductions in Employment Problems
and Improvements in Quality of Life in Substance Abusing Patients,” Psychology of Addictive Behaviors, vol. 28, iss. 1
(April 15, 2013), pp. 268-275, https://psycnet.apa.org/doiLanding?doi=10.1037%2Fa0032264.
(continued...)
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Several FRCAs have supported projects that provide employment services and other efforts to
address SUD. For example, in FY2024, NBRC partnered with HRSA’s Federal Office of Rural
Health Policy (FORHP) on the Northern Border Region Health Care Support Program to address
various aspects of SUD in parts of New Hampshire, New York, Maine, and Vermont.106 In recent
years, Congress has directed ARC to allocate a portion of annual appropriations to address SUD
in Appalachia. Additionally, ARC’s Substance Abuse Advisory Council developed a recovery
ecosystem model, which the council defines as “a complex linkage of multiple sectors, including,
but not limited to: recovery communities, peer support, health, human services, faith
communities, criminal justice, public safety, housing, transportation, education, and employers,
designed to help individuals in recovery access the support services and training they need to
maintain recovery and successfully obtain sustainable employment” (see Figure 5).
Figure 5. ARC’s Recovery Ecosystem Model for Substance Abuse Disorder
Source: ARC, “Report of Recommendations: Appalachian Regional Commission’s Substance Abuse Advisory
Council,” August 2019, p. 2, https://www.arc.gov/wp-content/uploads/2020/06/SAACReportofRecommendations-Sept2019.pdf.
Other FRCA Health Activities and Partnerships
In addition to their grant-making roles, FRCAs also coordinate activities and partnerships focused
on addressing specific health challenges. For instance, several FRCAs administer J-1 visa waiver
programs to recruit health care providers; certain FRCAs partner with federal agencies on
targeted health care system strategies in their regions; and select FRCAs coordinate research on
health issues or host occasional clinics in partnership with the Department of Defense (DOD).
Selected examples of FRCA non-grant activity and federal partnership are described below.
HHS has also awarded grants to address opioid use disorders using a formula that takes into account overdose mortality
and awarding funds to states with the highest overdose mortality rates—this included ARC states such as West Virginia
and Kentucky. See HHS, Substance Abuse and Mental Health Services Administration FY2022 State Opioid Response
Grants, Notice of Funding Opportunity, No. TI-22-005, Rockville, MD, p. 74, https://www.samhsa.gov/sites/default/
files/grants/pdf/fy-22-sor-nofo.pdf.
106 According to NBRC, the partnerships with HRSA on opioids and rural health care initiatives began in FY2021. See
NBRC, FY2023 Budget Justification, p. 9, https://www.nbrc.gov/userfiles/files/Annual%20Reports/
FY23%20NBRC%20Budget%20Justification%20Final.pdf.
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J-1 Visa Waiver Program for Physician Recruitment
FRCAs may support projects designed to recruit and retain physicians.107 FRCAs may operate as
interested government agencies (IGAs) for the Department of State’s J-1 visa waiver program
(see textbox).108
J-1Visa Waivers
Foreign medical graduates (FMGs) may enter the United States on a J-1 visa to undertake medical residency
training (called graduate medical education). These FMGs are required to return to their home countries before
they can apply for certain other nonimmigrant visas or legal permanent resident status to work as physicians in the
Unites States, unless they are granted a waiver of the two-year home residency requirement. A J-1 physician can
receive a waiver of the two-year home residency requirement if
•
an interested government agency (IGA) or state department of health requests the waiver;
•
the FMG’s return to their home country would cause extreme hardship to a U.S. citizen or legal permanent
resident spouse or child; or
•
the FMG fears persecution in the home country based on race, religion, or political opinion.
FRCAs are considered to be IGAs and a number of commissions operate J-1 visa waiver programs or are
considering doing so as part of their health-related activities.
Sources: See “J-1 Visa: Exchange Visitor” section in CRS Report R47528, Immigration Options and Professional
Requirements for Foreign Health Care Workers, coordinated by William A. Kandel.
J-1 visa waivers allow J-1 visa physicians (who have completed their medical training) to forgo
their commitment to return to their home country if they provide care in specific geographic
areas. As IGAs, FRCAs can establish programs and request J-1 waivers to meet their region’s
health care needs. The DRA’s Delta Doctors program, for example, is designed to address the
region’s health disparities and high levels of health professional shortages by granting J-1 visa
waivers to physicians who are willing to provide medical services in distressed DRA
communities. The DRA reported that between 2019 and 2021 it had sponsored 440 physicians to
work across the region, with about half of these placements in Alabama and Louisiana.109
For the J-1 visa waiver, a sponsoring entity (e.g., a health care facility) must demonstrate that it
has made a good faith effort to recruit an American doctor without success. The J-1 visa waiver
program involves collaboration and coordination with member states’ offices of public health
107 In an oversight hearing, NBRC’s federal co-chair noted that the commission
evaluates what role it should play in addressing obstacles that limit economic opportunity in rural
areas. Increasingly both housing and access to health care have emerged as significant priorities for
many rural communities. While the Commission is able to fund projects in both of these areas, we
are actively considering how to best leverage our resources in order to complement, and not
replicate, the work of other agencies. One such strategy is establishing a J–1 Visa Waiver program
that will allow for the recruitment of foreign-born physicians trained in the United States to rural
areas.
See House Committee on Transportation and Infrastructure, Subcommittee on Economic Development,
Public Buildings, and Emergency Management, Regional Commissions: A Review of Federal Economic
Development Program Effectiveness, 118th Cong., 1st sess., October 19, 2023, Serial No. 118–32, p. 29,
https://www.congress.gov/118/chrg/CHRG-118hhrg56927/CHRG-118hhrg56927.pdf.
108 See CRS Report R47528, Immigration Options and Professional Requirements for Foreign Health Care Workers,
coordinated by William A. Kandel.
109 See House Committee on Transportation and Infrastructure, Subcommittee on Economic Development,
Public Buildings, and Emergency Management, Regional Commissions: A Review of Federal Economic
Development Program Effectiveness, 118th Cong., 1st sess., October 19, 2023, Serial No. 118–32, p. 21,
https://www.congress.gov/118/chrg/CHRG-118hhrg56927/CHRG-118hhrg56927.pdf.
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and/or rural health. Requests are submitted to the FRCA from the state’s governor.110 As an IGA,
a FRCA is not limited in the number of physician waivers. This differs from the Conrad 30
Waiver Program (also known as the Conrad State Program) for J-1 visa waivers, which limits the
number of waivers each year to 30 per state.
A 2023 ARC evaluation of its J-1 program indicated that it improved patients’ access to high
quality care and shortened wait times.111 The medical practices surveyed indicated that the
program allowed them to serve more patients, provide more comprehensive care, and diversified
skills, among other impacts. The evaluation also reported several instances of physicians opting
for the ARC program because the Conrad 30 program in a particular state was full.112
Table 3 summarizes the J-1 visa waiver activity of FRCA with active programs.
Table 3. Summary of FRCAs’ J-1 Visa Programs
FRCA
Initial Year
Priority Areas
Type of Physician
Fee?
ARC
1991
Health Professional Shortage Area (HPSA)
or Mental Health Professional Shortage Area
(MHPSA)
Primary or Specialty
Care
No
DRA
2002
HPSA, MHPSA, or Medically Underserved
Areas/Populations (MUA/P)
Primary or Specialty
Care
No
NBRC
2023
HPSA or MUA/P
Primary or Specialty
Care
No
SCRC
2022
HPSA or MUA/P
Primary or Specialty
Care
Yes
Sources: ARC, “J-1 Visa Waivers,” https://www.arc.gov/j-1-visa-waivers/ and https://www.arc.gov/wp-content/
uploads/2024/04/J-1-Visa-Waiver-Program-FAQs.pdf; DRA, “Delta Doctors,” https://dra.gov/programs/humaninfrastructure/health/delta-doctors; NBRC, “NBRC J-1 Visa Waiver Program,” https://www.nbrc.gov/content/
J1Visa, and “NBRC J-1 Visa Waiver Expansion Program FAQ’s,” https://www.nbrc.gov/userfiles/files/J%201-Visa/
NBRC%20J-1%20Waiver%20FAQs.pdf; SCRC, “J-1 Visa Waiver Program Guidelines,” https://scrc.gov/sites/
default/files/2025-06/j1_visa_waiver_program_guidelines.pdf, and “FY2024 Congressional Budget Justification,”
https://scrc.gov/sites/default/files/Reports-2024/scrc-fy-2024-budget-justification-final.pdf.
Notes: ARC formally established its J-1 Visa Waiver Program in 1991 and accepted J-1 visa waiver requests on
an ad hoc basis prior to 1991. DRA started a pilot J-1 program in 2002 and formalized their program in 2004. As
of the date of publication, the SBRC has planned for a J-1 program, but it is not active.
Most FRCAs have the authority to collect fees. As of the date of publication, SCRC is the only FRCA that
charges a fee. The fee is paid by the employer (e.g., a health facility).
110 Examples of other interested government agencies include HHS and the Department of Veterans Affairs. For
additional information, see “J-1 Visa: Exchange Visitor” in CRS Report R47528, Immigration Options and
Professional Requirements for Foreign Health Care Workers, coordinated by William A. Kandel.
111 This paragraph draws from ARC’s “Report on the Appalachian Regional Commission’s J-1 Visa Waiver Program
Participants and Impact on Communities 2012–2021.”
112 Specifically, more than half of the ARC’s J-1 physician placements between 2012 and 2021 were in New York and
Pennsylvania. These states have higher numbers of medical residency and fellowship programs, which help with
recruitment and may be the reason for the higher number of physicians placed there during this time. See “Report on
the Appalachian Regional Commission’s J-1 Visa Waiver Program Participants and Impact on Communities 2012 –
2021,” pp. 18, 20.
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Selected FRCA-Federal Partnerships
FRCAs have partnered with federal agencies such as HHS, Department of Labor (DOL), and
DOD on issues such as health care access, health care technical assistance for health care
businesses, health care workforce development, and one-time health clinic events. For example,
•
•
•
•
HHS funding supported village primary care clinics, residential psychiatric
treatment centers, behavioral health facilities, long-term care facilities,
emergency medical service and telehealth equipment, and the design of Indian
Health Service replacement hospitals with the Denali Commission.113 The Denali
Commission has also partnered with the Centers for Disease Control and
Prevention to conduct rural Alaska health and drinking water related studies.114
HHS HRSA funding has supported several technical assistance initiatives in the
DRA and NBRC regions to help improve the administration of rural health care
organizations and hospitals and to enhance health care access and health care
workforce training.115
Through the Workforce Opportunity for Rural Communities (WORC) Initiative,
DOL partners with ARC, DRA, and NBRC for workforce and economic
development projects. Although the WORC Initiative is not exclusively for health
care-related activities, some WORC grants have supported health care workforce
development and training.116
ARC and DRA have hosted Innovative Readiness Training (IRT) medical
mission events in partnership with the DOD and military reserve forces. IRTs
generally provide one or more days of free medical, dental, and vision care while
providing a training opportunity for medical personnel in military reserve units.
IRT events provide services at scale and often prioritize economically distressed
areas within FRCA regions.117 The Denali Commission partners with the DOD on
IRT activities primarily for infrastructure, homeland security, and emergency
response objectives.118
113 Denali Commission, “Denali Commission Strategic Plan 2023-2027,” p. 18, https://denali.gov/strategic-plans/.
114 Denali Commission, “Special Projects & Initiatives,” https://denali.gov/programs/special-projects-initiatives/.
115 See HRSA, “Delta Region Community Health Systems Development Program,” https://www.hrsa.gov/grants/find-
funding/HRSA-25-033; “Delta Health Systems Implementation Program,” https://www.hrsa.gov/grants/find-funding/
HRSA-24-079; “Rural Northern Border Region Healthcare Support Program,” https://www.hrsa.gov/grants/findfunding/HRSA-22-166; and “FY24 Rural Health Network Development Planning Program Awards,”
https://www.hrsa.gov/rural-health/grants/rural-community/nbrc-fy-24-awards.
116 The Department of Labor (DOL) Employment and Training Administration (ETA) awarded the first round of
WORC funding in FY2019 for grants in the ARC and DRA regions. The ETA’s WORC partnership with NBRC began
in FY2023. In recent years, reports accompanying appropriations measures have directed DOL to set aside funding for
enhanced worker training in the ARC, DRA, and NBRC regions. See DOL, “Workforce Opportunity for Rural
Communities (WORC) Initiative,” https://www.dol.gov/agencies/eta/dislocated-workers/grants/workforce-opportunity.
See also the explanatory statement accompanying the Consolidated Appropriations Act, 2023 (P.L. 117-328),
https://www.congress.gov/117/crec/2022/12/20/168/198/CREC-2022-12-20-bk2.pdf#page=322, p. S8874.
117 DOD, “Innovative Readiness Training,” https://irt.defense.gov/. DRA began hosting IRT events in 2009. See
hhttps://dra.gov/programs/human-infrastructure/health/innovative-readiness-training/; and DRA, “2024 DRA Annual
Report,” p. 20, https://dra.gov/wp-content/uploads/2025/08/2024-ANNUAL-REPORT-0714.pdf.
118 Denali Commission, “Testimony for the Record,” House Committee on Transportation and Infrastructure,
Subcommittee on Economic Development, Public Buildings, and Emergency Management, Smarter Spending,
Stronger Results: Reducing Duplication and Ensuring Effectiveness Through Economic Development Reforms,
119th Cong., 2nd sess., January 22, 2026, https://www.congress.gov/119/meeting/house/118896/witnesses/HHRG-119PW13-Wstate-FentonJ-20260122.pdf.
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Health Research and Evaluation Activities
Most FRCAs face region-specific health and health care challenges, which may influence
economic development, health outcomes, and business location decisions. Some FRCAs have
coordinated research and evaluation projects to study health opportunities and challenges in their
regions and to better understand economic and workforce development impacts. For example,
•
•
•
•
In 2026, ARC completed an evaluation of its health grants that closed between
FY2017 and FY2021. According to the report, the grants used a range of
strategies such as the “procurement or purchasing of clinical equipment,
technology, and/or supplies; establishing, improving, or expanding clinical
services; and constructing or renovating health-related facilities.”119
In 2024, SCRC commissioned an assessment of health care needs and health care
access in its region. The assessment highlighted the high concentration in the
SCRC region of rural hospitals that closed nationwide during the 2011-2021
period (nearly 20% of the 76 closures were in the SCRC region).120
In 2024, DRA reported that each “Delta Doctor” is estimated to “create five fulltime jobs within their clinics and offices and an additional 3.4 full and part-time
jobs within the communities where they work.”121 In this context, the term “Delta
Doctor” refers to a foreign physician trained in the United States who received a
J-1 visa waiver to work in medically underserved areas because of the DRA’s
Delta Doctors program.122
In 2017, ARC commissioned a report on the impact of diseases of despair on
mortality in the ARC region. ARC made several updates to the original report
since 2017. The 2025 update noted that the ARC region “has experienced a
decline in the diseases of despair mortality rate since the peak in 2021,” and that
“[t]he 2023 data continue to demonstrate that the Appalachian Region is
rebounding more quickly than the non-Appalachian U.S., despite the continued
disparity and higher mortality rates in the region.”123
Advisory Councils
FRCAs may convene and lead health-focused advisory councils. Such councils involve public
and private sector stakeholders and provide a framework for gathering community input,
analyzing options, and receiving guidance and expertise on regional health concerns. For
instance, ARC’s Substance Abuse Advisory Council is tasked with analyzing opportunities and
119 According to ARC’s report, “Survey findings indicated that these grants aimed to improve health-related services or
infrastructure; strengthen the health-related workforce; and advance health through planning, education, or other
promotion strategies. Commonly reported project strategies included procurement or purchasing of clinical equipment,
technology, and/or supplies; establishing, improving, or expanding clinical services; and constructing or renovating
health-related facilities.” See ARC, “Evaluation of ARC’s Health Grants,” January 22, 2026, https://www.arc.gov/
report/evaluation-of-arcs-health-grants/.
120 SCRC, “2024 Annual Report,” p. 1, https://scrc.gov/sites/default/files/Reports-2025/scrc_annual_report_2024.pdf.
121 DRA, “FY2025 Congressional Budget Justification,” pp. 25-26, https://dra.gov/wp-content/uploads/2024/03/DRAFY-2025-Buget-Justification-FINAL_Updated03072025.pdf.
122 DRA, “Delta Doctors,” https://dra.gov/programs/human-infrastructure/health/delta-doctors/.
123 The 2017 study focused on “mortality from three main causes: alcohol, prescription drug, and illegal drug overdose;
suicide; and alcoholic liver disease/cirrhosis of the liver.” See ARC, “Appalachian Diseases of Despair, 2025,” July 30,
2025, https://www.arc.gov/report/appalachian-diseases-of-despair-2025/.
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challenges to developing a recovery ecosystem.124 ARC’s Substance Abuse Advisory Council
provided guidance on the development of ARC’s INSPIRE grant program.
Selected FRCA Features, Roles, and Activities
The FRCAs’ structural, governance, and operational features may facilitate collaboration and
contribute to economic development—particularly in distressed, rural FRCA areas—in ways that
may contribute to, or otherwise facilitate, the implementation of health-related programs.125 These
features are separate from, but related to FRCAs’ specifically health-focused activities discussed
above, such as the economic development grant-making activities (see “Examples of Health
Related FRCA Grant Programs”). Select features and examples are described below.
Links to Regional, State, and Local Organizations and
Convenor Roles
FRCAs’ connections to state, regional, and local development entities, health agencies, and
philanthropic organizations may be used for health-related initiatives in several ways. Many
FRCAs convene stakeholders from within and outside of their respective regions. FRCAs
occasionally facilitate or incentivize multi-jurisdictional or regional projects involving multiple
levels of government and private sector partners.126 For instance, although not focused
exclusively on health policies, DRA facilitates a leadership academy for public and private sector
participants. The activities involve regional economic development, government relations, and
collaboration.127
Additionally, FRCAs partner with state and regional development organizations, and these
partnerships could be used for expanded or new health-related initiatives.128 For instance,
administratively, most FRCAs coordinate their grant-making and other activities with member
states’ program offices, which are generally staffed by state employees. The FRCAs’ member
124 ARC, “Substance Use Disorder Advisory Council,” https://www.arc.gov/substance-abuse-advisory-council/.
125 U.S. House of Representatives, Committee on Transportation and Infrastructure, Subcommittee on Economic
Development, Public Buildings, and Emergency Management, Regional Commissions: A Review of Federal Economic
Development Program Effectiveness, 118th Cong., 1st sess., October 19, 2023, Serial No. 118–
32, https://www.congress.gov/118/chrg/CHRG-118hhrg56927/CHRG-118hhrg56927.pdf; Anthony Pipa et al.,
“Unlocking Investment in Distressed Rural Places,” The Brookings Institution, January 13,
2025, https://www.brookings.edu/articles/unlocking-investment-in-distressed-rural-places/; Tyler Morin and Mark
Partridge, “The Impact of Small Regional Economic Development Commissions: Is There Any Bang After Just a Few
Bucks?” Economic Development Quarterly, vol. 35, iss. 1 (February 2021), pp. 22-39, https://doi.org/10.1177/
0891242420972475; and John Pender and Richard Reeder, “Impacts of Regional Approaches to Rural Development:
Initial Evidence on the Delta Regional Authority,” USDA ERS, Report No. 119, June 2011, https://www.ers.usda.gov/
publications/pub-details/?pubid=44857.
126 Tyler Morin and Mark Partridge, “The Impact of Small Regional Economic Development Commissions: Is There
Any Bang After Just a Few Bucks?” Economic Development Quarterly, vol. 35, iss. 1 (February 2021), pp. 22-39,
https://doi.org/10.1177/0891242420972475; U.S. House of Representatives, Committee on Agriculture, “Federal
Health Policies in Rural Areas, Part 1,” October 1-3, 1974, 93rd Congress, 2nd sess.; and House Committee on
Transportation and Infrastructure, Subcommittee on Economic Development, Public Buildings, and Emergency
Management, Regional Commissions: A Review of Federal Economic Development Program Effectiveness,
118th Cong., 1st sess., October 19, 2023, Serial No. 118–32, pp. 14, 18, https://www.congress.gov/118/chrg/CHRG118hhrg56927/CHRG-118hhrg56927.pdf.
127 DRA, “Delta Leadership Institute,” https://dra.gov/programs/human-infrastructure/leadership/delta-leadershipinstitute/.
128 For additional information about regional development organizations, see CRS In Focus IF11511, The Role of
Regional Development Organizations (RDOs) in Economic Development, by Julie M. Lawhorn.
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state program offices generally coordinate activities with their states’ governors’ offices and other
state agencies and are often based in the state-level departments of commerce, community, and/or
economic development.
Most FRCAs’ authorizing statutes also require planning and other collaboration with local
development districts (LDDs), a type of regional development organization.129 LDDs are
generally available to advise on local priorities, and to assist local and regional stakeholders with
applications for federal grants, including FRCA and other federal programs.130 For instance,
NBRC partners with LDDs to provide project planning, coordination, and implementation
services to certain communities. NBRC notes that many of the small, rural communities in its
region “rely on part-time staff and volunteer leadership” and may face other leadership and
capacity constraints.131 FRCAs’ LDD connections may also provide a bridge to local elected
officials, philanthropic organizations, and business leaders. For example, an LDD in western
North Carolina partnered with a philanthropic organization to provide non-medical supportive
services to eligible Medicaid members in a multi-county health project.132
FRCAs’ Capacity for Regional and Multistate Projects
FRCAs may provide grants for projects that serve multiple counties or states (see “Health in
FRCA Strategic Plans and Investment Priorities”).133 Similarly, health care services and
workforce training may be provided in a regional or multistate manner.134 Though states license
health providers and facilities, many health care issues—including access to care and workforce
recruitment challenges—span multiple counties and states. FRCAs and FRCA members may
identify additional collaborative options for multistate or regional initiatives as they update
strategic and state plans or as new priorities or opportunities emerge.
129 See, for example, 40 U.S.C. §15505.
The U.S. Economic Development Administration (EDA), within the Department of Commerce, also partners with
regional development organizations (RDOs) that lead long-term economic development planning activities and provide
technical assistance or administrative support to member jurisdictions. Some local development districts (LDDs) are
also EDA-designated Economic Development Districts (EDDs). For information about EDDs, see EDA, “Economic
Development Districts,” https://www.eda.gov/about/economic-development-glossary/edd. For information about
RDOs, see CRS In Focus IF11511, The Role of Regional Development Organizations (RDOs) in Economic
Development, by Julie M. Lawhorn.
130 Certain FRCAs may provide financial assistance to LDDs for their planning and technical and administrative
assistance roles.
131 NBRC, “How LDDs Work with NBRC,” https://www.nbrc.gov/content/nbrc-ldd-partnership-program.
132 See NADO, Building Healthier Rural Communities: Economic Development Districts Address Social Determinants
of Health, August 2025, p.11, https://www.nado.org/wp-content/uploads/2025/08/Social-Determinants-ofHealth_v6.pdf. See also, Tim Sablik, “Connecting a Region Apart,” Economic Focus, Federal Reserve Bank of
Richmond, vol. 27, iss. 2 (2022), p. 18, https://www.richmondfed.org/-/media/RichmondFedOrg/publications/research/
econ_focus/2022/q2/economic_history.pdf.
133 See, for example, the Delta Revitalization through Innovation, Vision, and Empowerment (DRIVE) initiative, led by
the University of Memphis with support from DRA and DOL (https://www.drivempower.org/) and ARC’s Appalachian
Regional Initiative for Stronger Economies (ARISE) initiative that focused on large-scale, multistate economic
development projects (https://www.arc.gov/grants-and-opportunities/arise/).
134 For instance, the Pacific Northwest University (PNWU) of Health Sciences coordinates a regional graduate medical
education (GME) training for the rural and medically underserved areas of Washington, Alaska, Idaho, Oregon, and
Montana. See Pacific Northwest University of Health Sciences, “About,” https://www.pnwu.edu/about/.
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FRCAs’ Program and Funding Flexibilities
Outside groups and policymakers have noted that FRCAs are unique because of their program
and funding flexibilities. FRCAs’ broad-based assistance programs can be used by and for a
variety of different communities, conditions, and circumstances.135 FRCAs’ flexibility in
providing early-stage investment and/or support for small or pilot projects may also distinguish
them from other federal agencies.136 For example, FRCAs sometimes note that they are available
to meet emerging needs and provide “patient capital” for rural communities that often have
limited public financing options or philanthropic funding sources.137
Rural and economically distressed communities often face challenges in securing the nonfederal
cost share match for federal grants due to smaller populations and tax base and/or resource
constraints.138 Denali Commission, GLA, MARC, NBRC, SBRC, SCRC, and SNERC funding is
considered flexible because it may be used to meet the nonfederal cost share match in other
federal programs (unless otherwise prohibited), which provides an option for projects that require
matching funds.139 This flexibility can be used by rural and economically distressed communities
to meet match requirements for federal health facility construction in certain programs.
Additionally, United States Department of Agriculture (USDA) Rural Development (RD) funding
may be available for certain health facility construction projects in rural areas.140 If matching
funds are required for USDA grant programs, FRCA funding can potentially provide a portion of
matching funds for such projects.141
Generally, other federal funding for health facility construction is limited; a number of HHS grant
programs explicitly prohibit construction activities and there are no dedicated HHS programs that
support general health facility construction.142 An exception is funding that has been made
available in recent appropriations laws to support community projects (e.g., Community Project
Funding).143 Such funding is limited, generally available on a one-time basis, and requires
135 House Subcommittee on Economic Development, Public Buildings, and Emergency Management, Regional
Commissions: A Review of Federal Economic Development Program Effectiveness, Serial No. 118–32, pp. 14-15, 28.
136 Alison F. Davis et al., Program Evaluation of the ARC’s Health Projects, 20014-2010, prepared for ARC, pp. iv, 89,
92, https://www.arc.gov/report/program-evaluation-of-the-appalachian-regional-commissions-health-projects-20042010/.
137 House Committee on Transportation and Infrastructure, Subcommittee on Economic Development, Public
Buildings, and Emergency Management, Regional Commissions: A Review of Federal Economic Development
Program Effectiveness, 118th Cong., 1st sess., October 19, 2023, Serial No. 118–32, p. 21, https://www.congress.gov/
118/chrg/CHRG-118hhrg56927/CHRG-118hhrg56927.pdf.
138 Tony Pipa and Natalie Geismar, “Reimagining Rural Policy: Organizing Federal Assistance to Maximize Rural
Prosperity,” The Brookings Institution, November 2020; and Emily Corcoran and Jen Giovannitti, “The Flow of
Capital into Rural Areas,” Federal Reserve Bank of Richmond, Regional Matters, February 12, 2025,
https://www.richmondfed.org/podcasts/speaking_of_the_economy/2025/speaking_2025_02_12_rural_investment.
139 For the Denali Commission, see 42 U.S.C. §3121 note, Section 305(e). For GLA, MARC, NBRC, SBRC, SCRC,
and SNERC, see 40 U.S.C. §15507. As noted, FRCA funding may be used for the nonfederal match in EDA projects
(see 42 U.S.C. §3144(b)).
140 USDA Community Facilities Programs can fund construction of certain health facilities in rural areas. For more
information, see CRS Report R48462, Rural Community Facilities: A Guide to Programs, by Lisa S. Benson.
141 Federal grant programs may limit the share of total project expenses that may be provided by federal sources.
142 Facilities that serve members of American Indian and Alaska Native tribes are eligible to receive funding from the
Indian Health Service for facility construction and renovation. A number of HHS grants explicitly exclude construction
funding. For information about existing programs that support health facility construction, see CRS Report R48081,
Sources of Federal Funding for Health Care Facilities: Frequently Asked Questions, by Elayne J. Heisler et al.
143 CRS Report R46722, Community Project Funding: House Rules and Committee Protocols, by Megan S. Lynch, and
CRS Report RS22867, Earmark Disclosure Rules in the Senate: Member and Committee Requirements, by Megan S.
Lynch.
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sponsorship by a congressional office. As noted, FRCAs have the flexibility to fund different
types of projects that address different aspects of individual and community health and some
FRCAs have provided grants for health care facility construction activities. Health construction
funding from FRCAs can support facilities unable to secure Community Project Funding, or it
can expand the reach of existing Community Project Funding.
Recent Legislation and Policy Proposals Involving
FRCAs and Health
In recent years, Congress has enacted legislation to continue or expand FRCAs’ health and health
care roles and partnerships. Congress also directed FRCAs to address specific health and
development objectives in report language accompanying certain appropriations measures.
Certain FRCAs have requested explicit authority to carry out health-related grant activities.
Combined, the laws and proposals reflect a certain amount of interest in expanding the FRCAs’
role in health care and economic development.
Recent notable laws include
•
•
•
In January 2025, reauthorization legislation (P.L. 118-272, Division B, Title II)
was enacted that expanded certain FRCAs’ authority to develop health care
demonstration projects (e.g., to support the planning, construction, equipment,
and operation of demonstration health, nutrition, and child care projects to serve
distressed areas, including hospitals, regional health diagnostic and treatment
centers, and other facilities and services). The legislation also provided authority
for most FRCAs to collect fees, which may be used to support a physician waiver
program (i.e., the J-1 visa waiver program) to sponsor international physicians
residing in the United States.144
In reports accompanying annual appropriations laws for each of FY2020–
FY2023 and FY2026, Congress directed ARC to allocate appropriations to
address issues related to substance use disorder (SUD).145
In October 2018, the SUPPORT for Patients and Communities Act (the
SUPPORT Act, P.L. 115-271) was enacted, which authorized the ARC to support
projects and activities that address substance use, including opioid abuse, in the
region.146
An example of an authority proposal is one made by DRA requesting grantmaking authority to
align their statutory language with that of other FRCAs in terms of health care, conservation,
renewable energy, and related areas. One of the requests pertained to expanded grantmaking
144 The Economic Development Reauthorization Act (EDRA) of 2024—enacted as a part of the Thomas R. Carper
Water Resources Development Act of 2024 (P.L. 118-272 Division B, Title II) on January 4, 2025, reauthorized seven
FRCAs and authorized two new FRCAs. EDRA authorized GLA, MARC, NBRC, SBRC, SCRC, and SNERC to
administer a demonstration health project program that is similar to the ARC’s demonstration program and designed to
serve distressed areas. Prior to EDRA’s enactment, in addition to ARC, HHS was authorized to transfer funding to the
Denali Commission for demonstration health project programs as well. For the authorization of the ARC’s
demonstration health projects, see 40 U.S.C. §14502. For the authorization of the Denali Commission’s demonstration
health projects, see Section 307 of the Denali Commission Act of 1998 (42 U.S.C. §3121 note).
145 See explanatory statements accompanying P.L. 116-260, P.L. 117-58, P.L. 117-103, P.L. 117-328, and P.L. 119-74.
146 P.L. 115-271, Title VIII, Subtitle E—Treating Barriers to Prosperity, §8062. For additional information, see CRS
Report R45423, Public Health and Other Related Provisions in P.L 115-271, the SUPPORT for Patients and
Communities Act, coordinated by Elayne J. Heisler and Johnathan H. Duff.
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authority in severely economically distressed areas for grants that seek to improve basic health
care and other public services.147 As of the date of this report, the requested changes have not
been enacted.
Considerations for Congress
Interest in rural health care, determinants of health, and the health care workforce raise a number
of issues for Congress. The following sections describe some economic development policy
options involving FRCAs, including options to integrate health access, health care workforce
development, and health care business development with place-making and other regional
economic development goals. This discussion is not comprehensive.
Broadly speaking, Congress may consider options to further integrate health and health care
activities into existing FRCA investment and partnership initiatives. Congress may consider
directing FRCAs to focus on particular strategies or to address specific health challenges in
certain regions or communities. Congress could do so by authorizing new programs or by
directing FRCAs to allocate a portion of their appropriations to address a particular strategy or
initiative, for instance. Alternatively, Congress could maintain its general practice of providing
FRCAs with discretion to use state and other stakeholder input to determine priorities and
strategies—without providing new program authority or congressional directive to prioritize a
particular health condition or strategy to address it.
Congress may also consider limiting federal-FRCA partnership activities or addressing rural
health care and economic development through other policy channels. Some observers and
policymakers are critical of FRCAs generally or of their current framework, arguing that they are
duplicative, inefficient, and an unnecessary involvement of the federal government in local
economic development. Some policymakers and outside groups that view FRCAs as duplicative
have proposed phasing out, streamlining, or integrating their programs with others.148
Others have proposed enhanced coordination among federal agencies and among federal agencies
and FRCAs.149 Congress may also consider legislative or oversight activities on the coordination
of EDA’s and FRCAs’ economic development programs.150
147 The DRA request was to add the language to the DRA’s authorizing statute that would be similar to the following
subsections (i.e., (a)(5), (a)(6), and (a)(7)) of Section 15501 of title 40, which pertain to the GLA, MARC, NBRC,
SBRC, SCRC, and SNERC:
(5) to provide assistance to severely economically distressed and underdeveloped areas of its region that lack
financial resources for improving basic health care and other public services; (6) to promote resource
conservation, tourism, recreation, and preservation of open space in a manner consistent with economic
development goals; (7) to promote the development of renewable and alternative energy sources.
See House Subcommittee on Economic Development, Public Buildings, and Emergency Management, Regional
Commissions: A Review of Federal Economic Development Program Effectiveness, Serial No. 118–32, p. 23.
148 For examples of this perspective, see testimony by the Cato Institute in U.S. Senate Committee on Homeland
Security and Governmental Affairs, Subcommittee on Federal Spending Oversight and Emergency Management,
Wasteful Spending in the Federal Government: An Outside Perspective, S.Hrg. 114-59, 114th Cong., 1st Sess., June 10,
2015, pp. 9-10, https://www.congress.gov/114/chrg/CHRG-114shrg95798/CHRG-114shrg95798.pdf; and House
Subcommittee on Economic Development, Public Buildings, and Emergency Management, Regional Commissions: A
Review of Federal Economic Development Program Effectiveness, 118th Cong., 1st sess., October 19, 2023, Serial No.
118–32, pp. 2-3, 9, 35.
149 For instance, legislation enacted in FY2025 called for enhanced coordination among FRCAs and EDA. See P.L.
118-272, Section 2212.
150 P.L. 118-272, Section 2233 required GAO to complete the report by September 30, 2026.
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FRCA-Federal and Other Partnership Activities
In recent years, FRCAs have partnered with federal agencies such as DOL, USDA, and HRSA,
on a range of issues such as health care workforce development, health care facility development,
health care access, and technical assistance for health care businesses (see “Selected FRCAFederal Partnerships”). The FRCAs’ administrative and governance structures could further be
used for new or expanded FRCA-federal partnerships across one or more policy areas with the
intent to improve health (e.g., agriculture, transportation, disaster recovery). Congress could
direct additional agencies to partner with FRCAs in order to provide targeted funding for specific
initiatives, such as broadband-enabled telemedicine or other initiatives.151 Congress could direct
federal agencies to extend their partnerships to cover FRCAs not currently engaged in FRCAfederal agency partnerships or to change aspects of existing partnerships. Congress may consider
evaluating aspects of current FRCA-federal agency partnerships.
As convenors, FRCAs could continue to use their existing network (e.g., federal, state, regional,
and local government and private sector and philanthropic partners) to further health and
economic development projects to advance health related goals.152 In addition, Congress could
consider options to involve FRCAs in convening stakeholders or otherwise developing
partnerships to address additional socioeconomic factors related to health (such as employment,
economic mobility, and income security).
Federal agencies that address aspects of rural, health care, and health research policy could be
incorporated into FRCA partnerships in various ways, and existing partnerships could be
expanded. Such agencies may include the National Institutes of Health, the Department of
Veterans Affairs, the DOD, the Patient-Centered Outcomes Research Institute, HRSA, the Agency
for Healthcare Research and Quality, and USDA, among others. In some cases, for example,
federal agencies could be required to consult with FRCAs to coordinate projects and funding. Of
relevance, in recent years Congress has made community project funding available through the
HRSA account to support health facility construction and renovation, among other projects.
HRSA also provides funding to support rural hospitals and provides technical assistance to
struggling rural hospitals. These efforts could be coordinated to expand the reach of federal
funding (e.g., community project funding could be used to complete facilities supported by
FRCAs or vice versa). Should mandatory coordination be pursued, it may also be useful in
minimizing duplication: federal funding could be withheld from facilities that have received
funds from other sources, thereby stretching the reach of federal funds.
FRCA and federal agency collaboration could be especially useful in the case where federal
health agencies may provide time-limited funds to support a particular initiative; flexible FRCA
funding can support the project on an ongoing basis if the project is useful. One potential
opportunity for such coordination is the Rural Health Transformation fund included in the
151 For examples of FRCAs’ grants for broadband projects, see ARC, “Computer and Broadband Access in
Appalachia,” https://www.arc.gov/about-the-appalachian-region/the-chartbook/computer-and-broadband-access-inappalachia/; and NBRC, “NBRC 2023 Catalyst Grant Awards Press Release,” August 23, 2023, https://www.nbrc.gov/
userfiles/files/Announcements/NBRC%202023%20Catalyst%20Grant%20Awards%20Press%20Release%20%20August%202023%20FINAL.pdf. In the Broadband Equity, Access, and Deployment (BEAD) program (see the
Speed for BEAD Act, H.R. 1870) and potentially for broadband projects funded by the ARC (see the Expanding
Appalachia’s Broadband Access Act, H.R. 2474). For more information on broadband projects and ARC, see ARC,
“Broadband Projects,” https://www.arc.gov/broadband-projects/.
152 For example, in response to concerns about disparities in capital access, ARC conducted research on challenges and
opportunities in its region. Several years later, as government and private sector leaders convened, they assembled a
team to work on drawing more capital into the region. One of the strategies was the formation of the Appalachian
Community Capital, which received ARC startup funding.
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FY2025 Reconciliation law (P.L. 119-21), which provides five years of funding to states to test
innovative approaches to improve rural health care.153 FRCAs could be considered in conjunction
with this funding in several ways. First, the Rural Health Transformation funding is time limited
and FRCA funding may be a way to sustain successful projects. Second, this funding is made
available to states that were required to develop a state plan, and FRCAs—having established
state partnerships—could bring together neighboring states to examine how these funds were
used and lessons learned. The regional nature of FRCAs could also be useful in providing funding
to expand successful projects into neighboring states.
Pilot Programs to Address Nonmedical Determinants of Health
FRCAs may provide a vehicle for implementing policies to address some of the socioeconomic
factors that contribute to health. Outside groups note that addressing SDOH requires “a holistic,
cross-sector approach involving health care, education, housing, and economic development
agencies.”154 FRCAs currently address multiple objectives related to sub-national economic
development and growth and health, and many FRCAs have existing partnerships with health
care, education, housing, and economic development agencies at the state and federal levels.
FRCAs also have flexible grant-making authorities and existing partnerships with regional
development organizations (i.e., LDDs)—many of which provide technical and administrative
assistance to community stakeholders and implement regionally oriented projects. Certain LDDs
may work to expand broadband to improve access to telehealth, online education, and job
opportunities.
Congress could direct FRCAs to continue or expand investments designed to address non-medical
determinants of health. Existing FRCA grant programs could be used to support built
environment concerns and other activities that are generally considered supportive of positive
health outcomes—in addition to economic health. Such efforts could be undertaken through
grants for community and economic development initiatives entities that are currently partnered
with FRCAs or with additional types of partners.155
Congress could also encourage FRCAs to conduct additional, targeted outreach and engagement
activities. For instance, FRCAs may be positioned to convene public and private sector
stakeholders to identify specific health challenges in their respective regions. FRCAs could work
with LDDs to solicit input from local stakeholders on ways to reduce longevity gaps and create
interventions that are suited to communities or regions. Some researchers have noted the potential
impact of such programs that focus on changing health behaviors in particular.156
153 CRS Report R48633, Health Provisions in P.L. 119-21, the FY2025 Reconciliation Law, coordinated by Alison
Mitchell.
154 NADO, Building Healthier Rural Communities: Economic Development Districts Address Social Determinants of
Health, August 2025, https://www.nado.org/wp-content/uploads/2025/08/Social-Determinants-of-Health_v6.pdf.
155 In 2018, the U.S. Environmental Protection Agency (EPA) provided planning and technical assistance to facilitate
strategies for healthy, walkable downtown districts and neighborhoods with economic impacts. HRSA and certain
FRCAs also participated in the initiative. See EPA, “Healthy Places for Healthy People,” https://www.epa.gov/
smartgrowth/healthy-places-healthy-people.
156 Raj Chetty et al., “The Association Between Income and Life Expectancy in the United States, 20012014,” JAMA, vol. 315, no. 16 (April 26, 2016), pp. 1763-1764, https://jamanetwork.com/journals/jama/fullarticle/
2513561.
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Research and Evaluation
Several opportunities exist for additional research and evaluation of FRCA activities. Congress
may consider encouraging FRCAs to complete regular evaluations of health resources and
conditions in their region, as well as funding to support such evaluations. Additional research on
the economic impact of health or health care strategies could provide insight on aspects of rural
health care in the FRCA context. Research could be completed by GAO or through funding
provided to FRCAs for third-party evaluators of specific programs or initiatives. Outside groups,
for instance, suggest that additional research regarding the effectiveness of rural health care
workforce recruitment and retention and the effectiveness of telehealth as well as a better
understanding of technologies and interfaces, could be helpful to inform regional economic
development policies.157 Additionally, researchers who study the relationship between education
and health call for additional examination of the effects of early education as well as
postsecondary enrollment and attrition.158 Outside groups also call for additional evaluations of
evidence-based strategies that focus on what works in rural areas.159
Concluding Remarks
Researchers, policymakers, and federal agencies continue to study the relationships between
places, social policies, economic opportunity, and health.160 In documenting the relationships
between population health and socioeconomic conditions, some researchers have observed that
Improving the economic conditions of Americans at many income levels—from those who
are poor to those in the middle class—could improve health and help control the rising
costs of health care. Jobs, education, and other drivers of economic prosperity matter to
public health.161
Health is associated with a range of medical and non-medical determinants, including placespecific economic conditions.162 Community health and economic development practitioners
157 Robert Harrington et al., “Call to Action: Rural Health: A Presidential Advisory,” American Heart Association and
American Stroke Association, vol. 141, no. 10 (February 10, 2020), https://doi.org/10.1161/CIR.0000000000000753.
158 Jill S. Cannon et al., “Decades of Evidence Demonstrate That Early Childhood Programs Can Benefit Children and
Provide Economic Returns,” The Rand Corporation, Research Summary, November 16, 2017, https://www.rand.org/
pubs/research_briefs/RB9993.html; and Anna Zajacova and Elizabeth M. Lawrence, “The Relationship Between
Education and Health: Reducing Disparities Through a Contextual Approach,” Annual Review of Public Health, vol. 39
(April 1, 2018), pp. 273-289, https://www.annualreviews.org/content/journals/10.1146/annurev-publhealth-031816044628.
159 Georgia Health Policy Center, “Reimagining Rural Health: Landscape Analysis,” April 2025, pp. 39-40,
https://www.gih.org/wp-content/uploads/2026/01/Reimagining-Rural-Health-Landscape-Analysis.pdf; and Robert
Harrington et al., “Call to Action: Rural Health: A Presidential Advisory,” American Heart Association and American
Stroke Association, vol. 141, no. 10 (February 10, 2020), https://doi.org/10.1161/CIR.0000000000000753.
160 See, for example, William B Weeks et al. “Rural-Urban Disparities in Health Outcomes, Clinical Care, Health
Behaviors, and Social Determinants of Health and an Action-Oriented, Dynamic Tool for Visualizing Them,” PLOS
Global Public Health, vol. 3, iss. 10 (October 3, 2023), https://journals.plos.org/globalpublichealth/article?id=10.1371/
journal.pgph.0002420 and Alex M. Azar, “The Root of the Problem: America’s Social Determinants of Health,” 2018,
Speech delivered at the Hatch Foundation for Civility and Solutions, Washington, DC,
https://library.vbcexhibithall.com/the-root-of-the-problem-americas-social-determinants-of-health/.
161 Steven H. Wolf et al., “How Are Income and Wealth Linked to Health and Longevity?” April 2015,
https://www.urban.org/sites/default/files/publication/49116/2000178-How-are-Income-and-Wealth-Linked-to-Healthand-Longevity.pdf.
162 Amelia Whitman et al., “Addressing Social Determinants of Health: Examples of Successful Evidence-Based
Strategies and Current Federal Efforts,” 2022, https://aspe.hhs.gov/sites/default/
(continued...)
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increasingly design strategies (e.g., assistance for health care facilities, health care workforce
training, health care business assistance) to address a range of such factors—many of which
intend to enhance an area’s overall quality of place and seek to improve community health. These
strategies may also contribute to an area’s quality of place as well as business, resident, and
worker location decisions. Additionally, health care facilities are considered regional amenities
and public health assets and economic development practitioners view health care as a leading
industry sector for employment opportunities.
Macroeconomic constraints, state and federal policies, and changes to insurance coverage
contribute to some of the health care system challenges that are beyond the scope of FRCAs
resources and jurisdiction. The health care system’s challenges include rural hospital closures,
provider shortages, and quality of care concerns. Some observers anticipate that a decline in
federal funding for medical education and research may dampen the availability of new health
care workers (due to fewer training resources).163 Others point to low payment rates for health
services and a broader set of market-based and economic factors, including inflation, that may
contribute to higher housing prices and costs for other goods and services.164 Federal and state
law set economic policies that impact individuals’ income and benefits (e.g., federal nutrition,
education, social safety net programs that provide assistance to low-income households).
Collectively, these trends and policies may add to financial pressures on health care systems and
patients as well as the economic trajectory of certain regions.
As Congress considers the scope and scale of FRCAs’ authorities and appropriations measures,
policymakers may direct FRCAs to further integrate health-focused activities into their existing
regionally-oriented and community-driven approach to economic development. FRCAs currently
have a role in several aspects of community-based health and health care improvement initiatives
that address place-specific opportunities and challenges for regional economies. As there are no
universal remedies or one-size-fits-all road maps for improving health, some experts suggest that
social and economic policies as
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