Who Should Apply? Rural Health Transformation by the Numbers
With the Rural Health Transformation (RHT) Program application window now open, every state is asking the same question: Do we have enough rural population to justify applying? According to the Census Bureau, in 2020, the nation’s rural population was ~ 46 million (~ 19 % of U.S. population).
The truth is, every state with rural communities should apply. But some states can make especially strong cases, whether because of the sheer number of residents living in rural areas or because of how deeply rural dynamics shape the state as a whole.
Two Ways to Look at Rural
When we talk about rural health need, there are two lenses that matter:
Absolute numbers – How many rural residents live in the state?
This shows scale — the total number of people who could benefit from transformation funding.
Percentage of population – What share of the state’s population is rural?
This shows intensity — how strongly rural conditions shape the state’s healthcare delivery landscape.
Some states score high on one, some on the other — and a few stand out on both.
States With the Largest Rural Populations (Absolute Numbers)
Texas: ~4.7 million rural residents
North Carolina: ~3.5 million
Pennsylvania: ~3.0 million
Ohio: ~2.8 million
California: ~1.9 million
These states have huge rural populations, even if the percentage is lower (especially in California and Texas). Their proposals would affect millions of people and could have outsized national impact.
States With the Highest Rural Shares
Vermont: ~66% of the population is rural
Maine: ~62%
West Virginia: ~55%
Mississippi: ~54%
Montana: ~47%
Arkansas: ~44%
Alabama: ~42%
These states may not have the biggest absolute numbers, but rural realities dominate their healthcare systems. Their applications can strongly emphasize equity, access, and sustainability for populations that make up the majority of their state.
The chart on the left shows the top 5 states by absolute rural population.
The chart on the right shows the top 5 states by rural percentage of total population.
The Overlap: States to Watch
Some states combine both scale and share, making them especially strong candidates for competitive applications:
North Carolina – large absolute rural population plus a significant share of the state.
Pennsylvania and Ohio – big rural counts, with strong regional influence.
Kentucky and Alabama – not as large in total numbers, but with high rural shares and clear need.
And then there’s California — often overlooked in rural health discussions, but home to nearly two million rural residents, a number larger than the entire population of many rural-heavy states. While the share is small, the absolute scale makes California an important player.
Ultimately, Texas has the largest rural population by far with 4.74 million rural residents - 1.2 million more than the runner up, North Carolina.
Strategic Takeaways for States
Don’t self-select out. Even states with smaller rural shares can make a compelling case by focusing on absolute numbers and equity arguments.
Lead with data. CMS will want to see both population counts and percentages, paired with workforce statistics, closure trends, and health disparities.
Frame the impact. Whether the goal is stabilizing rural hospitals, expanding broadband-enabled telehealth, or strengthening the caregiver pipeline, the case needs to show how transformation funding will tangibly improve access and outcomes.
The Bottom Line
The Rural Health Transformation Program is relevant and valuable beyond the “most rural” states — the RHT has the potential to ensure that every rural community, no matter its size, has a sustainable path forward. Whether your state’s case is built on millions of residents (like Texas, North Carolina, and California) or a majority rural identity (like Maine and West Virginia), this is the moment to apply.
