For rural hospital leaders, the financial warning signs are no longer theoretical. In the 10 states that haven’t expanded Medicaid, 52% of rural hospitals are operating at a loss. The federal government is putting an unprecedented amount of money behind an effort to strengthen rural healthcare. Meanwhile, hospitals are dealing with immediate workforce shortages, service-line losses, reimbursement pressures and rising operating costs. Rural hospitals are being asked to transform while some are struggling to maintain existing services, offer competitive wages and absorb rising cybersecurity and insurance costs.