Why hub-based models matter — and how states should approach them

Without regional hubs, rural health transformation stalls at pilots instead of scaling statewide.

In brief

• Regional hubs aren’t red tape — they’re how states scale rural health without breaking central agency capacity.
• Hubs enable hyperlocal collaboration across providers and community partners to improve outcomes across regions.

Regional hubs can sound like another layer of administration. For some state leaders and community health stakeholders, the phrase raises concerns about governance complexity, new intermediaries or dilution of local control. In the context of the Rural Health Transformation Program (RHTP), that framing misses the point.

The Centers for Medicare & Medicaid Services (CMS) allows states to use regional hub-and-spoke operating models and identify “lead organizations” as a way to coordinate rural health transformation at scale. Although hospital providers, federally qualified health centers (FQHCs) or local health departments (LHDs) may become the “hub lead,” these hubs are not meant to centralize care delivery. Instead, they are designed to connect fragmented health ecosystems, align community partners and tailor innovative solutions to local needs without requiring states to manage every relationship directly.

Hubs enable scale without sacrificing local relevance

Rural health challenges vary dramatically across regions. Clinical workforce shortages, access gaps and infrastructure constraints rarely look the same from one county to the next.

Regional hubs allow states to:

• Set consistent statewide goals and priorities
• Coordinate care and social services
• Improve access to primary and specialty care (e.g., transportation, telehealth)
• Delegate localized execution of RHTP initiatives
• Accelerate progress across multiple initiatives simultaneously
• Efficiently obligate RHTP grant money to community hub partners
• Reduce overall costs and administrative burdens for state agencies

Rather than duplicating clinical, operational and financial resources at every rural provider, hubs create a structure for shared capacity while preserving local delivery.

A broader ecosystem of RHTP collaborators becomes possible

Only states were eligible to apply directly to CMS for RHTP funding. But states are explicitly permitted to subgrant funds to a wide range of implementing partners, including:

• Local health departments (LHDs) and community health centers (CHCs)
• Federally qualified health centers (FQHCs) and rural health clinics (RHCs)
• Nonprofit hospital organizations with rural facilities
• Disability service providers
• Academic institutions
• Community-based organizations (CBOs)

Without hubs, states often find themselves managing dozens — or hundreds — of bilateral relationships directly.

What this means for states

Regional hubs are not about relinquishing control. They are about accelerating RHTP implementation and governing smarter. States that use hub-and-spoke models effectively:

• Retain strategic oversight and accountability
• Delegate operational coordination to trusted local entities
• Increase visibility into regional performance
• Align rural health stakeholders and community partners around common priorities and collective actions

The hub-and-spoke model simultaneously improves innovation and public-private sector collaboration around RHTP initiatives.

What to do next if you’re considering a hub-and-spoke model for RHTP

For state agencies considering or refining hub models:

• Clearly articulate the problem the hub is meant to solve (care coordination, provider access, public-private collaboration, efficiency and scale).
• Engage rural health stakeholders and community partners early. 
• Define governance authority, operating model and accountability up front — hubs coordinate, states govern.
• Align funding, reporting and performance expectations from day one.
• Design a sustainable business model for an enduring impact.

When designed intentionally, regional hubs are not another layer of complexity. They are the connective tissue that allows rural health transformation to move from policy to practice.

The views reflected in this article are the views of the author and do not necessarily reflect the views of Ernst & Young LLP or other members of the global EY organization.