Open letter to Gov. Greg Abbott, and Executive Commissioner Texas Health and Human Services Commission Stephanie Muth: 

We write on behalf of the residents of Brewster County, Presidio County and the broader Big Bend region to respectfully request immediate review of the eligibility methodology being used for Rural Texas Strong Initiative 1—Make Rural Texans Healthy Again—and immediate inclusion of Big Bend Regional Hospital District as an eligible hospital district. We support the purpose of Rural Texas Strong. The program is exactly the kind of investment frontier Texas has needed for years: prevention, wellness, nutrition, chronic disease screening, after-hours primary care, and community-based health infrastructure. 

But the current implementation appears to have created an outcome that is difficult to explain to the public: one of the most rural, isolated, and medically underserved regions in Texas has been excluded from the very initiative designed to reach communities like ours. On April 23, 2026, Gov, Abbott and HHSC announced $60 million in initial federal funding to help rural hospital districts create or improve community-based prevention, wellness, and nutrition programs.

The governor stated that “Every community in Texas deserves to have a health system that works as hard as them” and that these funds would help make preventive care and health programs accessible to “every corner of our state.” The Big Bend region is not a rhetorical corner of Texas. It is a literal one. Brewster and Presidio Counties together cover more than 10,000 square miles and serve fewer than 20,000 residents. Both counties have extremely low population density, high uninsured rates, and persistent access barriers.

Presidio is approximately 90 miles from the nearest hospital in Alpine, and parts of the region can face a four-hour round trip for hospital-based care. Both Big Bend Regional Hospital District counties are federally designated as both a Health Professional Shortage Area and a Medically Underserved Area/Population. If Rural Texas Strong Initiative 1 is meant to transform rural health based on community need, Big Bend should be among the most obvious communities in Texas to include.

The problem appears to be the methodology. HHSC has not publicly released a clear methodology, scoring framework, or complete eligibility rationale explaining why some hospital districts qualify and others do not. Based on communications to date, the determining criterion appears to be whether a hospital district directly “owns and operates” a hospital. That criterion is not publicly defined, does not appear to be tied to the community’s health needs, and creates an arbitrary distinction between hospital districts that fulfill their public health responsibilities through direct operation and those that fulfill those same responsibilities through contract, lease, or other legally authorized arrangements.

Big Bend Regional Hospital District is not a private applicant asking for special treatment. It is a Texas hospital district created by state law. Texas Special District Local Laws Code Chapter 1007 provides that the district shall provide all necessary hospital and medical care to its needy inhabitants. Texas Constitution Article IX, Section 9 likewise recognizes hospital districts as public entities responsible for medical and hospital care for needy inhabitants. BBRHD fulfills that responsibility for Brewster and Presidio Counties, including through contractual and property arrangements supporting hospital and medical services in the region.

The District also has a direct and continuing property relationship with the regional hospital facility. BBRHD owns the land on which the hospital sits, and under the existing lease structure, the improvements on that property revert to the District if the lease ends or the hospital operator leaves. The District’s statutory responsibility, public accountability, and property interest all demonstrate that BBRHD is not outside the hospital-district framework. It is simply structured differently than districts that directly operate a hospital day to day.

Hospital District structure should not decide whether the people of Big Bend receive Rural Texas Strong dollars. Rural transformation funding should follow community need, not hospital deeds. Initiative 1 is not merely a hospital subsidy program. HHSC’s own description emphasizes community wellness centers, low- or no-cost chronic disease screenings, nutrition support, grocery stores, farmers markets, food pantries and after-hours primary care. These are largely community-health interventions, not hospital-based services. They are precisely the types of services a hospital district like BBRHD is legally charged to support for its residents, and precisely the types of services frontier communities need most.

If Initiative 1 funding is limited by an unpublished ownership-and-operation screen, the implementation misses the purpose of the program. It shifts the focus away from rural people and toward institutional form. It risks rewarding technical structure over public need. And it risks telling the residents of Big Bend—and potentially other similarly situated rural communities—that they are rural enough to need help, but not structured correctly enough to receive it. 

We therefore respectfully request that the Governor’s Office and HHSC take the following actions immediately: 1. Publish the Initiative 1 eligibility methodology, including the criteria used to identify eligible hospital districts, and the rationale for any ownership-and-operation requirement. 2. Disclose the list of hospital districts and entities determined eligible or ineligible for Initiative 1 funding. 3. Review and revise any criterion that excludes hospital districts based on technical ownership or operating structure rather than community health need, statutory responsibility, public accountability, and ability to execute the Initiative 1 purpose. 4. Recognize Big Bend Regional Hospital District as eligible to apply for and receive Initiative 1 funding, beginning immediately and, at minimum, for Budget Period 2 and all subsequent funding periods.

This request is not about asking for an exception from rural health policy. It is about ensuring that the policy is implemented according to its stated purpose. Big Bend is one of the clearest tests of whether Rural Texas Strong will reach the Texans with the greatest access barriers, or whether the program will be narrowed by criteria that were never publicly explained and do not reflect rural need. We ask for immediate correction so that Big Bend residents are not left out of a program created to make rural Texans healthy again. Respectfully, 

Valynda Henington, President, Big Bend Regional Hospital District
John Ferguson, City of Presidio Mayor
Lynette Brehm Executive Director, Big Bend Regional Hospital District
Manny Baeza, City of Marfa Mayor
Honorable Jose Portillo Jr., Presidio County Judge
Catherine Eaves, City of Alpine Mayor
Honorable Greg Henington, Brewster County Judge
State Senator César Blanco, District 29
Representative Eddie Morales Jr., District 74