This session will explore the financial health of rural hospitals, especially as it relates to the impact of payer cost containment strategies and government policies. Since 2005, more than 100 rural hospitals have closed and 600 more are at risk. Payer leverage in rate setting along with utilization management within plans like Medicare Advantage, along with public policy decisions, will be explored to help find common ground between rural access and affordability. We will also look at the one state with rate regulation, Maryland, to explore their solution to a balance of hospital financial health and health care affordability.