From his perch as director of the Arizona Center for Rural Health, Dr. Dan Derksen talks about the health care system the way wildfire crews talk about dry brush. The danger doesn’t arrive all at once, it builds quietly in places already under strain.
In rural Arizona health care systems operating on thin margins, the stress fractures are usually visible long before the rest of the state notices them.
“I don’t think it’s quite hit people yet,” Derksen said. “But we’re going to see a pretty substantial reduction in the number of people who have health coverage. And that’s going to affect everyone.”
Much of Derksen’s concern centers on a series of federal health care changes already beginning to take effect under H.R.1, the so-called “One Big, Beautiful Bill Act” — rising insurance costs in the Affordable Care Act marketplace, tighter Medicaid eligibility checks and upcoming work requirements that providers say will reduce the number of insured patients across Arizona.
“It’s not just going to affect the people who lose health insurance, which is troubling enough,” Derksen said. “But it’s going to affect everyone and their ability to get in to see providers when they really need hospitalization or emergency department coverage.”
As coverage declines, providers expect more patients to delay routine care until conditions worsen, increasing reliance on emergency departments and adding strain to hospitals already operating with limited capacity.
But it’s “not all gloom and doom,” Derksen insists. Somewhere else in the same federal package (he knows the page count) is a smaller, more hopeful line item. “About 17 pages out of roughly 870,” he said, with a wearied laugh. That’s where the Rural Health Transformation Program lives, sending about $167 million a year to Arizona over the next five years.
It’s a targeted investment he says could help offset some of the strain, particularly in underserved areas. For now, it sits in the background — a counterweight, maybe, as the rest of the system braces.
Access under strain
That pressure is already visible across Tucson’s health care system, where providers say access is patchy even before the full impact of policy changes takes hold.
“Access to care in Tucson is very uneven right now,” said Clinton Kuntz, CEO of El Rio Health. “We and the system around us are under real strain.”
At El Rio — one of the region’s largest community health providers, serving many low-income, Medicaid-insured and uninsured patients — access challenges stem from not a single bottleneck but a layering of obstacles that make it difficult for patients to get timely care.
“Access barriers are rarely just one thing — it’s cumulative,” Kuntz said. “Wait times are compounded by transportation barriers, unstable housing, language needs and insurance limitations.”
Even when coverage is in place, administrative complexity can slow the process. “Those delays can turn a manageable condition into something more serious,” he said. “Demand continues to greatly outpace supply, particularly for patients with complex medical and social needs.”
Primary care gap drives the system
Across providers, primary care remains the system’s most consistent pressure point — and the place where small gaps tend to create larger downstream effects.
“Access to primary care continues to be perhaps the biggest challenge,” said Mimi Coomler, CEO of TMC Health, the Tucson-based system that has spent recent years expanding outward with new hospitals, specialty centers and outpatient services closer to where growth is happening. “We have solid foundations of health systems, but they’re not always as accessible as they need to be.”
As the region grows and ages, that gap is widening.
“What we’re really seeing is increased demand as our population gets older for specialty care,” she said. “Patients come in not with one disease process, but with many.”
When patients can’t get care early, they often end up in higher-cost settings.
“Emergency departments have become acute diagnostic centers because insurance companies sometimes put up too many barriers,” Coomler said. She estimates that roughly 15% of emergency department visits could be handled in primary or urgent care settings if those services were more accessible.
“Patients are waiting for prior authorization for a CAT scan or MRI. Sometimes the ER becomes the fast path. But that just increases the strain on the entire system.”
Demand rising across the system
Banner Health is seeing the same pattern play out across its Tucson operations, particularly as population growth drives demand in new parts of the region.
“There is tremendous demand for primary care and certain specialty services,” said David Bruzzese, a spokesperson for Banner Health.
That demand is closely tied to access — or the lack of it. Bruzzese said the system is also beginning to see early effects of coverage instability.
“Changes made at the federal level are negatively affecting peoples’ access to health insurance, and the number of under- and uninsured patients is rising,” he said. “As a result, some people are unable to access primary care and may end up with conditions that require emergency intervention.
“As demand for emergency care rises,” he added, “we may see longer wait times.”
Workforce pipeline lagging behind demand
Even as demand rises, providers say their ability to respond is constrained by a workforce pipeline that has yet to catch up with the region’s growth.
“Workforce shortages are one of the most significant constraints on access,” Kuntz said.
At El Rio, the shortage extends beyond physicians to behavioral health clinicians and support staff.
“These shortages directly translate into longer appointment lead times and fewer options for patients,” he said.
Coomler sees the same dynamic from the hospital system side. “There’s just not enough primary care in the country,” she said.
Bryna Koch, who leads the health workforce data collection, reporting and analysis team at the Arizona Center for Rural Health agrees. “Every county in Arizona has a shortage of primary care providers,” she said. But she notes that the pipeline from medical college schooling to practice often bypasses the smaller communities.
“We know that health care resources tend to be clustered in urban areas,” she said. “So, we don’t want to just continue that same clustering. We want those pathways to practice to include rural health care facilities.”
Rural systems operating on the edge
Nowhere are those pressures more acute than in rural and tribal communities, where providers say the system is already operating with little margin for disruption.
“Almost all of our rural and tribal providers are operating on 1% or 2% margins,” Derksen said. “If you suddenly lose 10% to 20% of your paying population, it’s going to be very hard to make it work fiscally.”
Koch said those communities are particularly vulnerable because rural populations rely more heavily on Medicaid coverage. For safety-net providers, those policy shifts directly affect how quickly systems can grow.
“Serving a large Medicaid and uninsured population fundamentally shapes our operating reality,” Kuntz said. “Medicaid generally does not fully cover the cost of providing comprehensive care. That limits how quickly we can add staff or open new access points, even when demand is clear.”
Large systems face similar pressures. “Patients who go without preventive care may end up in emergency rooms and hospital beds, taxing an already stressed health care system,” Bruzzese said.
Investment offers a limited counterweight
Despite those constraints, providers are still investing in ways to expand access and stretch capacity.
“What’s making the biggest difference is care-team redesign, integrated behavioral health, telehealth and residency-based workforce development,” Kuntz said.
At TMC Health, investments have focused on expanding capacity and bringing services closer to where patients live.
“We’re investing in specialty services and putting them in locations around the city where we know patients need access,” Coomler said.
At the policy level, the Rural Health Transformation Program stands out as one of the few sources of new funding. “Arizona was awarded about $167 million a year for five years — that’s a significant investment,” Derksen said.
But he cautioned that its impact will depend on how effectively those funds are deployed.
“The key is making sure those funds actually reach rural communities,” he said.
Balancing growth with uncertainty
For providers across Southern Arizona, the challenge now is maintaining access and quality while navigating shifting policy and financial pressures.
“We continuously balance access, quality and financial sustainability,” Kuntz said.
“This is a community problem, not an individual organization problem,” Coomler added.
Derksen believes the system will likely absorb more strain before conditions improve.
“I suspect we will do some backsliding before people realize this is a disaster,” he said. Still, he hasn’t given up on the possibility that targeted investments like the Rural Health Transformation Program can soften the blow — if the funding reaches the communities most at risk.
“I try to remain optimistic,” Derksen said, with a smile. “I don’t like the alternative.”