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Rural America Nears a Cliff: Federal Funding Cuts Threaten Health Systems and Anesthesia Care. Rural hospitals operate on thin margins, sustained largely by federal funding through Medicaid and bolstered by the Affordable Care Act premium subsidies. As these supports erode due to recent federal legislative changes through the One Big, Beautiful Bill Act and a failure of the U.S. Congress to renew Affordable Care Act monies, millions will lose affordable insurance. For anesthesiologists, these changes will translate into closed healthcare systems, cancelled cases, less coverage for medication-assisted treatment used in opioid use disorder, and shrinking surgical capacity. These changes will be disproportionately felt in rural America, where residents already faced disparities in health care. Protecting coverage and rural hospital funding is not just a matter of equity; it is central to maintaining safe, timely anesthesia care for millions of Americans.