HJAR Nov/Dec 2025

46 NOV / DEC 2025 I  HEALTHCARE JOURNAL OF ARKANSAS RURAL HEALTH these efforts — enabling hospitals not only to survive but to serve as enduring anchors of health and economic stability within their communities. AUTONOMOUS DECISION-MAKING AND DESIGNATION AUTHORITY Beyond financial and operational consid- erations, governance and regulatory align- ment also play a crucial role in determining how effectively hospitals transition between designations. InArkansas, overlapping fed- eral and state authorities create both struc- ture and complexity. The Arkansas Department of Health (ADH) oversees trauma center designa- tions through a structured survey process that evaluates trauma response, surgical readiness, and staffing. Trauma centers are classified from Level I (comprehensive) to Level IV (stabilization), and theADH retains authority to revoke designations if standards are not met. By contrast, CAH and REH des- ignations are primarily federally governed. The Centers for Medicare & Medicaid Ser- vices (CMS) issues CAH certification, while the ADH’s Health Facility Services Division conducts compliance surveys. The REH des- ignation — created by Congress — is imple- mented at the state level under Act 59 of 2023, with theADH regulating applications and licensing. Hospitals themselves decide whether to pursue REH status based on in- ternal financial and operational analysis. This shared authority structure can cre- ate operational challenges, especially within the trauma system. Hospitals converting to REH status often lose eligibility for higher- level trauma designations because trauma standards require on-site surgical capability, anesthesia coverage, and inpatient stabili- zation. Since REHs are limited to 24-hour observation without inpatient beds, they typically qualify only as Level IV trauma centers. When a hospital transitions to REH and downgrades its trauma designation, the surrounding region loses trauma capacity. In rural and Delta counties, where trans- port times already exceed 35 miles, the loss of local trauma capability can significantly affect patient outcomes. The misalignment between trauma standards and REH regu- lations has created policy tension that Ar- kansas must navigate carefully. Balancing trauma readiness with financial viability will require coordinated action between federal and state agencies. Granting greater state-level flexibility could help resolve these conflicts. TheADH already possesses the expertise to evalu- ate trauma readiness, service demand, and geographic access. Expanding its authority to tailor CAH and REH criteria would allow Arkansas to align licensing with regional needs. A tiered system could allow certain REHs that meet enhanced stabilization cri- teria to retain limited trauma capability — preserving emergency care access while maintaining financial solvency. Further advancingArkansas’s role in hos- pital designation would support broader policy reforms strengthening rural hospital sustainability. Reducing regulatory delays in CAH recertification and improving cross- payer consistency would eliminate major administrative barriers. Combined with in- frastructure investment and value-based reimbursement, these reforms would help hospitals focus on patient care, workforce stability, and long-termplanning rather than compliance burdens. TOWARD A SUSTAINABLE RURAL HEALTH FUTURE Arkansas’s hospital designation struc- ture is evolving to meet the realities of rural healthcare. CAHs, REHs, and PPS hospitals each play a vital role in ensuring statewide access to care. The guiding principle must remain adaptability — matching each com- munity’s needs with the hospital model best suited to its population, geography, and available resources. In isolated Delta coun- ties, maintaining inpatient capacity through CAH designation remains essential. In oth- ers, the REH model offers a practical solu- tion to preserve emergency services without the financial strain of underused inpatient units. Larger regional hospitals will continue to function as PPS facilities — providing spe- cialized care and supporting smaller hospi- tals through coordinated transfers. Ultimately, hospitals should convert to what they need to be. Achieving that requires state-level flexibility, transparent collabo- ration, and data-driven planning among the ADH, CMS, policymakers, and hospital leadership. By advancingArkansas’s role in hospital designation and trauma integra- tion, leaders can create a more resilient and sustainable rural healthcare system — one that truly aligns access, accountability, and long-term stability. n Camille Watson is the senior data and evaluation specialist and executive assistant at Arkansas Rural Health Partnership. Watson graduated from the University of Arkansas at Fayetteville with a degree in political science and philosophy and later received amaster’s degree in public service from the Clinton School of Public Service. She is currently in the Master of Health Administration program at UAMS. “Arkansas’s hospital designation structure is evolving tomeet the realities of rural healthcare. . . . The guiding principle must remain adaptability—matching each community’s needswith the hospital model best suited to its population, geography, and available resources.”