Day in the life of a rural health facility CEO

You thought running a community health center was hard before? Now with pending Medicaid cuts from the One Big Beautiful Bill Act (OBBBA), rural providers say they’re prepping for more financial strain.

Fairview Community Health Center in Bowling Green, Kentucky, is no different. The federally qualified health center (FQHC) serves about 15,000 patients a year in a city with 79,076 residents, according to Census data, though there are other providers like the Medical Center at Bowling Green nearby. That care is solely medical (no dental or vision) and includes a prenatal care unit, a pediatric department, a family practice, and behavioral health services. Patients vary from Medicare and Medicaid members to commercial insurance policyholders and cash-only customers.

CEO John Lillybridge is far from new to rural healthcare’s challenges. Before leading the C-suite, he was CFO of the health center from 2011 to 2021, meaning he knows how to deal with operational costs and reimbursements. But with these changes coming from the OBBBA, the now CEO took us through a day in his life at the clinic and how he’s planning to prevent it from falling off a potential “fiscal cliff.”

Standard day

Like most CEOs, Lillybridge’s job is rarely ever the same, though it usually starts with a quick staff meeting with his C-suite colleagues to “get a feel for the day,” he said.

Otherwise, he takes a “walkabout” through the clinic to speak with staff and patients. He also focuses on finding grants, which are often the backbone of operations. (The federal government funded an average of $3.7 million per FQHC in 2022.) Additionally, he manages staffing issues that he said are “the daily battle of any business.”

The Kentucky FQHC is currently going through its annual audit, so right now, that’s taking a chunk of his attention.

Managing Medicaid

As CEO, Lillybridge’s daily life often also involves looking ahead. Lately, he said that includes understanding the changes coming to Medicaid under the OBBBA.

To understand the challenge, we have to go back in time. That’s because in 2013, Kentucky participated in a Medicaid expansion that dropped the state’s uninsurance rate from 40.2% in 2013 to 23.6% in 2014, according to independent research group the Commonwealth Fund.

“At that time, we had a board member who had never had healthcare. She signed up, got Medicaid, and found out she had all kinds of issues,” Lillybridge said, adding that the expansion “afforded a lot of people to sign up for healthcare.”

In 2026, as the expansion is still in place, KFF estimates 276,000 Kentucky residents are expected to lose health insurance by 2034 due to the changes.

“Kentucky is one of the states that are going to get hit hardest because we participated in the expansion. Tennessee, for instance, did not participate in the expansion, so they won’t feel the pinch as badly,” Lillybridge said. Having participated in the expansion means there are more Medicaid recipients to cut now.

He’s also concerned about work requirements for Medicaid, a requirement written into the OBBBA. Nebraska was the first state to launch a program last week, and Kentucky is expected to implement its own soon.

“Almost all Medicaid patients work anyway,” Lillybridge said, adding he’s worried the additional paperwork will cost some people care because it adds an extra step they may not be willing to take. Healthcare Brew previously reported that 2018 Medicaid work requirements in Arkansas didn’t improve employment and instead grew the insured population.

Starting next January, Medicaid enrollees around the US may also have to file paperwork twice a year to maintain their benefits, which he said could present additional bureaucratic challenges.

Making plans

In the meantime, Lillybridge said, “we’ve been planning for how we can better serve our patients.” That includes asking more from community health workers, who help patients navigate things like Medicaid applications and housing.

But the dark cloud hanging over his head is that he still doesn’t know exactly how much money will be cut.

You’re probably thinking: What about the Rural Health Transformation Fund that’s meant to offset some of the financial challenges from Medicaid cuts?

Well, Lillybridge said—and others have told us this previously, too—the funding will not be enough to prevent financial harm from the effects of the OBBBA.

While he’s not concerned about the facility closing outright, he said cuts could come.

“We will probably reduce some services, potentially reduce some staff, but we’ll still be able to operate and serve the community,” Lillybridge said.