Rural Health Fractured: Exploring the Health Effects of Rural Childcare Deserts

JH: I’m excited to dive into that here in just a minute. I guess let’s talk about setting the stage. One of the things that I know is access to childcare is difficult, but I only look at it from the lens of my community. So, what I would ask that you do is paint for us the picture of what childcare access looks like at a national level. Let’s start there. Let’s start really high level, and then we’re going to get into the weeds here in just a minute.

HH-B: So, one of the things that I think we want to share with your listeners today is that what we experience in our country is really classified as childcare deserts. That is a definition that means that to be considered a childcare desert, that there are approximately three children for every one licensed childcare slot. There’s some new research out recently that talks about the rurality of childcare deserts. That the deserts in rural communities are even more stark than that. What that means is that for moms and dads or families who are helping to transport children, when you want to live and work in a rural community, you need three things. You need a place to live. You need a job and you need childcare.

What we’re finding over the past decade or longer that we’ve been working on rural childcare supply, is that the triangulation of those three things means that families are potentially on the road multiple times for a long distance, trying to get to childcare. If they’re able to find childcare that can take all of the different ages of their children. So, if you’ve got an infant and a preschooler, you might not be able to find childcare in the same location. So, mom and dad, or maybe grandparents or helpers in that family are transporting children on the road twice a day, and it’s incredibly expensive, but you can’t find it.

So, what we know is that families are settling for childcare options that aren’t their preference, meaning that they’re just piecing together solutions. We know that parents are opting out of the workforce or they’re remaining underemployed, or they are tag teaming. Maybe mom as a nurse and working night shift dads, a firefighter on day shift and they’re just piecing together solutions. We also know that families, if they can’t accept a job because they don’t have a place to live and they can’t find childcare, they’re choosing to leave rural communities. That is the most concerning thing to me. I grew up in a rural community. I grew up in a rural state, and it’s a wonderful place to live and to grow up and to raise a family, and the quality of life that we talk about in world communities is one of the selling points. When people can’t live there and raise their family, it’s a serious issue.

JH: Heidi, let’s talk a little bit about urban versus rural. The research and work that you’ve done, I think I know the answer, but I could be wrong, the stark difference between access in both of those locations. Can you talk a little bit about that? It appears to me that our rural areas have been hit harder with this problem, but I need you as the expert nationally to tell me what the actual data says. So, could you could you help us understand the difference?

HH-B: I think the biggest difference really is disbursement. So, when we talk about where people live and work in an urban community, there is still not enough childcare in urban communities either, but the distance to where you have to travel to find it is much more manageable. There may be public transit that will help you get there. So, when we take that same context and we apply it to a rural community, we know that the distances between high quality childcare slots is even greater. That families just can’t get to them. That if you look at a county level and where childcare exists, it might be in a population center inside of that county, it might be in a town, but rural communities actually are relying on family childcare, home-based childcare, as one of the primary mechanisms for rural childcare. It’s incredibly important. So, as we think about the ability of people to own homes, that impacts the availability of home-based family childcare. It also means that, you know, we have an aging population of folks who have been doing this work for decades who are getting ready to retire, and there’s no one coming in on the pipeline to be able to start these small businesses and operate them.

So even if you’re looking at child care centers, which there are some of them in rural communities, they have a tricky business model that makes them unsustainable. They need to have a certain size of enrollment to be financially sustainable and rural communities really struggle to be able to have a child care center that can enroll 100 children or more to make that business sustainable. So, family childcare is that solution, and for the entire decades of childcare that we’ve been operating in this community, those are the two primary mechanisms; really small child care in someone’s home, predicated on the fact that someone lives in that home and can operate that business or child care center, which requires a significantly larger enrollment to make it sustainable. What I’m hoping to share with you are some innovative solutions that are rural in nature, that are working.

JH: Let me ask you a follow up question, because right now and it happened in my family, we have what’s called generational housing, and you have grandparents raising grandchildren, and you have some of those occurrences. So, but that’s not daycare. That’s not child care. That is, you know, my 87-year-old mother who is limited in her scope and in motion. So that’s not our answer, right? That is that is one of the options, but it’s really not a sustainable model. Could you talk a little bit about that?

HH-B: There’s nothing wrong with grandparents being involved. There are limitations. So, as folks are aging, that is one of the things that they have decreasing ability to be able to provide that. Or one of the things that I want to focus on is what high-quality child care looks like. Often, we think anybody can watch kids, and that is the deep respect that we need to cultivate for child care in our communities, that actually these folks are entrepreneurs and educators. We have learned a lot in the last 20 to 30 years about brain development of children, what they need in early learning environments, and people who do this work are incredibly intelligent, dedicated, fantastic individuals who are nurturing early brain development and healthy cognitive development.

Grandparents are fabulous and wonderful, but if this is not the career that they came from, they may not know how to do some of that work. So, if we’re talking about where children are for their awake hours the first five years, we want them to be surrounded by nurturing environments, people who understand early childhood development and can optimize those early years of brain development when all these synapses are happening and grandparents can be part of that, but if that’s not their field of study, we don’t want maybe to stress them out with having to take on a whole other career in their retirement.

JH: Yeah, it’s a great perspective. I mean, they serve a role, but in that developmental stage, it’s important that whoever is doing that is committed, understanding that it is of nature, a job, and a responsibility and not just a service. So, I think that’s a great perspective when we look at generational housing. It’s not the answer to child care deficiencies in our communities. It’s an answer to a lot of things, and certainly, the traditions that my mother passed down to my children and the long storytelling and those things are great, builds character and some of those things, but it doesn’t meet the same objectives as our child care would.

So, I’m going to tell you, one of the things I often hear in our communities is “I can’t afford child care”, and I have to either quit working and we have to find other solutions. That’s maybe a sports program that the kid stays over until 7:00 or 8:00 at night. Talk to me about some of those challenges and barriers, because cost is a factor. When we talk about rural America, where it’s relatively poor communities, individuals at minimum, or just slightly above minimum wage, is the affordability aspect of child care. Can you address some of that, what you’re seeing, and are there viable solutions at a federal or state level to help supplement child care? Do you think there could be some advocacy there?

HH-B: There’s so much happening. I could probably spend a couple of hours talking to you about this. You’re exactly right. Child care is expensive. I want to underline a point. When you do some math on the back of a napkin, people think, that lady down the street has ten kids in her house every day. If she’s making $200 a week times ten kids, that seems like a lot of money. When we actually study the business side of child care, the profit margins are incredibly slim. There isn’t a lot of money being made in this field. That’s why our nonprofit exists, is precisely because the business model is broken. There is no doubt that it is expensive. So, when you talk to young families, they are paying the equivalent of state college tuition for child care. Those costs are the same. In a time when they’re young in their career, they may not be making as much money as they will be down the road when they’re trying to get their kids in college.

So, we have to think about viable solutions at multiple levels to make child care affordable. When we think about doing that, that’s where your community has a role, and that’s where public policy also comes in. One of the places where we have an office at First Children’s Finance is Vermont, by large, a rural state, and we’re watching some transformative policy work happening in Vermont that is changing the availability of child care. So, Vermont passed something called Act 76, and they’re talking about how to create universal child care. Before you think Vermont is a crazy wild liberal state. It’s not, it has a Republican governor, but it is a state that said we have an aging workforce, an aging population. We need Vermont to have more young people, and if you need to be able to afford a house and live and work in our community, childcare is part of the equation. So, they have a small payroll tax that funds universality. It’s growing, but about right now in June of 2026, as we’re recording, I think about 98% of Vermonters who have young children are eligible for child care subsidy. So that is everybody. I think they’re at like 400% of federal poverty level. So, I think that equates to people who are high income earners actually being able to access child care subsidy. So that’s a really interesting thing that’s transforming Vermont. It was passed in the legislature. It has a lot of support even with a Republican governor and it is making child care available to all. So that’s really interesting. You might think, we’re not Vermont. We can’t do that. But I see same the same kinds of things happening at different scales in communities across this country.

We’ve seen really small communities say we have one child care center in in this small town, and it can’t be sustainable. We talked about that earlier. We don’t have 100 kids to enroll in it, but it’s so important that we’re going to pass a local levy to be able to buy that building or take all of the operational costs off of the budget so that we can make it work. That’s where rural communities are really thinking creatively about the facilities, the assets, the social capital, the financing or the policy that they have available locally to think about; how can we do this, make sure that it’s the right size for our community, that it’s sustainable and that we think about it as infrastructure.

I happen to live in the Upper Midwest, so one of the things that a community member said to me is, we have a pool, and that pool can only really operate in June, July and August. It doesn’t make money. It never even comes close to breaking even, but we think about it as important to the quality of life for people who live in this community. We don’t think twice about subsidizing the library or the pool. Yet child care, which makes sure that people can live and work in our community. We think that’s a family issue. Someone should be paying for that. We’re not going to do it. That has way more impact than the pool or the library. They started thinking about it as infrastructure. That’s what I would challenge rural communities to do, is not get caught on the problem, but think about what are the creative solutions that can be built in your community that make a difference and make that child care affordable.

JH: Very creative. Certainly, sounds like it’s nonpartisan in the state. Are you seeing or hearing anything at the federal level that’s being done to address this gap?

HH-B: Well for decades, the federal government has had a suggestion that no family should pay more than 7% of their income on child care. We have a blown passed that many, many years ago. There’s still that recommendation so, what we find is that states are working at different levels to be able to think about how to get to that 7%. They’re leveraging their federal dollars at the state level to deploy federal and state match dollars for the child Care Development Block grant in innovative ways. So, that really is a federal suggestion, not a requirement. I think the action comes down to the states. The advocacy is actually more local than you may think for that federal requirement.

JH: Well, that’ll be interesting to see how that plays out. Obviously, we have a lot of federal issues going on right now. Certainly, it doesn’t seem like Washington’s too involved in solving too many rural problems these days. I guess we’ll keep an eye on that. All right. Let’s talk about where the intersection occurs then between child care and healthcare, because I believe there is a true intersection there. So, what would you say that you have seen in that area of overlap? Is there an overlap number one, and tell us about your work with rural hospitals as it pertains to healthcare and child care.

HH-B: I would think about child care broadly as a social determinant of health. I’m going to talk about it in a couple of different ways, but let’s start with that. That nurturing, wonderful early learning experiences that positively impact young children create a social determinant of health. It means that kids have who have access even as infants. Infants are learning every day, all day long. You might think, they’re not in school. Well, infants are learning, and their caregivers, their parents, the people that they’re surrounded with and the environment, including child care, are framing that brain development, their cognitive development, in so many ways. There’s definitely in a direct crossover between child care and health.

As we think about child care at a community level, we know that child care is an important factor for a healthy, vibrant community. That regional economy is reliant on the supply of high-quality child care. When we think about just hospitals in general, healthcare also crosses over with child care because it’s an employer issue. In lots of rural communities, a hospital may be the primary employer, one of the largest in the region, and has a distinct workforce with needs that make a challenge for child care. So, when you think about 24-hour healthcare, who is working at night, who has to be on the floor providing nursing care at 6:00 A.M., where are they getting childcare? That is a huge challenge for hospitals. So, they are thinking about it from a health perspective, but they’re also thinking about it for a workforce perspective. How are they attracting doctors and nurses to move to their rural community, and how are they going to get childcare when there is nontraditional hour work shifts happening. When you are interacting with a female workforce, I think that even is more pronounced when we think about the amount of moms and dads who have young kids at home. Who are relying on childcare, nursing and associated healthcare careers are directly connected. So, it’s absolutely in the best interest of hospitals and communities to think about innovative solutions.

JH: So, let’s take it one step further for our final question of the day. What can hospital leaders, executives, do to help bridge this gap and work together to create opportunities instead of barriers for access to childcare? If you had the availability to tell healthcare leaders across the country what they should be doing in this arena? What advice would you give and where do they start?

HH-B: Well, first and foremost, I would say that hospital leaders should educate themselves about child care and start to think about it less as a family issue and to think about it as an infrastructure issue in your community. Just like healthcare, you want to think about child care in the same way, there’s a spectrum of possibilities available to explore. Hospital leaders and hospitals in general or hospital systems have a unique role to play. Every child care entrepreneur in your community is required to be certified in some basic things; CPR, first aid, preventing shaken baby and SIDs. Often in rural communities, those trainings are expensive and hard to find. So, make it available. Make it available at no cost, and you are immediately going to gain allies from the child care sector. All of those people need some of those basic things and they are struggling to find them.

The other thing is that hospital leaders want to think about their own workforce and their employees, and thinking about how they can provide options for child care in partnership with existing community-based childcare programs, whether they’re family, home-based, or child care center. They have unique needs, and they want to think about how they can be competitive in attracting and retaining their own workforce by partnering to be able to make sure that they have slots available for their employees. So that could be anything from a financial incentive, making sure that you’re providing dependent care, flexible spending accounts as part of employee compensation. That’s one end of the spectrum to something at the complete other end of the spectrum saying, this is close to our mission, this is mission aligned. Let’s think about how we not only serve our own employees, but we provide community childcare slots in unique ways. We’re going to put some dollars there, or we’re going to leverage our facilities, or we’re going to think uniquely about how we can partner to stabilize child care in our community and add to the supply that we need.

Another thing that you could think about is investing in local solutions that may have nothing to do with the health system or the hospital in your community. When the tide rises, all of boats float. So, thinking about investing in that care in your community is great. Then finally, healthcare leaders have a unique position to advocate. When child care folks go to the capital, they think, oh, isn’t that nice? They don’t necessarily have the ear of decision makers, legislators, governors, agency staff in the same way that hospital leaders do. If you go there as a hospital leader and say, we’ve got a child care problem and its impacting healthcare and hospital sustainability in our community, that gets listened to.

JH: Sure does. Advocacy, advocacy, advocacy, we often do it. I have spoken to our legislative body about access to housing, access to daycare, access to transportation. Seems to be three themes in rural America right now that we’re all struggling with. Be an advocate. If you’re listening today, senior executive or the executive at a hospital healthcare organization, advocate, be a voice because I guarantee you that a significant portion of your population of employees are struggling with these type of issues, specifically as it revolves around daycare and opportunities to find daycare to meet the needs of your shifts and schedules, it could be helpful for you to take an action on this particular subject and potentially partner to identify, maybe even give cash, financial support and payments that would help prop up a daycare of sorts.

So, we’ve looked at it here at Hillsdale, obviously, there’s so many competing interests. You need new technology and you need new infrastructure. You need to keep the community working and engaged, that it can be a heavy burden. We continue to look at that ourselves, we’re asking ourselves a question, what is important to us. Having a workforce that is able to work is critical, and what we find is a barrier is access to childcare. So very good points today, Heidi, extreme pleasure to have you on this podcast to explain to our listeners about what they can do, first of all, analyzing the problem in our country, which is significant, really sounds like whether you’re urban or your rural, the only impact for urban is you might have shorter distances to go, but there’s still problems, and for rural it is truly geography, lack of adequate coverage and then cost.

If you’re listening today, hopefully you’ve been charged up by Heidi and the example she gives of a state that did rise up. Maybe you’re listening today as a legislature, give some thought into leading your state in that discussion about how can we help support that infrastructure and truly looking at it as infrastructure. So, you’ve given me a lot to think about myself, Heidi. You’ve been a tremendous resource for us today. Before we conclude, we ask each of our guests to give a rural health leadership recommendation. In today’s very tumultuous environment of healthcare and the challenges from the one big beautiful bill to each respective state not picking up the Medicaid rates and the devastation that’s impacting us with recruitment and retention and all of the challenges, that it can be very daunting right now for a leader. So what advice, sage advice, what wisdom, what tip would you give to a young leader rising up today that’s saying, these are some rough times, but what advice would you give them for whether it’s your particular field or whether it’s just in general leadership to continue keeping on?

HH-B: I thought about this a lot before our conversation, and the one thing that I want to focus on is the strength of rural communities. This is going to get to a leadership thing in a moment here. I come from a place when something bad happens and it’s harvest time, everyone rallies and there’s no questions asked. People just come together and they get it done. That is the strength of rural communities. When you walk into a room in a rural community, you see an individual, but they’re wearing about five invisible hats on their head. They might be a trustee at the local church; they might be on the board of the local bank. They are connected to other things across the community. There are all these connections, and we don’t need a formal agreement. We don’t need a contract or a memorandum of understanding to work together. What we can do is think about what are the assets that are available to us, and we don’t need an endless supply of cash, although that would be nice, but the alternative, in times like we are right now, where states and communities are shuffling the deck to cover the operating costs, and some of the things that we know are critical are sort of on the chopping block, is to think about how we can build them sustainably and creatively with innovative solutions in our community.

So, think about what is the right size of the solution. You don’t need a five-gazillion dollar building. I’ve seen communities think about starting five new family childcare businesses in their communities for $50,000, with incentive funds, and the result is 50 new slots. Instead of trying to build something. So don’t get overwhelmed by the problems because there are many and the stacks of them around all the time. Focus on the leaders in your community, the assets, and to think about what do we have and what can we do with it. Think an innovative new ways, and don’t get stuck by policy or what the rules are. We can rewrite that; we can we can get a variance around that. Let’s figure out what we need. What’s the size that would be sustainable, what’s impactful and let’s go for it and build it here right now.

JH: If you build it, they will definitely come because we know that the need is there. So wonderful information you’ve presented today. It’s been great to have you on the podcast. I look forward to having you back. Hopefully we can talk about other states that are expanding and maybe the federal government that takes an interest in providing some resources back to the local communities. I think that’s critically important. So, Heidi, it’s been great to talk to you today.

HH-B: Thank you so much, I’m so glad for the invitation.

JH: And thank you to our listeners for tuning in to Rural Health today. Catch our next segment, Rural Health News to stay up to date on the current state of rural healthcare every Monday, wherever you get your podcast. Don’t forget to check out our latest updates and resources from Rural Health today at ruralhealthtoday.com, and make sure you subscribe so you never miss an episode. Until next time, remember Rural Health Strong.