Rural community health departments have limited capacity to fulfill key public health roles and provide critical public health services. Rural communities also face challenges in trying to follow accreditation and meet state standards. The ability to develop and acquire partnerships in rural health departments is also a major challenge, “unlike rural health departments, urban health departments operate with large budgets and staff, provide a broader range of services, and enjoy greater opportunities for develop partnerships with other non-governmental organizations” (Hale, 2015). Unlike rural local health departments, urban health departments operate within their communities with relatively greater resources and provide services in a way that rural communities cannot. To be precise, Forkland, Alabama is one of the poorest cities in the United States. It is located on the western tip of Alabama. Rural Americans are poorer, older and overweight, placing a financial burden on the hospitals and health services that serve them. When the Affordable Care Act became law, “the expectation was that virtually all of the nation's 48 million uninsured would obtain health insurance, either through subsidized health insurance policies purchased on health exchanges or through expanded state Medicaid programs.” (Buntin, 2014). ). In an effort to fund the ACA, the federal government began making large payment cuts to hospitals serving areas with high numbers of Medicaid patients like Forkland,