In 1997, the U.S. Congress created the Rural Hospital Flexibility Program (Flex Program) as part of the Balanced Budget Act (BBA). This program provides for cost-based reimbursement under Medicare to eligible small, relatively remote hospitals. A companion grant program supports state emergency medical services systems (EMS) and hospital participation in the program. The reimbursement component is the responsibility of the Center for Medicare and Medicaid Services (CMS), while the grant program is the responsibility of the Federal Office of Rural Health Policy (FORHP). Funding to support the monitoring efforts of the Flex Program Tracking Team was provided under the grant program appropriation. The Tracking Team was a consortium of six rural health research centers. Each Center had lead responsibility for several research components of the study. In 2002/2003, the WWAMI Rural Health Research Center took responsibility for assessing state program evaluations, evaluating a number of workforce issues faced by critical access hospitals (CAHs, and looking at the intersection of CAHs) and another federal program, the Mississippi Delta Hospital Performance Improvement Initiative. WWAMI also provided overall project direction and coordination to the participating centers. The main national goals for implementation of the grant component of the Flex Program in the states and participating hospitals included (1) preparing a state rural health plan, (2) converting eligible and willing hospitals to critical access hospital (CAH) status, (3) improving quality of care, (4) promoting networking among hospitals, and (5) improving emergency medical services.