Appalachia is currently dealing with a significant health crisis in the failure of several states to adopt the expansion of Medicaid offered by the federal government. The region is caught between research that points to community health initiatives as the most successful programs, as well as the most accepted by Appalachians, and pressure from state governments to seek national programs. Issues arise when considering that the regional culture often rejects large-scale, national ‘hand-outs’ in favor of depending on religious and familial care networks. However, there are several community programs operating in rural Appalachia that have proven successful; to include a mobile mammography unit and a home-based smoking cessation program. Communities have the power to gain agency in the region, the stage is set, and all that is left is for Appalachia to question its place in the system.