Federal Rural Definitions

Featured Speakers

	Sarah Heppner, MS, Associate Director, Federal Office of Rural Health Policy
	Greta Stuhlsatz, PhD, Statistician, Federal Office of Rural Health Policy

In 2025, many agencies across the federal government released new data allowing users to understand how rural populations and areas are changing. This webinar will provide a brief history of rural population over time and review how the term "rural" is defined. Presenters from the Federal Office of Rural Health Policy (FORHP) will focus on how FORHP compiles information from the Census Bureau, the Office of Management and Budget (OMB), and the United States Department of Agriculture (USDA) Economic Research Services (ERS) to identify rural areas in the United States for rural health grant program eligibility. Changes to rural areas, as identified by FORHP with their most recent September 2025 data release, will be highlighted.

From This Webinar

• PowerPoint Handout
• Listen to or download an audio version [MP3]

Transcript

Kristine Sande: Hello, everyone. I'm Kristine Sande, and I'm the program director of the Rural Health Information Hub. I'd like to welcome you to today's webinar. And today, we're going to be discussing federal rural definitions.

And now it is my pleasure to introduce our speakers for today's webinar. Sarah Heppner serves as the associate director of the Federal Office of Rural Health Policy in the Health Resources and Services Administration of the U.S. Department of Health and Human Services. In this role, Sarah provides programmatic, policy, and operational support for the office. Sarah has been with FORHP since 2012, serving as the research coordinator, the deputy director of the Office for the Advancement of Telehealth, and the director of Policy Research Division prior to her current role. She has an undergraduate degree in chemistry from Wells College and a master's in clinical and translational research with a concentration in research management from the University of Vermont.

Greta Stuhlsatz is a statistician with the Federal Office of Rural Health Policy. She supports data activities for the office, including analysis, evaluation, and visualizations. She has worked for the federal government since 2021 and previously worked for a research and capacity building center in Kansas.

And with that, I'll turn it over to Sarah.

Sarah Heppner: Thank you so much to everyone who's either joining us live today or who may be watching the recording later on. I really appreciate you taking time out of your busy schedules to be able to learn a little bit more about how FORHP defines rural and the role that plays in some of the work that we do in the office.

All right. So, what I'm going to do before I turn things over to Greta, who is one of the brains behind all of the data and analysis that happens, is just talk a little bit about the Federal Office of Rural Health Policy, why we exist, and why having a rural definition is very important to us in the work that we do.

So, for those of us who may not be familiar, we are the Federal Office of Rural Health Policy. Our acronym is FORHP. That's the fun, quirky way that we shorthand our name. And our goal is to collaborate with rural communities and partners to support community programs and provide technical assistance to improve health in rural America.

So, what does that actually mean? There's really three main buckets that our work falls into. And the first is to be the voice for rural across HHS. When our office was established back in 1987, that was one of the things that they wrote into our authorizing legislation, is that they wanted us to advise the Secretary primarily on the effects of Medicare and Medicaid policy on rural communities and folks who provide care in rural communities. So, we use that to be able to just make sure that we are amplifying the voices of rural Americans and to make sure that we are raising our hand when we think something is going to impact rural communities in a different way than it will their urban or suburban counterparts.

The next piece and why we are sort of located in HRSA, in the Health Resources and Services Administration, rather than being part of, say, the secretary's office or being part of our colleagues at CMS, is that we are a grantmaking office. And so we are located in HRSA, which is a grantmaking agency. And that's the red column that you can see on the slide here, where our goal is to use the money that Congress has appropriated to us and the programs that we create and that are authorized under our various authorities to increase access to healthcare for people in rural communities. And that happens at the state level, that happens at the community level, and that happens in the grants and cooperative agreements that we're able to fund to provide technical assistance, research, resource development, things like our colleagues and friends at RHIhub, to make sure that we are giving folks access to the information they need to do important work in rural communities.

And then the last piece is this cross-agency collaboration, technical assistance that we do, where we work across HRSA, we work across HHS, and we work across other parts of the federal government to make sure that we can help folks reach their goals and make sure that rural can be included as a consideration whenever possible. We joke around that we will be friends with anybody, we will collaborate with anybody if it helps to further the ability to increase access in rural communities.

So, one of the things that's really important about our ability to do this work and that Greta's going to be diving more into in a few minutes is, so how do we define rural? And what's important about having a national definition for rural? What are the things we need to take into consideration to make sure that we are targeting grant dollars to communities that are rural and to make sure that we are accurately defining and representing within the data we have accessible to us what rural communities look like compared to their counterparts in urban and suburban areas?

So, with that, I'm going to turn things over to Greta for the actual reason you all are here, which is to learn more about this topic.

Greta Stuhlsatz: Thank you, Sarah, for that great introduction. I had also some notes for this slide if I had to do it, and I'm glad I didn't because you did a much better job than I would have for explaining our office.

So, I just want to highlight one more time what Sarah said about this map here. This is kind of a spoiler alert of what we're going to be going into today. This shows all the areas in the U.S. that are considered rural, and it's all this blue area is rural and this white area is not rural.

So, again, my name is Greta Stuhlsatz. I'm a statistician with the Federal Office of Rural Health Policy. And I'm really excited to chat with you today about rural definitions.

So, here's a little overview as a roadmap of what we're going to talk about today. I'll start off with a little information about why rural definitions matter. And then we'll look at some graphs showing rural changes over time. Then we'll get into the meaty part of the presentation, which talks about who defines rural, and I'll focus on the Census Bureau, the Office of Management and Budget, the Federal Office of Rural Health Policy, that's us, and the United States Department of Agriculture Economic Research Services. We'll dive a little deeper to highlight and explain our rural designation process. And then we'll go over some useful tools. I do have some final slides that are some other definitions of rural from other federal agencies that we aren't going to dig into. We might have time to go over them at the end, but the slides will be there for you to peruse if we don't get to them. There's some maps and some explanations of how they are defined.

So, let's start with a little level-setting of why defining rural even matters. Congress directs funding specifically to rural communities and for rural issues. With this funding, programs focus on rural populations that they have to define in some way. They have to rely on some kind of criteria to determine who is eligible to receive these federal resources. Sometimes the term rural is defined in statute, while there are other situations where agencies have a little more flexibility to set their own definitions. And when we talk about rural, it's very important to know who we're talking about and how many people live in rural areas.

So, the charts on these next two slides show different cuts of the population by urban and rural. For now, we're just going to look at the population as determined by the Census Bureau. We're going to keep it simple for now before we dig in. The first chart shows the share of the U.S. population that is urban compared to rural from 1790 to 2020. The red line indicates the rural share of the population and the blue line is urban. You can see that in 1790, when the first census was taken, the share of the population that was rural was much greater. Urban areas held only about 5% of the population and rural areas held about 95%. And up until around 1920, there were more people in rural areas than in urban areas. You can see the lines crossing in 1920. And then after that year, there was a greater proportion of the population living in urban areas. In 2020, about 20% of the population in the United States is rural and 80% of the population is urban.

Now, as many of you are likely aware, the rural population is not declining. This chart shows the population by the numbers rather than percentages of the whole U.S. population. Urban is, again, shown in blue and rural is shown in red. Both populations have generally continued to increase with each decennial census. You can see in this chart that prior to 1880, there were fewer than 50 million people in the U.S. But as that's grown, the population in both rural and urban areas have grown. With the 2020 census, the urban population was a little over 265 million, and the rural population was about 66.3 million. So, no matter how you look at these numbers, there is a substantial number of people in rural areas who can benefit from federal resources.

So, the numbers we just looked at show the rural and urban population according to the Census Bureau. They maintain the official population count of the United States. But I want to talk a little bit more about who else defines rural. As I said, we're going to focus today on the Census Bureau, the Office of Management and Budget, the U.S. Department of Agriculture's Economic Research Services, but there's many, many others. The rural delineations used by these entities feed into the definitions that we use. So they're most helpful in understanding the Federal Office of Rural Health Policy's definition, but this list is not exhaustive. In fact, there's so many definitions of rural in the federal government that the Washington Post ran an article a few years ago about how many definitions there are, and the article listed about 12 to 17 definitions. But depending on what exactly you're looking at for defining rural, there can be even more definitions because statute may be even more specific. And I'll talk a little bit about why, while this may be an annoying feature, it's a necessary part of how we provide services.

So, let's look first at the Census Bureau definition that was used for the charts you saw. They use census blocks, which are the smallest geographic census unit, and these are subunits of census tracts, which are even smaller than counties. Census blocks are grouped into urban areas that are considered densely developed territory, and they encompass residential, commercial, and other non-residential urban land uses. For the census, rural, then, is the absence of an urban area, so all population, housing, and territory not included within an urban area. And the urban areas are updated with every decennial census, so about every 10 years. A census urban area comprises a densely settled core of census blocks that encompass at least 2,000 housing units or a population of at least 5,000. On the next couple slides, we'll look at some maps to see what this looks like on a national scale.

Here's the map of the 2020 Census Bureau areas, urban areas. The purple splotches and dots, those are my words, not the census's, represent urban areas. Some are large, like the shapes in Minneapolis, Seattle, or around New York City, while others are very small, like the dots speckled around Montana and Wyoming.

The next slide shows a zoomed-in version of the Census Bureau's wall map showing the Washington, Arlington, DC-Virginia-and-Maryland urban area. As you can see, the urban areas can cross state boundaries. In this map, you can also see some differences in how the urban areas are represented. These small dots are urban areas with a population less than 10,000, and the large, what I'm calling splotches, because of their irregular geographic shape, are urban areas that represent a population of 10,000 or more.

So, the next agency I'm going to talk about for their definition is the Office of Management and Budget. They take a similar approach as the census, but they add a little bit more detail and they take it up to the county level. So they consider commuting patterns, economic movement, and proximity to metropolitan counties. They define Core Based Statistical Areas, or CBSAs, which are county or counties associated with at least one core of at least 10,000 people, and then the adjacent counties that have a high degree of integration with that core. And I'll show you a map in a second, in case you want a little more of a visual.

There's two types of cores. There's either metropolitan, which has a core of 50,000 or more people, or it could be a micropolitan core, which has a core of between 10,000 but less than 50,000. So the metropolitan cores are large population centers, and then the micropolitan cores are still large population centers, but definitely smaller than the metropolitan ones.

Counties are then determined to be either central or outlying based on settlement patterns, where people live, and their integration to other areas based on the commuting patterns to where they work. Greater population percentages and a greater integration into the urban core will make the county qualify as a central county.

So, this is an example in Kentucky. For those of you that like the visual, this is a Core Based Statistical Area. And these are the Core Based Statistical Areas that are relevant to Kentucky. So, if we look at the one at the top here, this is the Cincinnati-Wilmington-Maysville CBSA, and this is a good example because it shows that some of the Core Based Statistical Areas can cross state lines. This one includes at least one county in Indiana, Kentucky, and Ohio. The dark green indicates counties that are metropolitan. And the light green indicates counties that are micropolitan.

So, in this example, the Cincinnati-Wilmington-Maysville example on the top, all of the counties are metropolitan except Mason down here in the bottom right, that light green one.

So, the following map shows what we looked at in Kentucky, but on a national scale. And then this one only highlights in purple the metropolitan counties. Many reports and documents will talk about metropolitan and non-metropolitan counties. And typically, this means they're using the OMB delineations and separating out the metropolitan counties that have that large population core from the non-metropolitan counties. And in this case, non-metropolitan counties include the micropolitan counties and what we would call non-core counties that aren't included in OMB's lists to show metropolitan and micropolitan. So, in this map, all the purple areas are metropolitan, and then these beige or gray are non-metropolitan. So they could either be micropolitan or non-core.

I talked about two pretty good definitions. And so, you may be thinking, "With the definitions that already exist, why does the Federal Office of Rural Health Policy need to create another one?" And there are a few reasons. One is that many of these definitions focus on urban areas and then consider rural areas as other or what's not looked into. So the Federal Office of Rural Health Policy tries to focus on identifying areas that are rural. Our focus is on rural, not necessarily focusing on urban and then everything else being considered rural. Rural also means different things to different programs or for different research topics, and we need different ways to talk about rural.

So, why don't we use OMB's county designations? One of the reasons we don't use county designations is that counties are very large, especially counties west of the Mississippi. If we depend on county classifications, we may miss smaller areas within larger counties that don't have access to as many resources. The example here shows San Bernardino County, which is a large county in Southern California. According to OMB, this is a metropolitan county, and that's likely because the southwest corner of the county dips into Los Angeles and Long Beach, which is an urban area. However, this county is over 2,000 square miles. The folks in the gray area on the map might not have access to the same resources as those closer to Los Angeles would. So the gray area in this map is considered rural by the Federal Office of Rural Health Policy. And again, we'll get into that more as I go through these slides.

So, the counties are too big. Why don't we focus on something smaller? I've talked about the census urban areas, and they're a smaller level of geography, based on census blocks. So why don't we use that? Well, urban areas cross state and county lines, making it administratively difficult to use in identifying rural areas in a way that will be useful for program implementation. So what we try to do is we bring all of the information from many useful resources together in a way that allows us to identify rural areas to enhance access to critical initiatives and programs.

I want to take a moment to talk about something called the Goldsmith Modification. In 1992, the Goldsmith Modification was outlined in legislation as a way to identify rural areas within metropolitan counties. Today, the Federal Office of Rural Health Policy works with the USDA Economic Research Services to develop tools to help identify census tracts that are rural within metropolitan counties. The way we identify these areas is considered the current implementation of the Goldsmith Modification. So, you can see again in this map, all these purple areas with the lighter blue lines, those are boundaries for census tracts, and those are considered rural with the current implementation of the Goldsmith Modification in this larger metropolitan county.

So, I mentioned the Economic Research Services with the USDA. They developed the Rural-Urban Commuting Area codes in partnership with FORHP. These are classified by census tract, mirroring the theoretical concept used by OMB. OMB is the Office of Management and Budget. They consider population density, urbanization, and daily commuting. There are 10 primary and 21 secondary codes that are designed to be used in different ways depending on research and program needs. They're designed using census tract data, but there's also ZIP code approximation files for users. The Federal Office of Rural Health Policy uses the census tract information.

So, this map shows the RUCA codes. The black to gray scale shows metropolitan census tracts with different levels of integration into a core area. So, if you look at those first three, the black is a metropolitan core. The lighter, darker gray is metropolitan with a high commuting and connection into a core. And then there's metropolitan low commuting, is that next level. The green color gradient shows small town areas. And the purple shows the micropolitan areas. And then the beige is all rural. So we'll dig in a little deeper in a moment about which RUCA codes FORHP uses. But then I have one more USDA ERS tool that the Federal Office of Rural Health Policy uses before we dig into FORHP's definition.

So, the USDA ERS has a couple of new products that are the Area and Road Ruggedness Scale. When the Federal Office of Rural Health Policy published a Federal Register notice about updating our definition in 2020, many of the comments suggested that FORHP identify difficult and mountainous terrain because travel on roads through such terrain is more difficult and time-consuming. At the time, there wasn't a dataset that would allow us to identify this on a national scale at the census tract level. Now, these datasets exist and everyone has access to them.

The USDA ERS developed two scales that identify ruggedness as defined by changes in elevation. The full report is available on their website if you want to take a look at it in more detail. And FORHP uses the Road Ruggedness Scale because roads, rather than overall topography, have a more defensible connection to access to healthcare.

So, this map shows the census tracts across the U.S. and their corresponding Road Ruggedness score. The darker the area is, the more rugged it is. So you can see some of the mountain ranges in the U.S. reflected in the census tract scores. You can see the Appalachian Mountain range over Kentucky and West Virginia and some of the Rocky Mountain range in northern Idaho and many mountain ranges along the West Coast.

So, now that you have some of that background and scaffolding information, I can get into the definition that I am most excited to share with you, the Federal Office of Rural Health Policy's definition. And I'm going to step us through the definition, but I want to point out that we have these five components of our definition. We look first at the county and then, within the county, at census tracts. And an area only needs to meet one of these components in order to be considered rural by the Federal Office of Rural Health Policy's definition.

So, we're going to look first at non-metropolitan counties. We'll look first at the counties. And I'm going to show you this map again that shows these metropolitan counties and non-metropolitan counties. So, the first step in our definition is to pull in all the non-metropolitan counties in the U.S. based on OMB's delineations. So, all these gray areas that are non-metropolitan are considered by FORHP to be rural and just our first step of the definition.

And then we also have outlying metropolitan counties with no population from an urban area of over 50,000 or more people. So, that lets us identify metropolitan counties that don't have dense population centers.

So, then we take a look at the census tracts with RUCA scores of 4 through 10 in metropolitan counties. This is the RUCA code map. So this is any of the RUCA codes that go from 4 through 10. So that's all the purple, all the green, and all of the beige. And then, when we look at that, we're also looking at census tracts of at least 400 square miles in areas with population density of 35 or less per square mile with RUCA codes of 2 through 3. So this allows us to pull in some of the gray-gradient census tracts for large census tracts that have small population, low population density.

And then, finally, we use census tracts with RRS 5 and RUCA codes 2 through 3, again, that's that gray that you saw in the previous map, that are at least 200 square miles in area in metropolitan counties. And these are the most rugged census tracts that are considered highly rural. So all of these dark red, as long as they do not also have a RUCA code of 1.

So, here's the map of the rural counties and census tracts that are considered rural under FORHP's definition. You already saw this map at the beginning of the presentation, and now you can kind of understand a little bit more about what components go into our definition and how we pull in areas to identify rural populations in the United States. About 20% of the population is considered rural by FORHP's definition. But as you can see by this map, the vast majority of land area in the U.S. is considered rural.

So, with all the definitions available, it may be dizzying to figure out how they all fit together and why it matters. So I want to point out some of the overlap. And looking at the three definitions that FORHP uses most frequently, we have these very rough and unscientific Venn diagrams. They are not to scale. It's just to kind of show the overlap. But we can use them to see that all people and areas that are non-metro according to the Office of Management and Budget are also rural according to the Federal Office of Rural Health Policy. But when we look at the census definition, some people in areas that are considered rural according to the census are not rural according to the Federal Office of Rural Health Policy and vice versa. So, there are also some areas that are not considered rural by the census, but they are rural according to the Federal Office of Rural Health Policy.

And it's important to note the different purposes for all of these definitions. Both OMB and census focus on statistical uses and built area, whereas the Federal Office of Rural Health Policy has a particular focus on people in rural areas and access to medical care. So, for example, with the 2020 census, they changed the way that they consider urban areas to also include housing units. And so there may be places like beach towns that have a whole bunch of housing units but might not have consistent populations there. So, we try to focus on people rather than buildings.

So, here's a quick summary of the most recent change that we implemented in September of 2025 compared to our November 2024 update. So, in September of 2025, there were no methodology changes. And in November of 2024, our update prior to the most recent one, we added the RRS codes, the Road Ruggedness Scale, and we also addressed the Census Bureau's removal of size differentiation in urban areas. And I didn't get into that on this presentation, but the census used to differentiate their urban areas on population size. And now, instead of having two separate designations, they're just urban areas. And so we wanted to maintain a difference between the large urban areas and the small urban areas. And so we changed our definition a little bit to say that "All outlying metro counties without an Urbanized Area to be rural," we changed that to "Outlying metropolitan counties with no population from an urban area of 50,000 or more people," to pull in and maintain the population size differentiation.

So, for data updates, in November of 2024, we didn't have a lot of the 2020 census and USDA ERS information. And so we were still using 2010 census tracts and census tract data, USDA ERS RUCA codes and the RRS codes. So, in 2024, we had the 2023 OMB county designation updates. So we updated the metropolitan and non-metropolitan information. In September of 2025, we were able to incorporate the 2020 census tracts, with the exception of Connecticut because Connecticut changed to planning regions. And so we incorporated that as well. And then 2025 USDA RUCA codes and 2025 USDA RRS codes. And those use the 2020 census tract data.

We also have information about the available files that you can find on our website. We have ZIP code approximations that are useful if ZIP codes are the only information you have and you want to use the Federal Office of Rural Health Policy designations. However, our definition is based on counties and census tracts. So wherever possible, we encourage people to use the county and census tract files.

And then I just have a little information about the total land area, population, and population number from 2024 to 2025 with our most recent update. And we see a small increase in rural land area and a small decrease in rural population percentage in the whole U.S. And then the population number has increased from 62.8 million people with our 2024 update to 64.5 million people with our 2025 update.

And then, here is a map to visually see where some of the changes occurred. So, with our September 2025 update, you can see that most of the land area, this light green, remained rural. So there were no changes. It was rural and it is still rural. But there are some of these darker areas, this dark orange, for example, and this dark green, that changed status from 2024 to 2025. So, the orange changed status from rural in 2024 to not rural in 2025. And the green changed status from not rural in 2024 to rural in 2025.

So, looking ahead, I want to talk a little bit about what's next and what does it all mean. For upcoming applications for the Federal Office of Rural Health Policy, applicants have a period of one year to lean on their previous rural status if they lost eligibility. So, if anybody is in this part of the U.S. where they were rural and are now finding they are not rural, they still have a year that they can still receive Federal Office of Rural Health Policy funding.

Do we plan on updating our rural methods like we did to incorporate the Road Ruggedness Scale in 2024? We don't anticipate that happening, but we are constantly monitoring for new data that will allow us to accurately pull together information to identify rural areas. It won't occur... We haven't noticed anything that will make that occur anytime soon.

You may also want to know what happens when the underlying data updates and if we anticipate any of that to happen in the near future. So, as you've learned, we use four main sources of data. We use the census, USDA ERS RUCA codes and RRS codes, and the Office of Management and Budget. Three of those update on this cadence of the census every 10 years. And we have the 2020 update from those datasets. So, the RUCA codes, the RRS codes, and the census, we won't be updating any of our data with those until after the next decennial census, which is in 2030.

The Office of Management and Budget updates their data more frequently, but we don't anticipate any update until later in 2026. Or if they update, it won't be until later in 2026, and they may decide that it's not a big enough change to necessitate having more data, publishing different data. So, in OMB updates, we will be updating our data files, but we don't anticipate that happening anytime soon. And then the timing of any of this happening will align with the FY 2027 Federal Office of Rural Health Policy NOFO releases.

And I'm just looking at the time. And so I am going to go through some useful tools for you, but I don't think we will have time for some of the other rural definitions that I have. So I will encourage you all to, when you get the slides, look over those to see if you have any questions and feel free to reach out to us or the agency that develops them if you would like to learn more about those.

So, I'm going to go into some useful tools for you and your partners. And I'm going to start with the Rural Health Grants Eligibility Analyzer. This is a tool that's developed within HRSA that allows a user to type in an address or to look by state and county to see if their county or their address is in an area that is considered rural. So, in this example here, it's been searched by county and it shows Baldwin County, Alabama. So someone can select Alabama, select Baldwin County, and then click search. And this is considered the source of truth for whether or not an area is considered rural. And often applications for our funding opportunities will ask for some sort of proof from this tool that shows that your service area or facility is in a rural health area. And in this map, this shows the outline of the county and then the areas in the county that are considered. So in this one, it says that "Some parts of Baldwin County, Alabama, are eligible for Rural Health Grants."

I'd encourage you, if you're just looking at this and you see that... If you type in your facility address and you see that your address is not rural, but you know that you serve rural populations, I encourage you to look at specific NOFO opportunities to see what the eligibility requirements are. Because even if the facility is not in a rural health area, if your service area or if many of your patients are rural or live in rural areas, there's still opportunities for funding.

The other one is the Rural Health Information Hub's Am I Rural? Tool. And this works best with a full address. The tool will provide data for a centroid with any other geography. So you want to make sure to type in a full address here in order to get the most accurate results. And this is a tool that's been developed by RHIhub that allows you to type in an address and it'll spit out a report of all the different rural definitions that you could ever imagine. Probably not. There may be some more. But it provides many rural definitions.

So you can see in the example here, we used the HRSA headquarters address, which is not rural by any definition, but it shows the Core Based Statistical Areas and whether or not it is metropolitan or micropolitan or non-core. It shows what the CBSA name is and then its ID. So you can use this information to either justify, for other grant opportunities, to justify if your area is rural according to a different definition, and then also just kind of learn more about the federal definitions of rural and the state of your address or facility or service area.

And then, we also have the Federal Office of Rural Health Policy Data Files. And these are available. They're linked in the PowerPoint. And we have a county and census tract list in our Excel files. And it'll show you, when you pull them up, a list of 2020 census tracts, and it'll say whether or not it is FORHP Rural... There's a column that says FORHP Rural and yes or no if it is rural.

And then there's also a list of 2023 counties, and you can see in that list, you can look up the county, and then you can also see, in the column labeled County Eligibility, if it is not fully FORHP Rural or if it is fully FORHP Rural.

And I want to point out one more thing about using RHIhub in connection to the data files. Both RHIhub's Am I Rural? Tool and our Rural Health Grants Eligibility Analyzer in the report will tell you what the census tract is. So, a lot of people don't know what their census tract is off the top of their head. It's not something that comes up in casual conversation, like perhaps your county. And so you can find your census tract to look it up in our data files using any one of the previous tools.

And then we also have a ZIP Code Approximation Excel File. And I want to encourage again, wherever possible, that you use the County and Census Tract Excel File. But if you only have ZIP code, then this is an approximation of whether or not that ZIP code would be considered rural or not, or a location in that ZIP code.

And then there's also the HRSA mapping tool, and this allows you to select and plot health centers, shortage areas, rural health areas, HRSA grants, all sorts of things. And then you can also upload your data if it has latitude and longitude data points. So you can upload your data set to see how they fall on, for example, this rural health layer. And to do that, you go into the map and you click on “Facilities, Providers, Sites/Areas”, and then click on “Rural Health Areas”, and it will put an overlay on the map that is green that shows you what the rural health areas look like.

And then I'm going to stop here and ask for questions. Sorry to make you dizzy. I just wanted to put our final slide up here about connecting with HRSA. So you can learn more about our agency at hrsa.gov, and then you can sign up for the HRSA e-newsletter that will have all sorts of information about upcoming opportunities. And then HRSA is on all of the social media platforms. So, I will end there and see if there are any questions.

Kristine Sande: So, the first one is about a frontier definition. It says, "Is frontier no longer a classification for very rural areas?"

Greta Stuhlsatz: That's a great question. And that's one of the definitions that we didn't get a chance to dig into today. So if you explore the slides once they become available to you, you can see that the USDA Economic Research Services has a frontier and rural data file that you can see the frontier definition, and you can use their data to identify that. We don't use it in our definition with the Federal Office of Rural Health Policy, but it does still exist and you can still use it. And I believe they're updating their data files sometime in the near future. But right now, they have, if I remember correctly, and let me check my notes, 2010. Right now, it's updated to 2010, and they're based on ZIP code information. So, sometimes that's useful for research that only has ZIP codes or, like you mentioned, is interested in the very remote or geographically isolated communities.

Kristine Sande: Great. Thank you. So, a couple of questions about the map showing the changes from the '24 to '25. The first question is, "The map was created in August of 2025. So did it use the September 2025 updated rural definition?"

Greta Stuhlsatz: Yes. Yeah. Thank you for pointing that out. The map has the Updated 8/8/25 because it was made before we published the final data files. But it is still the September 2025 data files. And we call it the September 2025 data files because that's when it was updated and available publicly. That's when we published it. But we have some internal tools that we developed prior to publishing. And so, I don't think that will be corrected for these slides, but in future presentations, we'll make sure that those are aligned.

Kristine Sande: All right. And then, "Is there a state-level breakdown available for the changes that are shown on that change map?"

Greta Stuhlsatz: Yeah. We don't have state-level breakdowns available, but if you reach out to us, we can help walk through what those changes look like. And we can help support understanding those differences and what might have lost rural status and what might have gained rural status. Also, with each of the funding opportunities that the Federal Office of Rural Health Policy is going to publish for this fiscal year, it includes a list of counties that have experienced a change between the 2024 and 2025 update. And then we also have a data file that shows if a census tract within that county lost rural status. So, when a NOFO is published with the Federal Office of Rural Health Policy, if you're interested in that specific opportunity, the information will be available to you. But if you're more interested generally in what this looks like at your state, feel free to reach out. We're happy to work with you on that.

Kristine Sande: All right. And then a question about whether the two rural determination sites are updated with the new definitions or the new data.

Greta Stuhlsatz: Yeah. I think what you're referring to, and correct me if I'm wrong, the two rural determination sites, that would be the Federal Office of Rural Health Policy's Rural Health Grants Eligibility Analyzer that I talked about in the tool category, and then the Rural Health Information Hub's tool for Am I Rural? And yes, both of those are updated with the September 2025 data. The Rural Health Grants Eligibility Analyzer is an internal tool to HRSA. And so we update those as we publish the data. And then we also work really closely with RHIhub so that whenever we publish a data source or a data update, RHIhub has that information too so that we all simultaneously update so that there isn't a lag in the information that you all are seeing when you're using our tools.

Kristine Sande: Another question about, "How do these definitions or changes interact with HPSA scores? Do they? And if so, how?"

Greta Stuhlsatz: So, the HPSA scores are Health Professional Shortage Areas, and those are not a component of the Federal Office of Rural Health Policy's rural definition. So we don't incorporate any HPSA score information. And then the Health Professional Shortage Areas are based on a formula that also does not consider the Federal Office of Rural Health Policy's rural definition. And I'm not sure how much of the HPSA criteria leans on some similar source material. Like we use, the Office of Management and Budget, we use the census information. I believe HPSAs do as well. So some of that source information could be similar, but we don't do any sort of overlapping as far as our methods goes with HPSAs.

Kristine Sande: All right. "Does the definition of rural used in the Rural Health Transformation Program align with the HRSA definition?"

Greta Stuhlsatz: Yeah. So, I don't know, Sarah, if you want to go into more detail on the Rural Health Transformation part. But I'll start. And then if you have more things to add, feel free.

Sarah Heppner: Sure.

Greta Stuhlsatz: So, the Rural Health Transformation Program mentions the Goldsmith Modification as a way to identify rural areas within metropolitan counties. And so that's one of the reasons that we highlight the Goldsmith Modification in this presentation, because it is partnered with the Rural Health Transformation Program's definition of rural. Sarah, if you want to add to that.

Sarah Heppner: Yeah. So, I would say, I would maybe even take a step back, Greta, and just... For folks who are listening, the Rural Health Transformation Program is run by our colleagues at CMS. And so I want to be really careful that we don't sort of step into their lane. Of course, we're collaborating and working together through all of this, but I think if folks have a specific question about a state's plan versus what was in the NOFO versus the various definitions of rural, if you feel free to reach out to us, we can make sure that you get connected with the right person that can answer your questions specific to the state you're thinking about and things like that.

Kristine Sande: All right. Next question is, "Does the FORHP definition take into account any seasonal population fluctuations?"

Greta Stuhlsatz: We do not. Seasonal population fluctuations is not something that we consider. And that's a good example of the data not being easily accessible. And so, if you know of a dataset that shows that, we're happy to dig into it and see what it looks like, but we don't currently.

Kristine Sande: All right. So, next question is, "Is there a gold-standard definition of rural? It seems like OMB might be, but not sure." Second question, "What is the basis for mid-decennial population estimation that OMB might use?"

Greta Stuhlsatz: Okay. So, the first question is if there's a gold standard for rural. And I love that question. And when I first started working in rural health, I, too, said, "Why do we have all these definitions of rural? Surely there must be one gold standard." And I have changed my tune over the many, many years where I do realize the benefit and value to having all these definitions, even though they can be baffling and difficult to put together.

My understanding is that there's not a gold-standard rural definition. My perspective from the Federal Office of Rural Health Policy is that we have a pretty darn good one that takes into consideration all these different data sources. But there's so many different priorities that look at and include rural that it would be very difficult to identify one gold standard.

One of the examples that I use is the census definition includes built-up areas and includes buildings. Whereas there may be other sources that are looking at agricultural land. And so they're more focused on how much of the land is not settled. And so, there's just so many different components, so many different programmatic priorities that make it very difficult to identify one definition that can be used for everything.

And the example you provided, the Office of Management and Budget, that one's at a county level. And so, when we start looking deeper into counties to see who might have access where, that kind of dulls the gold shininess of what the Office of Management and Budget might look like. And it's also designed to be used for statistical purposes. And so when we look at programmatic implementation, it can start to get much more sticky.

I know that's not the answer you were hoping for, but that's what I have for you.

Kristine Sande: All right. So, the next question is, "Can we expect that these rural definitions that you talked about today will be in place until the next census data is released, or will there be modifications between now and then?"

Greta Stuhlsatz: Yeah. So, the only modification that we anticipate is if the Office of Management and Budget updates their data. And so, when the underlying data updates, we do incorporate those updates and publish a new data file. We align it with programmatic needs. And so, if that happens, when that happens, we'll publish the data in a way that is aligned with our next season of funding opportunities so that it's not, "Six months ago, we updated this thing, and now we have this opportunity. And should we be using the 2024, the 2025, or 2026 definition?" So we try to align it as well as we can, and we try to make sure to communicate that information so that it is very clear in the funding opportunities what should be used. But we do not anticipate an update until the next... We don't anticipate a census tract update until the next census, decennial census, with the caveat that the Office of Management and Budget is the one that could update prior to that.

Kristine Sande: All right. Another question is, "If an area lost federal rural status but is still considered rural by the state, can the State Office of Rural Health still use their federal funding to support that area?"

Greta Stuhlsatz: So, that would be a specific programmatic question that you would need to look into the specifics for the funding mechanism that you're thinking about. Sarah came off of face mute, so she may have something to add.

Sarah Heppner: Yes. Just to say two enthusiastic thumbs up on your answer. But yeah, for specific questions about how the State Office of Rural Health Program or really any of our grants, you should reach out to your project officer. If you don't know who your project officer is, email Greta, only because her email address is the one on the screen, and we'll make sure you get connected to the right person to answer the question specific to the work plan you're referring to, just to make sure we're giving everyone the most accurate information possible.

Kristine Sande: "Are shapefiles available for FORHP's updated designations at the census tract level in ArcGIS online if we want to add a layer with that data to our own mapping projects?"

Greta Stuhlsatz: They are not. And so, I would encourage you to use the HRSA mapping tool to see the overlay and see the overlay with your data. Or if that's not, you can reach out to me too, and I can get you connected to potentially different resources. But we do not have a shapefile that's available to download through ArcGIS.

Kristine Sande: Follow-up comment from one of our attendees related to the Health Professional Shortage Areas, just suggesting that if anyone has questions about HPSAs, to contact your state's Primary Care Office. There's a list of those on the HRSA website. So, good suggestion. The folks at the Primary Care Offices are very well versed on those definitions.

Sarah Heppner: I believe that I inaccurately marked this question as having been answered. And that is, "Could you formally define the Goldsmith Modification? I'm not sure I fully understand what it means."

Greta Stuhlsatz: I can tell you that the information in legislation is that the Goldsmith Modification is designed to identify rural areas within metropolitan counties. And that is the extent to the information that we work with to fit our rural definition into being able to identify rural areas within metropolitan counties.

So, our definition, if you look at our rural health data files page, there's a page before it on our website that says “How We Define Rural.” And it shows the definition that I stepped through during the presentation. And so you can see the county-level information. But then anything beyond that... Is the county non-metropolitan? That's our first step. Is the county non-metropolitan? If it is non-metropolitan, it's considered rural.

Anything beyond that is how we identify non-metropolitan census tracts. Sorry, let me rephrase that. Anything beyond that is how we identify census tracts in metropolitan counties. So those four other components where we look at RUCA codes, and we look at the size and population density of a census tract or county, and we look at the Road Ruggedness Scale. Those are how we identify census tracts that are rural in metropolitan counties.

Kristine Sande: All right. Maybe a question for Sarah, asking whether the USDA and HRSA grant programs and the RHTP program would interface at all in terms of... says, "This is important from a grant's mutual exclusivity standpoint." Do you have any thoughts on that?

Sarah Heppner: Yeah. So, I think I'm going to answer this question, but please reengage if I'm not answering the question you're intending to ask.

So, we have relationships with both the USDA ERS folks, with our colleagues at CMS who are working on the Rural Health Transformation Program. And so, we are absolutely working together, talking, talking, making sure we're all aware of available resources, making sure that we're sharing our knowledge, sharing our work plans for things that we funded, all sorts of activities, to make sure that we are not duplicating efforts, to make sure that we are moving forward in our respective lanes for advancing our investments that we already have made or will be making over the next few years in rural communities.

So, if your question is about how we are working together and how we're making sure good stewards of federal dollars, lack of overlap, we are absolutely doing that. I've even had calls today about that. If that's not the question you're asking, I'm happy to try to re-approach.

Kristine Sande: On behalf of the Rural Health Information Hub, I'd like to thank our speakers for the great information and insights you've shared with us today. And also, thank you to all of our participants for being with us.