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Rural Health Information Hub

Rural Definitions and Data: Changes after the 2020 Census

Duration: approximately minutes

Featured Speakers

Sarah Heppner Sarah Heppner, Federal Office of Rural Health Policy
Steve Hirsch Steve Hirsch, Federal Office of Rural Health Policy
Greta Stuhlsatz Greta Stuhlsatz, Federal Office of Rural Health Policy

The Census Bureau and the White House's Office of Management and Budget (OMB) have been releasing new data from the 2020 Census this year that will affect how federal resources are directed to rural areas in the United States.

Both the Census and OMB made adjustments to their criteria prior to the release of the Census 2020 data. The Census Bureau made the most significant changes to how they define urban and rural areas in over a century.

This webinar will review how rurality is defined by the federal government, what changes in these definitions were made recently, and how this may affect rural areas' eligibility for federal funding.

From This Webinar


Kristine Sande: I'm Kristine Sande and I'm the program director of the Rural Health Information Hub. And I'd like to welcome you to today's webinar and we're happy to be doing this webinar on rural definitions in partnership with the Federal Office of Rural Health Policy. We have provided a PDF copy of the presentation on the RHIhub website and that's accessible through that URL that's on your screen. And now it's my pleasure to introduce our speakers for today's webinar. First is Sarah Heppner. Sarah 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 that 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 of the Advancement for Telehealth, and the director of the Policy Research division.

Our next speaker will be Steve Hirsch. Steve is the semi-retired rural guru with FORHP, and he has worked for FORHP for over 20 years, and prior to that was an information specialist at the Rural Information Center's Health Services. He now lives in a semi-rural area of Maryland. And we'll also hear from Greta Stuhlsatz. She's a statistician with FORHP, where she supports data activities for the office, including analysis, evaluation, and visualizations. She has worked for the Federal Government since 2012 and has 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 for joining us today, and thanks to my colleagues, Steve and Greta for inviting me to be part of their presentation. I wanted to start by just setting the stage a little bit for this webinar and making sure that everyone knows who we are and why we care about rural definitions. We are all part of the Federal Office of Rural Health Policy, or FORHP, for which was created by Congress in 1987. Technically, we were just the Office of Rural Health Policy when we were created, and our office plays two main roles. The first is to administer grant programs designed to build healthcare capacity at the local and state levels. Our grants are designed to strengthen health networks, enhance healthcare delivery in rural communities, provide technical assistance and support to rural hospitals, and to address barriers to treatment for substance use disorders. The second is to act as the voice for rural across HHS, by coordinating activities related to rural healthcare within the Department of Health and Human Services.

We have a department-wide responsibility for analyzing the possible effects of policy on residents of rural communities. And woven into both of these roles is a need to understand the numerous federal and state level definitions of rural that have been created over the years. As part of our office's larger efforts to support rural communities and other rural stakeholders, we provide technical assistance on what all of these various ways to define rural actually mean. So today, two of those experts, Steve and Greta, are going to provide some history and some explanation to a few of the most common definitions that are currently in play. So, without further ado, let me turn things over to Steve. Thanks, everyone.

Steve Hirsch: Thank you Sarah, for the intro and thanks Kristine and the RHIhub staff for making sure I got online and I'm able to do this. Why do rural definitions matter? Sarah just kind of covered that. Federal program funding often goes to places that have the most population so that larger numbers get more resources. There are programs, however that are targeted for rural populations, and those have to rely on some kind of criteria to target the funding. So the way rural is defined can determine who's eligible to receive federal resources. And this is a newspaper story that appeared on the front page of the Washington Post a little over 10 years ago. And if you can read the fine print, Lenoir is a small town in western North Carolina with 18,000 people. Is it rural? The U.S. Government has an answer. Yes, no, and it depends. Yes, yes. No, no, no, no.

The reporter identified at least 15 official definitions of the word rural that are applied by the Federal Government, and there are probably more than that. That's a low number. And one of the reasons there are so many different definitions is that some of them are statutory. Congress might write into a law and specify how rural should be defined, and others are programmatic. That is that the programs are left to decide how to identify what's rural and what's not, and therefore, how to direct resources. And there are good reasons that there may be different definitions used by various agencies, depending on what the program is aiming to do and how large the population is that they want to help. One of the few things that's written in the Constitution that the government has to do is perform a census every 10 years. And it's Article 1, Section 2, and it says they started immediately with the start of the U.S., soon after the Constitution was ratified and have done it every 10 years since then.

And so, we have a really good snapshot of what the U.S. population looks like every 10 years since 1790. And occasionally, I've seen some people who seem to believe that the founders wrote into the Constitution some protections to make sure that rural voters wouldn't be overwhelmed by the mass of urban voters in the U.S., but that's something I find extremely unlikely, if not impossible. And the next slide, I'll be able to show you why. The blue line is the urban population of the U.S. and the red line is the rural population of the U.S.. And these numbers are based not on how people were classified at the time, but it's a retroactive look back done by the Census Bureau. But easily only 5% of the population of the U.S. could be considered urban in 1790. 95% of the population was rural. And really, that is the way ever since civilization started, that the overwhelming number of people did not live in large cities or even large towns.

They lived in rural areas because they had to produce food that they could eat. When you have a scale here that runs from under 3 million to over 300 million, essentially starting in 1790, the urban population doesn't even show up. Back then, 200,000 people might've been considered rural out of a population of almost 4 million in 1790. And it isn't until about 1830 that you can even see the beginning of the urban population starting to show up on this graph. By 1920 though, the urban population exceeds the rural population, the first time that it went over 50% of the population. And after that, obviously the urban population surges by a huge amount so that you have 80% of the population is rural by 2010 or 2000. And the urban population continues to grow. But one of the interesting things to note is that around 1980, the rural population is classified by the Census Bureau, settles in around 60 million and stays there through 2010.

So, a good 30 years. The rural population didn't really shrink in overall numbers, but it didn't grow either. It was the urban population that surged. And then in 2020, due to some changes mostly that the Census Bureau made in how they define rural, which we'll discuss later, the population grows by a sudden 6 million people up to 66 million, as classified after the last census. So, what happened? Why did the urban population surge in such a way in comparison to the rural population? And the answer is agricultural productivity. In 1870, almost half of people who worked, worked in agriculture, and by 1980, just 4% of employed people were in agriculture and each one supplied food for nearly 70 more people beyond that.

So, it's a huge, huge change in agricultural productivity that enabled people to leave rural areas if they wanted to leave rural areas, or perhaps had to leave rural areas because jobs were no longer available in agriculture, with so much more productivity. Just to give you an idea, in 1910, 12 million people worked on farms, and by 2000, that number had shrunk by a huge margin down to 1.6 million. So about 90%, 96% of farm work had farm workers, people were no longer required to work on farms. So, the urban population took off as agricultural productivity allowed, and farm machinery allowed people to leave the farms and go elsewhere and find jobs. So, the Census Bureau, and this is from a publication on the Census Bureau's website, began identifying urban places following the 1870, 1880, and 1890 censuses. And what they were doing was looking at towns with at least 2,500 people and classifying them as urban. And then everything else is considered rural.

And in large part, that's how the Census Bureau continues to identify urban and rural. Everything that's not considered urban is rural. They're not really defining what rural is, it's more a definition by exclusion. So, anything that's not urban is considered rural. And why did they pick towns of 2,500 people? And I'm not sure that they know exactly why the Census Bureau around that time defined a population cutoff of 2,500 people, other than they probably considered any town that had 2,500 people as having a sufficient base of population to support any needed services.

Whereas today, we would think of a town of 2,500 people as being a tiny, small place. That continued to be used essentially as the basic definitions as, through 1950 they always were considering incorporated places, so anything outside of the city limits became rural. And for towns with 2,500 or more, and those were considered urban. But beginning in 1950, the census realized that there were suburbs growing up around large cities, and these suburbs were integrated with the city, even if they were not within the city limit. So, they began to look at population density and to, as long as the population density did not fall below 1,000 people per square mile, they would consider it to be urban. And they also considered places with population density as low as 500 people per square mile, because of parkland, schools, commercial or retail or industrial areas could be included within the urban area.

So, below the 50,000, they did not apply this density screen to areas around those towns. So, anything from 2,500 up to 49,999, it was still within the city limits that was considered urban and everything outside was considered rural. So, with the 1990 census and with technological advancements and computing power, they could now apply the density criteria across every kind of town in the U.S. from 2,500 or more people. They could look at density surrounding those towns and include urbanized areas outside of the city limits. And so that began to happen in 1990. With 2000, the Census Bureau began to distinguish two different kinds of urban areas. So, they had urbanized areas that have at least 50,000 and went up to however far it went, and urban clusters, which had a core that started at 2,500 people but had fewer than 50,000 peoples. Now, the Rural Health Clinic program, as Congress wrote it, identified that Rural Health Clinics could be cited in areas that were not urbanized.

So, urban clusters could be considered rural for the purposes of citing a Rural Health Clinic. There are criteria for citing Rural Health Clinics, that they'd be located in a HPSA, Health Professional Shortage Areas. But in essence, any town under 50,000, any urbanized core that had less than 50,000 could be the site of a Rural Health Clinic. And that allowed many towns to have them within their town limits. Sort of counterintuitively, if you can see, there's a pink area here, which represents the urbanized areas of the United States. And there are green dots which represent the urban clusters. So, towns, urban cores of under 50,000 people. You may notice that there's lots of white space. That's all the rural area of the United States. Most of the United States by far is rural by the Census Bureau's definition, most of the area of the United States, 80% of the people in the U.S. live in the green dots in the pink area.

So, that's only less than 5% of the land area of the United States. But over 95% of the land area of the United States is considered rural by the Census Bureau, and that includes some suburban area that doesn't reach the population density. So, pretty quickly you can get under 1,000 or 500 people per square mile. Now, the Office of Management and Budget at The White House delineates metropolitan and micropolitan statistical areas. They started out only doing metropolitan areas, and back in essentially 1949, the core areas had to have 50,000 people. The difference between what the Office of Management and Budget, OMB does and what Census does, is that OMB is designating whole counties. Census is using much smaller areas, census blocks as the building block to develop urban areas. But if a county is part of a metro area, the whole county becomes considered metro, without any regard to how densely populated it is or pretty much any other considerations currently.

So that the Grand Canyon is my favorite example. The Grand Canyon is a metropolitan area because it's in a county that has Flagstaff, Arizona in the southern part of the county. Starting really with 2000, which is when they began to designate micropolitan areas in addition to the metro areas. So, they began to talk about Core Based Statistical Areas. So, there are two types of Core Based Statistical Areas, the metro areas that have a core population of 50,000 or more, and then micropolitan areas that start with a core population of 10,000 but less than 50,000. And they work similarly. They take the core county that has the urban core, and then they look at commuting patterns to look at which counties are economically integrated with the core area and build out from the central counties. So, there are outlying counties and there are central counties within both metropolitan and micropolitan areas.

The criteria for qualifying as a central county of a core-based area is at least 50% of the population, or has a large slice of the urbanized population within the county. The outlying counties are more or less based on commuting patterns so that at least 25% of their workers are commuting into the central area, or workers from the central area are commuting out into outlying counties. So, this is how the metro areas looked back in 1950. To me, it's interesting to note that there's several states that don't have any metropolitan areas, states like Idaho, Montana, North Dakota for example, don't have any metropolitan areas. And one of the things that also is interesting is that if you look at Southern California, the Los Angeles metro area stretches all the way from LA to the borders of Nevada and Arizona. And one of the reasons for that is that San Bernardino County is in that large black metro area, and San Bernardino County has about 20,000 square miles, an area larger than the state of Delaware.

In fact, it's about 10 times larger than the state of Delaware. And so, a metro area, when you get out in the eastern part of San Bernardino County, you're sort of out in Death Valley area, where there are very few people living. So again, by including the whole county, OMB is getting what isn't just rural but maybe considered frontier or practically unpopulated areas. And sorry about the map being divided in half, but that's how I found it. By 1980, every state had some metro area, even Alaska did. And as you notice, the metro areas have grown and are much larger and cover a lot more area of the United States, but still not the majority of the area. But even in 1980, there is far less. There's still far more non-metro area than there is metro area. I mentioned some ways that metro and non-metro are sort of counterintuitive, and one is that you can have commuting in reverse.

And this is from an article by Ken Jennings, who yes, is the host of Jeopardy! now, but he wrote about Kalawao, which is the smallest county in the United States by area. It's 12 square miles, it's part of Maui County in Hawaii, and Kalawao is partly parkland and partly a Hansen's disease colony, and it's extremely isolated. But Kalawao is part of a reverse commuting. People are leaving the urbanized core to go work in Kalawao, and that is pulling it into the metropolitan area. It's not that people leave Kalawao and commute into the city. And there are other examples of this, and one I know of is in Idaho, where a very sparsely populated county has a nuclear plant and people are leaving the urban core to go work out in the nuclear facility, and that is pulling the whole county into the urban core. So, I'm going to turn it over to Greta to take it from this point.

Greta Stuhlsatz: Thanks, Steve. Steve did a beautiful job of explaining the background and also what's happened in the past, and how we got to where we are today. So, I'm going to talk a little bit more about the more recent history and what we have going into 2020. With the 2020... I'm sorry, not going into 2020, we're past 2020, but moving on with the 2020 census numbers. So, with the 2020 census, there were three key changes to urban classifications, which in turn has an effect on rural classifications because as a reminder, as Steve said, generally everything that's not designated as urban is rural. It's not necessarily something that is defined more than it is excluded, and that's where we come in. So, the three changes are first, the census is no longer differentiating between urban clusters and urbanized areas. Instead, everything is going to be an urban area. And before, urban clusters were areas with at least 2,500 people and up to 49,999 people, and urbanized areas were urban areas with 50,000 or more people. So, now those are all clumped together into urban areas.

Second, housing unit density is incorporated to identify qualifying census blocks, qualifying as urban areas, rather than using population density as the primary indicator. And then third, the minimum threshold for qualification of an urban area is that the area has greater than or equal to 2,000 housing units or at least 5,000 persons. Now, these are the three big changes for 2020, but there's a description of all the changes and updates. There are a few other minor changes that don't have as big of an impact, and those are all available at the Federal Register notice that's linked on this slide. So now, as a reminder, Steve already showed you this map. This is what the map looked like in 2010, where there was a differentiation between urbanized areas, which are shown in purple or pink, and the urban clusters that are those little dots of green.

And then, this is the current map, where all of the urban areas are the same there. You can still see that the majority of land area in the United States is rural, and it does look very similar to just looking at the maps visually, the difference is that they're all being treated the same instead of showing the difference between urban clusters and urbanized areas. So, let's revisit the Office of Management and Budget, or OMB designations to see how things have changed over the years. This chart shows the change in counties and county equivalents and populations in the United States, and this doesn't include outlying territories. So, these numbers don't include Puerto Rico. And these show the numbers every 10 years since 1980. The data is based on metro and non-metro delineations developed by OMB, where metropolitan counties and county equivalents are metro counties, and then micropolitan and all other counties and county equivalents are in the non-metro category.

The population numbers show estimates from the census using the OMB delineations, and some patterns to note are the increase in metro counties, in contrast to the decrease in non-metro counties. The metro county population is also increasing, while non-metro population is decreasing. And there's many explanations to why these changes are happening. Steve explained some. Some of it has to do with people moving to urban areas away from rural areas. Some urban areas are more condensed and not as spread out into the suburbs as they may have been in the past. That's also happening opposite in some areas, there's more of the urban sprawl. And it's important to remember the impact of how we measure urban areas. So, there's some towns that haven't changed in population size at all, but may be reclassified based on the changing definition.

So again, Steve did an amazing job illustrating the history of the designations. And the next couple slides look from 1990 to today, this shows the 1990 OMB delineations based on the 1990 census. And the green areas are all metropolitan statistical areas and primary metropolitan statistical areas. But the different color gradients show the population size, where the darker the green, the greater the population is in that area. On this map, the green areas represent metropolitan and micropolitan statistical areas from the 2010 census, where the darker green is highlighting metropolitan statistical areas, and the lighter green is highlighting micropolitan statistical areas. And then, if we move to the next slide, we can see the 2020 delineations. This shows the most recent OMB delineations, where the dark blue represents metropolitan statistical areas and the teal or light blue shows micropolitan statistical areas. The beige is everything else.

In 2021, OMB proposed some changes to the minimum urban area population that would qualify to be classified as a metro statistical area. They wanted to change that minimum area or minimum population from 50,000 to 100,000. And the justification included that the minimum population requirement hadn't kept pace with the population growth. They were saying that, and this is true, the United States population has more than doubled since 1950. And so, with this change, areas with an urban area population of between 10,000 and 50,000 would continue to qualify as micropolitan, as they had in the past. But there are some metropolitan statistical areas between 50,000 and 100,000 that would also then be designated as micropolitan. OMB published a request for comment about these suggested changes. And they did indeed receive quite a few comments. There were over 700 comments submitted and the vast majority of them opposed the change.

Many of the comments noted concerns with programmatic consequences and concerns about the economic development in areas that would be reclassified as micropolitan, where they had been metropolitan. In response to the comments, as well as committee recommendations and additional reviews, OMB opted to not implement any substantial changes to the 2020 standards update. And again, as I said before, the additional information is available at that link on the slide with the whole list of the responses to the comments. And so, this is just to highlight that there is an impact on these changes and there is... while the OMB and census are very clear that the delineations that they identify are meant for statistical purposes, the public comments did illustrate that there was still concern that there would be programmatic consequences of those changes and they were very vocal about that.

So, on this slide, I just want to talk a little bit about moving beyond the Census and OMB delineations and sharing that rural means different things to different people, and it has varied implications depending on program and funding priorities. So, we've talked about the two main federal definitions, which are from the Census Bureau and the Office of Management and Budget. The Census Bureau defines urban areas as areas that represent densely developed territory. And then rural encompasses all population housing and territory not included within an urban area. OMB defines metro and micropolitan statistical areas that have a core area containing substantial population nucleus, and they don't...

The Federal Office of Rural Health policy then can take those definitions and use them to help define what makes sense for rural areas. So, these definitions might not meet the needs of individual programs, research or funding priorities. And indeed, they don't focus specifically on rural. So, alternatives do exist, and many of them build off the Census and OMB delineations. Most relevant to us as employees with the Federal Office of Rural Health Policy is the definition that comes from our office. This definition includes rural areas that are all non-metro areas. All non-metro counties are rural areas, and we use the OMB delineations of non-metro counties, and these include micropolitan statistical areas. And then, building on that, all census tracks with RUCA scores between four and 10 that are in metro counties. And I'll explain in a couple of slides what the RUCA scores are.

And then, adding on top of that, census tracks that are over 400 square miles, with fewer than 35 people per square mile and RUCA scores between two and three, that are in metro counties. And then again, building on that, all outlying metro counties with no urbanized area population. So, this map shows all the census tracks and counties that are eligible for FORHP funding. This map looks a little opposite of the rest of the maps we've looked at because we are highlighting rural areas, where most of the other maps you look at are highlighting the non-rural areas. And we share that the rest of the U.S. is rural.

So, you can see that rural seems to take up the land area, rural seems to take up most of the map. This shows a table of the census, OMB, and FORHP population numbers. And as you can see here, OMB has the most restrictive definition, with 46 million people in the rural areas. And FORHP has the most expansive. The Federal Office of Rural Health Policy has the most expansive definition, with 60.85 million people in that rural and non-metro area. And then the census falls in between there with 59.5 million. And I want to highlight that this is based on 2010 census data. There's the RUCA codes, that again I'll discuss in a minute, depend on a census commuting package that hasn't been released yet. So, once we get that data and the United States Department of Agriculture's Economic Research Services can update their RUCA codes, we can update our numbers to reflect 2020 census data.

The next few slides, I will go through a couple of other common coding schemes that can be used for identifying rural and urban areas. The first is what I keep teasing that I will talk about soon, the Rural Urban Commuting Area codes. And these RUCA codes were developed in combination with the Federal Office of Rural Health Policy and the U.S. Department of Agriculture's Economic Research Service. They are classified using U.S. Census tract and they use population density, urbanization, and daily commuting. These mirror theoretical concepts used by the Office of Management and Budget, but they're applied on a more granular level.

So, the Office of Management and Budget identifies counties. The RUCA codes are for census tracts. There's 10 primary codes and 21 secondary codes. These are the 10 primary codes that can be used to select a combination of codes to meet varying definitional needs. So, the Federal Office of Rural Health Policy uses codes four through 10 in their first level of the definition, and then also codes two and three when the area is in a large census tract that's over 400 square miles, with fewer than 35 people. There's also another method of measurement that again comes from the U.S. Department of Agriculture Economic Research Services, and this is the Frontier and Remote Area codes. And these are used to identify areas with a combination of low population size and high geographic remoteness. And these are by ZIP Code. So, you may notice a lot of these definitions use different types of geographies and those are aspects that you can use when trying to decide which method of measurement might be most useful, because if you only have ZIP Codes, FAR codes may be the most useful.

There are levels of FAR codes ranging from one to four, which can be used again, based on the needs of the person using the codes. So level one is a rural and urban area up to 50,000 people that are 60 minutes or more from an urban area of 50,000 or more people. And then down to level four, which gets a little bit more information, rural areas that are 15 minutes or more from an urban area of 2,500 to 9,999 people, 30 minutes or more from an urban area of 10,000 to about 25,000 people, 45 minutes or more from an urban area of 25,000 to 50,000 people, and 60 minutes or more from an urban area of 50,000 or more people. And on these next two slides, you can see the areas that are considered frontier and remote, and how they change based on the level used.

So, these first two maps highlight the most land area that's covered by the FAR codes, level one and level two. Level three and level four, since they're a little bit more restrictive, they contain less land area. A third delineation, also from the U.S. Department of Agriculture Economic Research Service considers Rural Urban Continuum Codes. And these are based on population size, and whether or not the county is adjacent to one or more metro areas. So, the metro counties are just based on population size of the metro area they're a part of. And then, the non-metro counties have two different aspects of their classification. They're divided into three urban-sized categories based on the urban population in the county, and then they're subdivided on whether or not that county is adjacent to one or more metro areas.

And this shows that in a little bit more detail with the exact codes. Metro is one through three, based on population size. And then, non-metro counties are four through nine, based on the urban population area and its adjacency to a metro area. And this map shows the metro counties, mostly in green, and the non-metro counties along the Rural Urban Continuum Code. Green areas have lower Rural Urban Continuum Code scores, while the red counties have the highest Rural Urban Continuum Code. And then, I'm going to go ahead and pass it off back to Steve for our next couple slides and to wrap up the presentation. Thank you.

Steve Hirsch: All right, so let's talk about how federal funding can follow these definitions. This is from a Brookings Institution report of a few years ago. “Over 400 programs are open to rural communities,” they said, and they divided up the funding streams by the department. So, USDA was by far the largest, and then Department of Transportation, and then HHS, but they identified $201 million. That's way under undercounting because they are not considering some of the CMS programs that have differential, I think reimbursement for rural areas. Now, beyond FORHP funding streams, our budget, I believe includes about $350 million. That's putting aside all the pandemic funding that came through during the pandemic, but the basic budget for our programs, including the grant programs is about $350 million. But much of the money for rural health funding, which is what I'm going to concentrate on, because that's the area that we know at best, goes through Medicare and Medicaid.

And so, much of it is directed to rural hospitals and the Centers for Medicare & Medicaid Services, rural generally means hospitals that are outside of a metro area, so non-metro hospitals, and that includes the micropolitan counties, they are classified as non-metro. Now, hospitals in metro areas can be reclassified as rural, and that means that hospitals that are on the usual Medicare payment system, the Prospective Payment System, can ask to be reclassified depending on these criteria that you can see on the screen. And it's led to some interesting recent, in the last few years, where there are some advantages to being classified as a rural hospital, including getting Indirect Medical Education Payments that are higher and being eligible for some pharmaceutical discounts through what's called the 340B Program, Critical Access Hospitals, which I hope most people on this call are familiar with, make up a large proportion of the hospitals in the United States.

These are small, rural hospitals. They can't have more than 25 inpatient beds, and generally they're in non-metro counties, or they can meet the FORHP definition or be designated by states as rural, but they usually must be a 35-mile drive from another hospital or a 15-mile drive by secondary roads or mountainous terrain, and they get increased reimbursement. About 10 years ago, the last time I saw MedPAC had estimated that this directed a funding stream of about $2 billion to the Critical Access Hospitals above what they would've received under the PPS payments if they had been PPS hospitals. Then there's also a sole community hospital designation. A few years ago, there were about 450 of those in the U.S. and it's based on hospitals' distance in relation to other hospitals and whether a facility is rural. And generally, again, that means non-metro hospitals. This is a new designation for hospitals, Rural Emergency Hospitals, that went into practice in January of this year. And there have been several hospitals that have already converted into Rural Emergency Hospitals, so they get a 5% increase on their outpatient department services to Medicare patients.

They are still providing emergency services, but they don't really have extended inpatient services available. Rural Health Clinics. Wow. There are about 4,000 certified Rural Health Clinics, which it is certified by CMS, so they are not just a clinic in a rural area. They have to be certified by CMS to receive differential payment under the designation. Now, one of the interesting or problematic things that happened because Census eliminated this distinction between urban clusters and urbanized areas, is that Census now only designates urban areas which run from a population of 5,000 up to 20 million, which means to me, and apologies to anybody from the Census Bureau on the line, that it's not a very useful distinction. If something goes from 5,000 people up to 20 million, it's not extremely effective.

Fortunately, CMS, earlier this or late last year issued an update that said that they will continue to designate Rural Health Clinics in areas that were considered urban clusters as of 2010, and those that are still considered rural based on the 2020 Census Bureau designation. So, that was a very good thing for CMS to do so because it doesn't simply mean that newly designated Rural Health Clinics can go into what used to be considered urban clusters. If a clinic built a new facility, they would have to be certified. And there was some question about whether they'd be able to do that, given the change in the way Census Bureau was designating urban areas in the elimination of urban clusters. There are more than this, but there are some other CMS funding streams. One is the Ambulance Fee Schedules that has a bonus payments for ambulances that pick up a patient in a rural ZIP Code.

Telehealth payments used to be based on geography, that was eliminated during the pandemic and it's still not in the... geographic requirements have not been reinstated yet. There's been a statutory suspension of the geographic limits, but that has a time limit. So, Congress may have to revisit it, but it used to be that non-metro counties were completely eligible within medical facilities to be an originating site for telehealth consultations. And then, if you were in a metro county, it had to be a census tract that FORHP designated as rural, but that also had to be in a shortage area. And then, there's the Section 340B that allows hospitals or participating healthcare organizations to get discounts on pharmaceuticals. And so, all of these are direct, as I mentioned, with the Critical Access Hospitals, and that was 10 years ago, it meant up to $2 billion a year.

So, it far exceeded the other kinds of funding streams that, for example, OHP has available with our grant programs for rural areas. So, if you want to learn more about HRSA, you can go to the HRSA site, but also will take you to the FORHP website and you can learn more about the grant programs there. And we have several grant programs that are open to public or to healthcare organizations that are looking for funding for new and creative projects. So, the Rural Health Outreach grants are a terrific opportunity. And the other opportunity I would say is to subscribe to RHIhub and their alerts on their weekly newsletters and their information about funding sources, because they're tremendously helpful.

And we are not implying that OHP or Department of Health and Human Services are the only funding sources for rural areas. Department of Transportation, but especially USDA has some. And some of those can be used for rural health projects. So, distance learning or community facility loans or grants can be used for healthcare facilities. So, you can also seek those out or ask our RHIhub for help to identify those. And so, thanks to Greta and Sarah Heppner. And now I think we can take questions if we have time and there are any questions.

Kristine Sande: So, starting with the first question that came through, do any of the panelists have an idea of if and when the OMB will update the CBSAs based on the new Census Bureau definition?

Steve Hirsch: Yes, they did it in July. So, the list of new micropolitan and metropolitan areas came out in July.

Kristine Sande: All right. And also, any idea when the RUCAs will be updated? So, when the RUCAs will be updated and when the commuting package will be released.

Steve Hirsch: It's looking like it will be next year, and that USDA won't be able to get the data from Census until next year. And so, we are hopeful that sometime in the fall next year we'll be able to have new RUCA codes. And the RUCA codes, by the way, for every census tract in the United States.

Kristine Sande: All right. Can you speak a bit about Medically Underserved Areas and how those areas connect or correlate to rural areas?

Steve Hirsch: Well, Medically Underserved Areas can be rural but are not necessarily rural, but rural areas are far more likely to be medically underserved or Health Professional Shortage Areas than urban areas are. Now, there are Medically Underserved Areas in urban areas, and there are Health Professional Shortage Areas that are urban, but if you're in a rural area, it's far more likely to not have a sufficient provider base for healthcare.

Kristine Sande: So, another question about when updated data will be available, when will the 2020 RUCC codes be published?

Steve Hirsch: I don't know. We don't know. USDA will be updating that, so I am not sure.

Kristine Sande: Is there a resource or Excel spreadsheet that lists the U.S. cities and states that are considered rural?

Steve Hirsch: On the Census Bureau website for metro areas, and they have pages devoted to metro and micro areas, and then another page for urban areas, you can download spreadsheets that include all the urban areas from the urban page, or all the metro areas and metro counties from the metro page. Anything that's not included on those are considered rural. Now, the Census Bureau urban areas, it's not as easy to tell because they don't follow the city lines the same way that OMB's designations. If it says a county is metro, the whole county is metro.

But for example, the urbanized areas of New Bern, North Carolina doesn't follow the New Bern city limits, it extends outside. And the same for Washington, DC or Chicago. The Urbanized Area can spread much further beyond the city limits and you can't tell just from looking at that. Census has a website called TIGERweb where you can map the Urbanized Areas. And actually, you can also use RHIhub's Am I Rural? to discover if your address or your area is considered rural or urban, based on a bunch of different definitions that will give you the FAR code, the RUCA code, and whether you're urbanized by the Census Bureau or part of a metro area.

Kristine Sande: Any idea when CMS might release a final guidance for RHC rural location requirements?

Steve Hirsch: I'm not aware of when they will do that, but I was very encouraged by the way they chose to deal with the change in Urban Areas and Urban Clusters.

Kristine Sande: Yes, it was nice to get that interim guidance, for sure. Is the ambulance rural bonus that you mentioned, the schedule, is the ambulance rural bonus fee schedule automatic or does a hospital need to sign up for that?

Steve Hirsch: As far as I understand, it's automatic. If an ambulance company files for a Medicare payment for a patient they picked up, they would put in the ZIP Code location where they picked up the patient. And my understanding is that it would be an automatic increase in payment based on the ZIP code. Somebody else may know different.

Kristine Sande: All right. One other question. Is anyone looking at commuting codes in rural definitions and the impact of teleworking from home?

Steve Hirsch: That is a great question and it has greatly concerned me, I think, and other people, is that the census took place in spring of 2020 during the height of the initial outbreak of the pandemic. And so, lots of people were working from home that didn't usually work from home. And I do not know how Census is handling that, or even how OMB decided to use commuting data. So, I believe that they're using a running American Community Survey data on commuting so that it didn't just include what happened on the date of the 2020 census when data was gathered then, but includes a longer period of time. So, that may flatten out some of the effect of the pandemic.

Kristine Sande: All right, thank you. And it looks like there are a couple of questions about Health Professional Shortage Areas and who to talk to with questions about that or where to go for information about HPSAs. Can you help with that question?

Steve Hirsch: Well, yeah. HPSAs are done within the Health Resources and Services Administration by the Shortage Designation Branch. But there are also primary care offices in every state and they work with HRSA and the Shortage Designation Branch to do the HPSA scoring. And so, if you can, you can search for a primary care office in your state and look for the phone number for the primary care office in your state and begin by talking to them. And yeah, I see Kathleen McElligott made the same point, talk to your PCO, your primary care office in your state if you're concerned about losing a HPSA designation and want to find out why that happened, or anything else to do with HPSAs.

Kristine Sande: Thank you so much to our speakers today for sharing some really great information. And thanks to all of you for joining us today. The slides used in today's webinar are available on the website in the webinars section. And in addition, a recording and a transcript of the webinar will be made available on the website, and we'll also send those out to you by email so that you can share that information with others or watch again. And so, we thank you for joining us, and have a great day.