[Federal Register Volume 85, Number 185 (Wednesday, September 23, 2020)]
[Notices]
[Pages 59806-59809]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2020-20971]


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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Health Resources and Services Administration


Revised Geographic Eligibility for Federal Office of Rural Health 
Policy Grants

AGENCY: Health Resources and Services Administration (HRSA), Department 
of Health and Human Services.

ACTION: Request for public comment.

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SUMMARY: HRSA's Federal Office of Rural Health Policy (FORHP) has 
sought to identify clear, consistent, and data-driven methods of 
defining rural areas in the United States. FORHP uses the Office of 
Management and Budget (OMB)'s list of counties designated as part of a 
Metropolitan Statistical Area (MSA) as the basis for determining 
eligibility to apply for or receive services funded by its rural health 
grant programs. FORHP designates all counties that are not part of a 
MSA as ``rural'' and eligible for rural health grant funding or 
services. In addition, FORHP designates census tracts within MSAs as 
rural for grant purposes using Rural-Urban Commuting Area (RUCA) codes. 
FORHP is proposing modifications to how it designates areas to be 
eligible for its rural health grant programs so that community 
organizations serving rural populations within MSAs will be able to 
apply for resources and allow more of the rural populations within MSAs 
to access services provided using grant funds. This notice seeks 
comments on the proposed methodology for designating areas eligible for 
rural health grant programs.

DATES: Submit written comments no later than October 23, 2020.

ADDRESSES: Written comments should be submitted to 
[email protected].

FOR FURTHER INFORMATION CONTACT: Steve Hirsch, Public Health Analyst 
FORHP, HRSA, 5600 Fishers Lane, Rockville, MD 20857, Phone number: 
(301) 443-0835 or Email: [email protected].

SUPPLEMENTARY INFORMATION: FORHP was authorized by Congress in the 
Omnibus Budget Reconciliation Act of 1987, Public Law 100-203, codified 
at 42 U.S.C. 912, and located in HRSA. Congress charged FORHP with 
informing and advising the Department of Health and Human Services on 
matters affecting rural hospitals and health care and coordinating 
activities within the Department that relate to rural health care. 
Since the 1990s, FORHP has also issued grants for programs of 
innovative models of health care delivery in rural areas. Historically, 
applicant organizations for these grants, authorized under Section 330A 
of the Public Health Service Act, were required to be located in rural 
areas. However, when the programs were recently reauthorized under 
Section 4214 of the Coronavirus Aid, Relief, and Economic Security Act 
the requirement was amended to allow organizations to apply that are 
located in urban areas but serve rural areas.
    Historically, there have been two principal definitions of 
``rural'' that were in use by the Federal Government: the Census Bureau 
definition (https://www.census.gov/programs-surveys/geography/guidance/geo-areas/urban-rural.html) and the OMB definition (https://www.census.gov/programs-surveys/metro-micro.html). Neither definition 
defined ``rural'' directly, but rather defined ``urban'' areas and then 
designated locations that do not meet the ``urban'' definition as 
``rural.''
    In the early 1990s, the Census Bureau defined ``rural'' as all 
areas that were not part of an urbanized area (UA) or were not part of 
an incorporated area of at least 2,500 persons. UAs were defined as 
densely settled areas with a total population of at least 50,000 
people. The building block of UAs is the census block, a sub-unit of 
census tracts. The Census Bureau introduced the urban cluster (UC) 
concept for the 2000 Census. UCs are defined based on the same criteria 
as UAs, but represent areas containing at least 2,500 but fewer than 
50,000 people. Both UAs and UCs use 500 persons per square mile as 
their minimum density criterion.
    The other major federal definition was based on the OMB's list of 
counties that are designated as part of a MSA. All counties that were 
not designated as a part of a MSA were considered ``rural'' or, more 
accurately, non-metropolitan. MSAs, in 1990, had to include ``a city of 
50,000 or more population,'' or ``a Census Bureau defined urbanized 
area of at least 50,000 population, provided that the component county/
counties of the MSA have a total population of at least 100,000.'' At 
that time, around three quarters of all counties in the United States 
were non-metropolitan and not classified as parts of MSAs.
    After the 2000 Census, OMB also began to classify counties using a 
smaller urban core. The concept of a Micropolitan statistical area 
closely parallels that of the MSA, but a Micropolitan statistical area 
is based on an urban core with a population of 10,000 through 49,999 
and Micropolitan counties are still considered non-metropolitan.
    As currently classified, OMB builds both MSAs and Micropolitan 
Statistical Areas around a central county, or counties, which contains 
an urban core. Surrounding counties can be designated as part of the 
Core Based Statistical Area (CBSA) based on the presence of core 
population and/or the commuting patterns of the working population. A 
county may be included in only one CBSA.
    A county qualifies as a central county of a CBSA if it meets the 
following requirements:
    (a) Has at least 50 percent of the population in urban areas of at 
least 10,000 population; or
    (b) Has within the boundaries a population of at least 5,000 
located in a single urban area of at least 10,000 population.
    Since urban areas are not defined by administrative boundaries, 
such as city limits or county borders, they can extend into one or more 
counties as long as the population density criterion (a minimum of 500 
people per square mile) is met.
    A county qualifies as an outlying county of a CBSA if it meets the 
following commuting requirements:
    (a) At least 25 percent of the workers living in the county work in 
the central county or counties of the CBSA; or
    (b) At least 25 percent of the employment in the county is 
accounted

[[Page 59807]]

for by workers who reside in the central county or counties of the 
CBSA.
    Outlying counties are not required to include any UA or UC 
population. In some cases, counties may be considered outlying because 
of reverse commuting into the county from other counties in the MSA.
    Because Micropolitan counties are not included in MSAs, they are 
included in the set of non-metropolitan counties along with counties 
that are not part of any CBSA.
    There are measurement challenges with both the Census and OMB 
definitions. Some policy experts note that the Census definition 
classifies quite a bit of suburban area as rural. The OMB definition 
includes rural areas in MSA counties including, for example, the Grand 
Canyon which is located in a MSA county. Consequently, one could argue 
that the Census Bureau standard includes an over count of the rural 
population whereas the OMB standard represents an undercount. To 
address these concerns and find a middle ground between the two 
definitions, FORHP funded the development of Rural-Urban Commuting Area 
Codes (RUCAs) (https://www.ers.usda.gov/data-products/rural-urban-commuting-area-codes/) in partnership with the Economic Research 
Service (ERS) of the Department of Agriculture. FORHP believes RUCAs 
allow more accurate targeting of resources intended for the rural 
population. Both FORHP and the Centers for Medicare & Medicaid Services 
(CMS) have used RUCAs to determine programmatic eligibility for rural 
areas inside of MSAs, identified as rural census tracts within these 
MSA counties.
    RUCA codes classify census tracts using measures of population 
density, urbanization, and daily commuting. RUCA codes are based on the 
same theoretical concepts used by the OMB to define county-level 
Metropolitan and Micropolitan areas. By using the smaller census tract 
unit instead of the county, RUCAs permit a finer delineation of 
``rural'' and ``urban'' areas to reflect the experience of residents. 
Using data from the Census Bureau, every census tract in the United 
States is assigned a RUCA code. Currently, there are ten primary RUCA 
codes with 21 secondary codes (see Table 1).

                    Table 1--Primary RUCA Codes, 2010
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           Code classification                      Description
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1.......................................  Metropolitan area core:
                                           Primary flow within an
                                           urbanized area (UA).
2.......................................  Metropolitan area high
                                           commuting: Primary flow 30%
                                           or more to a UA.
3.......................................  Metropolitan area low
                                           commuting: Primary flow 10%
                                           to 30% to a UA.
4.......................................  Micropolitan area core:
                                           Primary flow within an urban
                                           cluster of 10,000 to 49,999
                                           (large UC).
5.......................................  Micropolitan high commuting:
                                           Primary flow 30% or more to a
                                           large UC.
6.......................................  Micropolitan low commuting:
                                           Primary flow 10% to 30% to a
                                           large UC.
7.......................................  Small town core: Primary flow
                                           within an urban cluster of
                                           2,500 to 9,999 (small UC).
8.......................................  Small town high commuting:
                                           Primary flow 30% or more to a
                                           small UC.
9.......................................  Small town low commuting:
                                           Primary flow 10% to 30% to a
                                           small UC.
10......................................  Rural areas: Primary flow to a
                                           tract outside a UA or UC.
99......................................  Not coded: Census tract has
                                           zero population and no rural-
                                           urban identifier information.
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Current FORHP Definition of Rural

    In addition to all areas of non-metro counties, specific census 
tracts in Metropolitan counties are considered rural and eligible for 
grant funding or to receive services under FORHP grant funding. These 
include census tracts inside MSAs with RUCA codes 4-10 and 132 large 
area census tracts with RUCA codes 2 and 3 that FORHP has designated as 
rural. The 132 MSA tracts with RUCA codes 2-3 are at least 400 square 
miles in area with a population density of no more than 35 people per 
square mile.
    Following the 2010 Census, the FORHP definition included 
approximately 57 million people, or about 18 percent of the population 
and 84 percent of the area of the United States. More information about 
the current FORHP definition of rural is located on the HRSA website 
(https://www.hrsa.gov/rural-health/about-us/definition/index.html) and 
information on whether counties or individual addresses qualify as 
rural can be identified in a search tool at the HRSA Data Warehouse 
(https://data.hrsa.gov/tools/rural-health).

Why We Propose Modifying FORHP's Rural Definition

    The goal of FORHP is to increase access to care for underserved 
populations and build health care capacity in rural areas. To support 
that goal, we must ensure that there are clear, consistent, and data-
driven methods of defining rural areas in the United States. Further, 
FORHP must ensure that the rural definition used to determine 
eligibility to apply for or receive services under FORHP's rural health 
grant programs accurately identifies rural communities. FORHP believes 
that the combination of non-metropolitan counties with the set of 
``rural'' census tracts within MSAs has allowed FORHP to correctly 
classify much of the rural population in the country as eligible for 
rural health grants. However, since the 2010 Census we have received 
feedback from rural stakeholders expressing concern that some areas 
with rural character in MSAs are not being identified through the 
current methodology.
    FORHP believes that the increasing concentration of job growth in 
MSAs and changes in how OMB designates outlying counties as part of 
MSAs have led to growth in the number of MSA counties that either have 
no population in either UCs or UAs or that have no population in a UA 
but do have UC population.
    Both the designation of outlying counties in MSAs and the 
classification of RUCA codes in census tracts are dependent on 
commuting data and therefore the location of jobs. During the 
recession, employment losses in non-metropolitan counties began earlier 
and were deeper than losses in MSA counties. While job growth in MSAs 
and non-metropolitan counties were initially similar, in the long term 
employment in non-metropolitan areas remained below the level where it 
had been before the recession. According to ERS, ``Between 2010 and 
2018, non-metropolitan employment grew at an average annual rate of 0.4 
percent, compared to 1.5 percent per year in MSAs. By the second 
quarter of 2019, non-metropolitan employment remained more than 1 
percent below the pre-recession level, while MSA employment exceeded 
the pre-recession level by more than 9 percent.'' In the years since 
the recession, job growth has been concentrated not just in MSAs, but 
in

[[Page 59808]]

the largest MSAs. According to a McKinsey Global Institute report from 
2019, ``Just 25 cities (megacities and high-growth hubs, plus their 
urban peripheries) have accounted for more than two-thirds of job 
growth in the last decade . . . By contrast, trailing cities have had 
virtually no job growth for a decade--and the counties of Americana and 
distressed Americana have 360,000 fewer jobs in 2017 than they did in 
2007.''
    Starting with the 2000 Census, OMB eliminated the use of measures 
of settlement structure, such as population density and percent of 
population that is urban, as criteria for inclusion of outlying 
counties as part of an MSA. Instead, commuting became the sole deciding 
factor as long as
    (a) at least 25 percent of the employed residents of the county 
work in the CBSA's central county or counties, or
    (b) at least 25 percent of the jobs in the potential outlying 
county are accounted for by workers who reside in the CBSA's central 
county or counties.
    After the 2000 Census, the number of outlying MSA counties with no 
urban population quadrupled from 24 in the 1993 OMB listing to 96 in 
the 2003 listing. After the 2010 Census, there were 97 MSA outlying 
counties with no urban population.
    For counties with no urban population, some stakeholders have 
raised the concern that commuting patterns may not reflect suburbs and 
urban amenities spreading outward from an urban area into rural areas. 
Instead, a lack of job opportunities in the rural area is causing 
workers to commute into an urban area from a rural area. This increased 
commuting does not represent an increase in access to services for 
rural residents but can instead represent a local economic decline. As 
OMB states, ``For instance, programs that seek to strengthen rural 
economies by focusing solely on counties located outside metropolitan 
statistical areas could ignore a predominantly rural county that is 
included in a metropolitan statistical area because a high percentage 
of the county's residents commute to urban centers for work.''

Comparing Rural and Urban Counties

    The data presented in Table 2 shows that outlying MSA counties 
which have no UA population are more similar to non-metropolitan 
counties than they are to central MSA counties. Table 2 displays 
characteristics of the mean population and land area for counties in 
the United States (excluding Alaska and Puerto Rico). The average MSA 
county has a large population, over 200,000 people, most of whom live 
in UAs (84 percent of the total) with another 4 percent in UCs. Only 12 
percent of the average MSA county population is rural as defined by the 
Census Bureau. The average non-metropolitan county has only 
approximately 10 percent of the population of the average MSA county, 
with the majority of people (59 percent) living in Census defined rural 
areas.
    When looking at central MSA counties compared to the outlying MSA 
counties, there are large differences between the two. The average 
central county's population is seven times larger than the average 
outlying county and almost half the outlying county's population is in 
Census defined rural areas compared to just under 10 percent of the 
average central county's population. Even more striking, comparing 
outlying MSA counties that have no UA population at all or that have no 
UA or UC population at all shows that these MSA counties without 
densely settled areas are much more similar to non-metropolitan 
counties than they are to central MSA counties.
    In population totals, density, and the proportion of the population 
living outside Census defined UAs and UCs, the outlying MSA counties 
with no UA population most closely resemble Micropolitan counties. The 
outlying counties with no UA or UC population at all, which do not 
include any town of even 2,500 residents, resemble the non-CBSA 
counties.

                                                    Table 2--Counties by Urbanization and Density \1\
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                                                                                                                                       Pop.
                                  County   Number of    Urban     Urban                                           Census             density   Land area
     County classification         pop.     counties     pop.      (%)     UA pop.     % UA   UC pop.    % UC     rural    % Rural   per sq.     in sq.
                                                                                                                   pop.                mile      miles
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Metro.........................    224,809      1,166    197,393       88    188,132       84    9,262        4     27,416       12        276        813
Metro Central.................    331,742        728    300,832       91    291,341       88    9,491        3     30,910        9        367        929
Metro Outlying................     47,077        438     25,468       54     16,588       35    8,880       19     21,609       46         76        621
Metro Outlying w/No Urbanized      23,185        286      6,969       46          0        0    6,969       46     16,216       54         36        650
 Area \2\.....................
Metro Outlying w/No Urban          10,880         97          0        0          0        0        0        0     10,880      100         17        624
 Population...................
Nonmetro......................     23,341      1,946      9,468    40.60        125     0.50    9,344    40.00     13,872       59         23      1,034
Micropolitan..................     42,004        654     21,576    51.40        350     0.80   21,226    50.50     20,428       48         39      1,074
Neither.......................     14,255      1,292      3,486    24.50         12     0.10    3,474    24.40     10,769    75.50         14      1,013
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Proposed Methodology To Determine Eligibility for Rural Health Grants
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    \1\ This table excludes counties in Alaska and Puerto Rico. 
Alaskan boroughs (county equivalents) are much larger than counties 
in other states. One Alaskan borough would qualify as Metro Outlying 
with No Urbanized Area.
    \2\ The two bolded, italicized rows represent the counties that 
would become eligible in their entirety for Rural Health grants 
after this notice. The number of counties with no UA includes the 
counties that have no Urban population.
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    FORHP proposes to modify its existing rural definition by adding 
outlying MSA counties with no UA population to its list of areas 
eligible to apply for or receive services funded by FORHP's rural 
health grants. Compared to the current definition, this modification 
would have the following impacts. The current set of eligible non-
metropolitan counties and rural census tracts within metropolitan 
counties would still be eligible. Additional counties would gain 
eligibility for rural health grants.
    Using OMB's April 2018 update of MSAs and the 2010 Census data on 
urban population by counties, there are 287 counties (286 reflected in 
Table 2 plus one county equivalent in Alaska) that are outlying 
counties in an MSA that have no UA population. Out of those counties, 
97 had no UA or UC population at all. Many of the 287 counties (201) 
are already partially or fully eligible for Rural Health grants because 
they contain eligible census tracts. However, 86 previously ineligible 
counties would become fully eligible. These 86 counties include 42 
outlying MSA counties that have no UA or UC population at all. Lists of 
the counties that will be designated as rural if this proposal is 
adopted are available at https://www.hrsa.gov/rural-health/about-us/definition/datafiles.html.
    It is also important to note that there is no single definitive 
source for assigning rurality to a particular geographic area 
3 4 Rural definitions are

[[Page 59809]]

highly context dependent and while definitions of rurality may take 
into account a range of characteristics (e.g., population density, 
commuting distance, land use, etc.), rural definitions do not reflect 
any single, inherent geographic attribute.\5\ FORHP's proposal to 
modify our eligibility criteria to apply for or receive services funded 
by FORHP's rural health grants reflects our efforts to be responsive to 
stakeholder feedback and best target our programs towards the intended 
communities. This does not eliminate the fact that other rural 
definitions may be set by statute or regulation or the fact that other 
programs established outside of FORHP's 330A authorization may need to 
use a different definition of rural to meet program goals. No single 
definition of rural is perfect or advisable given the geographic 
variation that exists nationally and the varying needs of rural 
programs.
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    \3\ U.S. Census Bureau. 2019. Understanding and Using American 
Community Survey Data: What Users of Data for Rural Areas Need to 
Know. Available from: https://www.census.gov/programs-surveys/acs/guidance/handbooks/rural.html. Accessed December 20, 2019.
    \4\ U.S. Department of Agriculture, Economic Research Service. 
What is Rural? Available from: https://www.ers.usda.gov/topics/rural-economy-population/rural-classifications/what-is-rural.aspx. 
Accessed December 20, 2019.
    \5\ For a deeper discussion of this topic, please see: (a) 
National Academies of Sciences, Engineering, and Medicine 2016. 
Rationalizing Rural Area Classifications for the Economic Research 
Service: A Workshop Summary. Washington, DC: The National Academies 
Press. Accessed December 20, 2019. Available from: https://doi.org/10.17226/21843; and (b) Ratcliffe M, Burd C, Holder K, and Fields A, 
``Defining Rural at the U.S. Census Bureau,'' ACSGEO-1, U.S. Census 
Bureau, Washington, DC, 2016. Available from: https://www.census.gov/content/dam/Census/library/publications/2016/acs/acsgeo-1.pdf.
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Request for Public Comment

    FORHP is proposing to modify the rural definition it uses to 
determine geographic areas eligible to apply for or receive services 
funded by FORHP's rural health grants and requests comments from the 
public on the proposed methodology described above.
    This request for comments is issued solely for information and 
planning purposes; it does not constitute a Request for Proposal, 
applications, proposal abstracts, or quotations. This request does not 
commit the Government to contract for any supplies or services or make 
a grant or cooperative agreement award or take any other official 
action. Further, HRSA is not seeking proposals through this Request for 
Information and will not accept unsolicited proposals.
    HRSA is not obligated to summarize or publish a response to 
feedback received, or to respond to questions about the policy issues 
raised in this request. Responders are advised that the United States 
Government will not pay for any information or administrative costs 
incurred in response to this request; all costs associated with 
responding to this request will be solely at the interested party's 
expense.

List of References

Urban Area Criteria for Census 2000. Federal Register, Vol. 67, No. 
51. March 15, 2002 https://www.federalregister.gov/documents/2002/03/15/02-6186/urban-area-criteria-for-census-2000.
Rural Employment Trends in Recession and Recovery. Economic Research 
Report Number 172, August 2014. https://www.ers.usda.gov/webdocs/publications/45258/48731_err172.pdf?v=0.
Rural America at a Glance, 2019 Edition. https://www.ers.usda.gov/webdocs/publications/95341/eib-212.pdf?v=3322.
The future of work in America: People and places, today and 
tomorrow. McKinsey Global Institute. July 2019. https://www.mckinsey.com/featured-insights/future-of-work/the-future-of-work-in-america-people-and-places-today-and-tomorrow#.
Standards for Defining Metropolitan and Micropolitan Statistical 
Areas. Federal Register/Vol. 65, No. 249/December 27, 2000. 82228-
82238 https://www.bls.gov/lau/frn249.pdf.
2010 Standards for Delineating Metropolitan and Micropolitan 
Statistical Areas; Notice. Federal Register/Vol. 75, No. 123, June 
28, 2010. 37246-37252. https://www.govinfo.gov/content/pkg/FR-2010-06-28/pdf/2010-15605.pdf.

Thomas J. Engels,
Administrator.
[FR Doc. 2020-20971 Filed 9-22-20; 8:45 am]
BILLING CODE 4165-15-P