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Setup Instructions

ONE DEPARTMENT

SERVING RURAL AMERICA

HHS Rural Task Force

Report to the Secretary

July 2002

Contents

Executive Summary

Section 1: Introduction

Secretary Thompson's Challenge to the Task Force

Rural America in 2001: Challenges and Opportunities

Section 2: Rural Task Force Findings

One Department, Serving Rural Communities:

Overview of the Federal Role

Barriers to Serving Rural Communities

Research and Policy­Making Efforts

Section 3: Task Force Goals, Strategies and

Recommendations

Public Comment to Inform the Task Force

Cross­Cutting Recommendations:

One Department, Serving Rural America

Section 4: Implications for Administration­Wide Activity

Other Administration Initiatives

Notes

Executive Summary

On July 25, 2001, Secretary of Health and Human Services Tommy G.

Thompson charged all HHS agencies and staff offices to examine

ways to improve and enhance health care and human services for

rural Americans. As the former governor of a predominantly rural

State, Secretary Thompson recognizes the unique characteristics and

needs of rural America and the important role HHS plays in ensuring
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healthy rural communities.

There are 65 million Americans who live in rural areas. Health care

and social service programs in rural communities provide needed

support of communities' well­being and represent a significant segment

of local economies. Health care can represent up to 20 percent of a

community's employment and income. In some lower income

communities, federal support may account for as much as 50 percent

of income in the community through funding for social and health

services. These same programs, however, experience difficulties

related to inadequate funds, personnel and support networks.

These challenges may compromise the effectiveness of service to

rural residents. The loss or reduction of these services may adversely

affect entire communities which suffer greater poverty, poorer health

and less solvent economies. Ensuring the health and welfare of rural

Americans is an essential part of a national policy that promotes the

self­sufficiency of all Americans.

HHS Rural Task Force

In response to the Secretary's charge, HHS created a Rural Task

Force to bring together representatives from each of the HHS agencies

and staff offices. While members represented their respective

agencies, the work of the Task Force was a unified effort and

represented diverse perspectives as well as the central goals of HHS.

Task Force members examined current program investment,

regulatory policy and barriers to providing services, and developed

strategies to improve HHS services in rural communities.

Recognizing the value of input from people living in rural communities,

the Task Force invited public comment through a notice in the Federal

Register published in August 2001. The Task Force encouraged

people at the local, State, and Tribal level to share their thoughts about

how the Department can better serve rural communities. More than

450 individuals and organizations shared their insight and experience.

Comments ranged from people simply offering thanks to Secretary

Thompson for his focus on rural services to technical comments about

the impact of particular HHS health care financing regulations on small

rural providers. Highlights from these public comments are featured

throughout this report.

The Rural Task Force found that while there are statutory, regulatory

and resource­related barriers that impede HHS' work in rural

communities, there are also innovative strategies, both immediate and

long­term, that the Department can implement to better serve rural

communities.

Three Important Findings

The Rural Task Force's efforts resulted in three important findings:

HHS lacks a common definition of "rural" or set of definitions that

are used by all agencies and staff offices and that accounts for

the gradient between metropolitan and rural areas. As a result, it

is difficult to target grants, evaluate services, develop policy and

quantify HHS' investment in rural and frontier communities.

More than 225 HHS programs currently serve rural communities.

Despite the breadth of support, rural communities struggle to
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access resources because individual programs have unique

application, implementation and evaluation requirements. This

lack of coordination in HHS is amplified at the State and local

levels.

The HHS policy development process does not consistently

consider rural concerns. As a result, HHS policy decisions may

have negative consequences for rural areas or fail to capitalize

on opportunities to improve rural health and social services.

Recommendations to Improve Rural Health and Social Services

Coordination

The Rural Task Force identified several actions that could improve the

way that HHS manages rural policy development and services

delivery. These actions have the potential to better integrate HHS' rural

efforts and create "One Department, Serving Rural America."

Create a formal structure within HHS with responsibility for

coordinating rural policy initiatives among HHS agencies and

staff divisions, as well as with external partners.

Based on the work of this Rural Task Force, create an

interagency workgroup that follows up on the proposed

strategies. This workgroup would meet quarterly with the

Secretary, or the Deputy Secretary, and report on HHS' progress

towards achieving the goals proposed by the Task Force. It

would update this plan periodically.

Ensure that the annual HHS budget development, legislative and

Government Performance and Results Act (GPRA) processes

include a specific focus or crosscutting discussion about serving

rural America.

Develop a common methodology for determining HHS'

investment in specific communities and populations.

Five Task Force Goals

The Rural Task Force set five goals to improve key areas of the

provision of health care and human services in rural areas and

developed strategies and activities for each goal area. The goals are:

Goal 1: Improving rural communities' access to quality health and

human services.

Goal 2: Strengthening rural families.

Goal 3: Strengthening rural communities and supporting

economic development.

Goal 4: Partnering with State, local and Tribal governments to

support rural communities.

Goal 5: Supporting rural policy and decision­making and

ensuring a rural voice in the consultative process.

These goals were intended to broadly capture most of the

Department's rural programs and policy­making efforts. Each agency

and staff office was asked to develop a plan addressing these five

goals. Five goal workgroups used these as a basis for developing an

HHS­wide plan and making recommendations to the Secretary.

HHS Rural Task Force Report
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This report describes the current health and social services challenges

facing rural America, outlines HHS components whose programs

currently serve rural and frontier communities, discusses the barriers

that Task Force members identified, shares the common themes from

the 450 public comments and details a number of strategies for

improving health care and human services in rural communities.

The Rural Task Force drew from the experiences of rural leaders,

existing literature and from the lessons shared through the public

comments to frame the discussion under the "Rural America in 2001:

Challenges and Opportunities." The strategies presented in this report

represent a broad range of actions that could be taken. The next step

in this effort will be to review these strategies and establish priorities.

HHS' action on these suggestions can make an important and

discernible difference in the lives of rural Americans. This report is a

first step towards achieving this goal.

Secretary Thompson's Challenge to

the Task Force

For the 65 million people living in rural America

(1)

, the US

Department of Health and Human Services' (HHS) mission to protect

health and to provide help to those who need assistance is especially

relevant. Health care and social service programs in rural communities

provide needed support of communities' well­being and represent a

significant segment of the local economies. These programs, however,

frequently lack adequate funds, personnel and support networks.

Public health financing programs such as Medicare, Medicaid and the

State Children's Health Insurance Program (SCHIP) and social welfare

programs such as Temporary Assistance for Needy Families (TANF),

child care and child welfare also play a key role in rural communities,

yet many rural service providers perceive that they work under

regulations designed specifically for urban and suburban providers.

This challenge may compromise the effectiveness and availability of

service to rural residents. Concurrently, the loss or reduction of these

services adversely affects entire communities who suffer greater

poverty, poorer health and weaker economies.

On July 25, 2001, recognizing the unique characteristics and needs of

rural communities and the relevance of HHS' mission to these

communities, the Secretary of Health and Human Services, Tommy G.

Thompson, issued a charge to all HHS divisions to improve and

enhance the provision of health care and social services to rural

Americans.

"As former governors of States with large rural

populations, President Bush and I know how important

it is for people outside of urban centers to have access

to quality health care and social services. We have

carried that understanding to the White House and

HHS."

Secretary Tommy Thompson

The HHS Rural Task Force was created under the leadership of the
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Health Resources and Services Administration's Office of Rural Health

Policy and the Department's Office of Intergovernmental Affairs. The

Rural Task Force brought together representatives from each of the

HHS agencies and staff offices. Task Force members contributed

specialized expertise about how their programs serve rural areas. With

these unique perspectives, members examined program investment

and regulatory policy in rural America as well as barriers to providing

services. In addition, the Task Force asked for public input through a

notice in the Federal Register. This report to the Secretary is the result

of a multi­faceted analysis of all HHS programs and public comments.

Highlights from these public comments are featured throughout this

report.

The Task Force focused on improving five key areas: access to

services; the strength of rural families; rural economic development;

relationships with State, local and Tribal governments; and policy and

research to inform decision­makers concerning rural communities.

Rural America in 2001: Challenges

and Opportunities

Rural America today is significantly different from rural America in the

mid­twentieth century or even rural America of the 1980's. It is also

very different from the stereotypes that still characterize America's

perceptions of its rural areas. These differences create formidable

challenges for federal government agencies, programs and policy

makers. Consideration of these differences, as well as important

distinctions between rural and urban/suburban areas, is essential for

understanding and improving health and social service programs in

rural America.

Demographics

Significant and uneven rural population shifts have occurred

throughout the last decade. The 1990 Census indicated that 61 million

people lived in rural America. Projections for the year 2000 estimate

that an increase of 3.9 million people occurred over the last 10 years in

rural areas. Data collected by the USDA Economic Research Service

show that 70 percent of rural counties grew in population from 1990 to

1999; in this same time period, 2.2 million more Americans moved

from the city to the country than from the country to the city.

However, much of the rural population growth was largely

concentrated in only 40 percent of rural counties. In addition, the

number of rural counties with decreasing population rose from 600 in

1990­1995 to 855 in 1995­1999. Mining and farming dependent

counties had the greatest relative fall off in population growth rates.

Significant rural population declines continue in the Great Plains, the

Appalachian coalfields and other areas where job losses in mining and

farming persist.

(2)

Population shifts throughout the last decade have included changes in

many communities' racial and ethnic makeup. Many growing rural

counties are experiencing concurrent growth in the diversity of

residents. One source of increasing diversity is the change in

immigration patterns in response to employment opportunities in rural
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areas. Many immigrants, especially Hispanic and Asian immigrants,

are increasingly settling in the rural US. As with other characteristics,

each region within the US has distinct patterns of racial and ethnic

makeup. In general, non­metropolitan immigrants are concentrated in

the Western and Southern US.

(3)

"As a member of the Rural Caucus of the Texas

Legislature, you can be assured that I am well aware of

the problems and challenges of the rural areas of this

great state. I applaud your efforts to identify and

eliminate the regulatory barriers that hinder the efficient

delivery of programs to rural areas." ­ Member of the

Texas Legislature

In the South, non­Hispanic Black Americans accounted for more than

18 percent of the population in the most rural counties in 1998. In the

West, American Indians and Alaska Natives constituted nine percent of

the population and people of Hispanic origin constituted 11 percent in

the most rural counties.

(4) (5) "Rural minorities often live in distinct

communities where poverty is high, opportunity is low, and the

economic benefits derived from more education and training are

limited."

(6)

The age distribution of rural communities' residents is also important

for understanding the demography of these communities. In general,

rural areas have a higher proportion of elderly residents. This trend is

most dramatic in the South and Midwest

(4)

. From the perspective of

HHS, this is significant in that the elderly use more health services

than the non­elderly and use a significant proportion of social services.

This contributes to a trend in which rural health care systems are

increasingly dependent on Medicare as a primary funding source.

Exacerbating the age differences between rural and metropolitan

areas is that many of the youngest and most highly educated people

are moving away from rural areas.

(7)

Economics

The economies of rural communities have profoundly changed in the

last fifty years. Most importantly, rural areas' economies are not onedimensional, characterized only by agricultural activity. Rather,

agriculture is a small segment of rural economies, accounting for only

7.6 percent of rural employment.

(7) Rural communities also experience

challenges in remaining economically competitive. These challenges

include the inability to attract new investments, significant numbers of

working poor and difficulty in achieving economies of scale in

delivering health care, social services, education and training.

(8)

In

addition, the "rural digital divide" continues to compromise educational,

social service and economic opportunities. While some States have

created Statewide infrastructures that enhance access to technology,

many rural areas lack access to many of the communication and

information technologies that urban and suburban areas have. For

example, Internet access is not readily available in many rural areas.

This inaccessibility has negative implications for an information

technology­based "new economy" in rural areas.

Rural workers are nearly twice as likely as urban and suburban

workers to earn the minimum wage. Rural workers also remain more
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likely to be under­employed and are less likely to improve their

employment circumstances over time. Rural poor families are more

likely to be employed and still poor.

(7)

Between 1990 and 1996 there was a negligible change in nonmetropolitan job earnings, remaining more or less around $22,493

(1996) per year per job.

(10) The largest percent growth in nonmetropolitan earnings between 1990 and 1996 occurred in the finance,

insurance and real estate segments of the economy. The largest

percent decline in earnings during this same time period occurred in

agricultural services, forestry and fishing.

(10)

Rural Areas Differ By Region

When considering rural America, it is important to remember that as

each rural community is distinct, each US region has distinct

characteristics that help define its rurality. For example, small towns

and cities mark the Northeast US, particularly the New England area.

This area's economy is largely dependent on fisheries and timber and

has a predominantly white population. Thus, job decline in the fishery

and timber industries has profoundly affected the economies of many

of these communities.

The rural South is marked by high rates of poverty and racial diversity

(with a high proportion of African Americans) and a rural economy

dominated by low­tech manufacturing. The Midwest and Great Plains

States have a higher percentage of rural elderly with shrinking

communities. This region also relies heavily on agriculture and recent

economic circumstances have included an increase of meat­packing

and rendering operations accompanied by an influx of mostly Hispanic

employees. The Southwestern border States see a high influx of

immigrant workers. The West has vast frontier areas in which much of

the land is federal park and Forest Service land. Consequently, the tax

base is extremely limited.

Health and Social Services in Rural Communities

Effective, coordinated health care and social services in rural

communities are essential for the health of these communities and

well­being of their residents. The necessity of these services lies not

only in their more obvious and immediate benefits, but also in their

central role in local economies. Health care provides and generates up

to 15 to 20 percent of jobs in many rural communities.

(11) Social

services also creates jobs and contributes to the health of local

economies. In addition, twenty percent of total personal income in rural

America comes from Federal transfers to rural residents, including

Social Security and Temporary Assistance for Needy Families

payments.

(7)

In addition, the presence of effective social services

increases the likelihood that businesses will locate to these

communities and further bolster the economy. Despite their

importance, rural health care and social services struggle to remain

viable because of inadequate service coordination and funding,

workforce challenges, barriers and characteristics inherent to rural

areas and residents they serve (e.g., relatively smaller and more

dispersed populations).

Coordination of Services

The strong relationship between adequate income, sufficient food,
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strong social networks and good health necessitates coordination

among various health care and social service agencies. This

coordination is especially important in rural communities, where

services and providers are limited in numbers. In many rural

communities, service providers often make alliances with one another

and exhibit extraordinary resourcefulness and resilience.

(12)

In some

cases, rural providers facilitate a better response to people in need

than urban providers because of smaller office size and more

familiarity with clients. When given the opportunity, local administrators

are often energized by the increased responsibility to attempt

innovations in social service provision.

(13)

"Our seniors are literally dying on the farm, slowly

starving trying to live on toast and coffee, because they

are so lonely, and they don't know how to reach out." ­

Rural Resident

However, coordination in rural communities is difficult for a number of

reasons. Some services are becoming more fragmented as rural

service providers specialize in an attempt to simplify administrative

responsibilities and to meet federal grant requirements.

(14)

In addition, State and federal authorities, often make decisions

regarding funding for specific programs based on cost. Cost­based

decisions invariably disadvantage rural areas because it costs more to

serve a dispersed population than a concentrated one.

(14) Possibly the

most important factor in fragmentation and lack of coordination in rural

areas is the continuing conceptual and practical separation among

primary health care, behavioral health care and social services.

Although health and social welfare are strongly associated with one

another, in many cases federal, State and local planning efforts

continue to address them separately.

Rural American Culture

The culture of rural America also plays an important role, both positive

and negative, in the delivery of health and social services. Because

rural communities have relatively small populations, strong social

networks often exist accompanied by a sense of familiarity, or of

knowing people in the community. Such phenomena provide

supportive safety nets and empathy with those in need of services.

Conversely, this familiarity may create a sense of limited privacy and

stigma associated with certain services, like mental health and

substance abuse treatment. The strong ethos of reliance on informal

rather than formal institutions, independence and individualism in

many rural communities may also hinder the effectiveness of these

services as they limit rural residents' willingness to use them. Rural

residents may also perceive that certain social welfare issues (i.e.,

substance abuse among TANF recipients) are urban issues and will

not support services that address such issues in their communities.

(14)

Access

Two central issues predominate when considering health and social

services in rural communities: lack of access and, related to this lack of

access, poorer health and greater poverty. A number of factors

inherent to rural areas affect rural residents' access to health care and

social services. Geography plays an important role in limiting rural
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residents' access because they often must travel longer distances to

see health care and social services providers.

(15) Service providers are

frequently located in county seats or other population centers and

often do not provide sufficient outreach to less populated areas. This

reality often makes services much less accessible for all residents, but

particularly those with special needs such as people with

developmental disabilities who may need personnel assistance, home

health services and respite care for their care givers. Complicating the

longer travel distances is the scarcity of public transportation in rural

areas. With limited public transportation, rural residents without reliable

private transportation have fewer options for accessing these services.

This dearth of transportation options also makes finding and

maintaining employment difficult.

(12) (15)

In addition, most government

programs designed to address these issues have a specific population

focus, like children with special health care needs or elderly. Many

rural communities do not have a critical mass of these populations to

qualify for specialized funding or to make the effort to apply worthwhile.

Rural residents in need of health care and social services may not

have access to these services because there are no services in their

communities, there is limited access to appropriate transportation or

telephone services or because they cannot pay for them. Research

has illustrated that rural residents have less access to job training and

education, health care, childcare, social services for the elderly and

emergency services.

(16) One study of 12 rural counties in four different

States showed that public transportation, workforce development

services, shelters, rehabilitative services and 24 hour childcare (an

important service in some rural counties, where shift work is common)

were available in few counties.

(12) Such a lack of services limits rural

residents' economic options. Service availability in rural communities

varies by State. Thus, State policies and State spending priorities

influence the location and availability of services.

An inability to pay for health care also compromises access to these

services. Rural residents are less likely to have health insurance, a

significant factor in their ability to access health services. In 1997,

between 18 and 20 percent of central metropolitan and nonmetropolitan county residents lacked health insurance, compared to 12

percent of suburban residents.

(5) (17) One cause of lower rates of

insurance in rural areas is the prevalence of industries less likely to

insure. There are also more part­time workers in rural areas than in

urban areas. Rural residents are also less likely to have other benefits,

like paid sick leave, than their urban counterparts.

(18) One factor in this

disparity is the prevalence of small businesses in rural areas. Many

small businesses do not have the resources to provide health

insurance.

Another important influence on the quality of rural health care and

social services is the presence of qualified professionals. As of 2001,

only 9 percent of the nation's physicians practiced in rural areas while

roughly 20 percent of the nation's population lived in rural areas.

(19)

Currently, 22 million rural residents live in federally­designated Health

Professions Shortage Areas (HPSAs), or Medically Underserved Areas

(MUAs).

(7) Mid­level health care providers, including physician

assistants, nurse practitioners, counselors and certified nurse

midwives, provide outstanding care in many rural communities.

Nevertheless, varying State regulations regarding these practitioners'

independence limits their use in many rural areas. Moreover, the
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supply of dentists in relation to population is as low as 29 per 100,000

in the most rural counties compared to 61 per 100,000 in metropolitan

counties.

(5) (20) Recruitment and retention of social welfare

professionals to rural areas are also often difficult. Most social work

education programs focus on urban issues and pay relatively little

attention to rural populations. Thus, many agencies' staff are provided

little or no professional training specific to rural issues.

(21) Rural

agencies frequently offer lower salaries and require less education

than their urban counterparts.

Statutory and Regulatory Barriers Related to Rural Health and

Social Services

In addition to difficulties related to access, federal regulations have

limited the effectiveness of rural health and social services.

(19) One

example of such a regulatory impediment is federal health care

financing policy. Health care financing in rural areas exacerbates

difficulties associated with accessing health care and provider

shortages.

(19) Medicare remains the primary source of health care

reimbursement in rural areas with Medicare patient expenses in 1998

accounting for 47 percent of total patient care expenses for rural

hospitals, compared to 36 percent for urban hospitals.

(22) The

transition to prospective payment and fee schedules beginning with

legislation in 1983 and most recently in 1997 and 1999 has threatened

rural hospitals.

(19) Because rural hospitals have lower volumes of

patients with higher fixed costs, they often require special payment

arrangements under prospective payment systems. Furthermore, poor

financial status limits a hospital's ability to recruit and retain qualified

health care providers, access needed capital and maintain other

services like home health and skilled long­term care.

(19)

Another example of federal legislation without explicit considerations of

rural communities is the 1996 Personal Responsibility and Work

Opportunity Reconciliation Act (PRWORA), the act that reformed

welfare. Inherent in this legislation authorizing the TANF program were

four central assumptions. The first was that welfare recipients in all

communities would move from welfare to work.

(7) The federal

government provided States significant flexibility in developing

programs that would meet communities' diverse needs. Welfare to

work policies mixed with a strong economy helped move a significant

number of welfare recipients off of welfare. However, during a

recession, States need to be aware that their rural areas may be at an

increased risk of unemployment and may require additional supports.

A second assumption of welfare reform was that as workers transition

off welfare, they can better support their families.

(7) While many

families have increased their capacity to support themselves, many

jobs obtained by rural welfare recipients pay the minimum wage.

(12)

The average weekly salary of a non­metro woman with less than a

high school education is 213 dollars.

(7)

In addition, family median

income is typically lower in rural areas, with no rural districts in the top

100 family median income districts.

(7)

"Typically, funding formulas for federal funds favor

highly populated states, creating a variety of challenges

for rural areas."
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­ Aging Program Director

Third, with the implementation of welfare reform, many state welfare

programs provided welfare­to­work participants with supplementary

services to enter the workforce, e.g., child care, transportation and

substance abuse and mental health services. Because of the

geography of rural communities, these services are difficult to provide

and access. This lack of adequate services may impede successful

employment.

Lastly, while States have flexibility in establishing work requirements

under TANF, a limited range of activities count as work in determining

State participation rates. The TANF rules and the High Performance

Bonus measures encourage States to support families as they move

into jobs and to help recipients retain and advance in jobs. Because

rural residents often do not have access to formal employment, States

may need to focus more proactively to help these residents find and

obtain jobs that can more easily meet the participation rate standards.

TANF also provides a good example of a program administered

through State block grants. Block grants provide States the opportunity

to design programs that address the unique needs of their

communities including flexibility to prescribe the amount or scope of

services to rural communities. Programs administering HHS block

grants may want to consider providing technical assistance on the

specific needs of rural health and social service providers.

Health and Social Service Outcomes in Rural America

Rural residents experience relatively poorer health and social welfare

outcomes. The most dramatic health­related disparities between rural

and urban residents are in the areas of mental health, substance

abuse, public health outcomes and oral health.

(5) Human servicesrelated disparities include greater poverty and higher rates of

unemployment.

(7)

Some of the greatest rural/urban health disparities are in tobacco and

illicit drug use. In 1999, adolescents living in the most rural counties

had the highest percentage of cigarette use (19 percent compared to

11 percent of urban adolescents).

(5) (24)

In addition, adults living in the

most rural counties are the most likely to smoke (27 percent of women

and 31 percent of men in 1997­1998).

(5) (25) Higher rates of smoking in

the most rural counties may reflect two factors­­delayed access to the

medical and media resources that help change unhealthy behaviors,

(5)

(26) and lower educational attainment, which is strongly associated with

smoking.

(5) (27) Use of illicit drugs is also more prevalent in rural areas.

In 1999, rural eighth graders were more likely to have used marijuana,

cocaine, crack, methamphetamines and alcohol than urban eighth

graders. In the case of methamphetamines, rural eighth graders were

twice as likely to have used them than urban eighth graders.

(28)

Some of these disparities may be related to inadequate access to

mental health care, substance abuse treatment and youth

development programs in rural communities. Difficulties include a

shortage of mental health professionals and less funding for the

community mental health system(14)that provides a substantial

proportion of rural mental health services. The stigma of mental health
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care and substance abuse as well as concerns regarding

confidentiality also limit rural residents' use of these services. With

limited budgets, mental health care providers in rural areas are forced

to focus on acute mental illness to the detriment of prevention

programs.

(14)

Also of concern are continued low rates of early prenatal care among

rural women, especially those from certain minority groups and high

rates of childbearing among rural teenagers.

(29) (30) (31) Postneonatal

death rates are also higher in rural areas.

(32)

Better health insurance coverage and improvement of the public health

service system could reduce some of these issues. However, rural

public health programs and agencies also struggle because of budget

restrictions and shortages of professionals. Non­metropolitan local

public health agencies rely to a much greater extent on reimbursement

for services (22 percent of their income is reimbursement, compared to

8.5 percent for urban public health agencies).

(33) When confronted with

budget shortages, local public health agencies often sacrifice services

like family planning, mental health services and chronic disease

monitoring, which have less obvious impact on the community's overall

health.

(33) Non­metropolitan public health agencies also rely more

heavily than metropolitan public health agencies on health care

providers because of small staffs and budget restrictions.

(34) This

reliance can create difficulties as a result of the perpetual provider

shortage in rural America.

Rural public and mental health services have the potential to address

higher rates of unintentional death, injury and suicide in rural areas.

Nationally, the age­adjusted unintentional injury and death rate

increases significantly as counties become less urban.

(35) The excess

risk of unintentional injury and death in rural areas is associated with

the higher incidence of fatal motor vehicle crashes and to some extent

with more hazardous occupations such as commercial fishing, timber

cutting and farming.

(5) (36) (37) The higher incidence of fatal crashes is

related to poorer road conditions in rural areas and also to lower rates

of seat belt and child safety seat use, a situation that could be

remedied with public health programs. Also important in increasing the

rural fatal crash rate are long emergency medical services response

times and lack of medical emergency and trauma care facilities.

(5)

Suicide rates for men also increase as urbanization declines. Possible

factors in this increase include more increased firearm ownership in

rural areas and fewer treatment options for mental illness.

(5) (38) (39)

Elderly rural residents also experience poorer health than their urban

counterparts. For example, the age­adjusted edentulism (total tooth

loss) prevalence among seniors generally increases as urbanization

declines.

(5) (25) This urban­rural increase in total tooth loss is

consistent with the urban­rural decrease in the number of dentists per

population.

(5) Rural seniors also purchase more prescription

medications than urban seniors. Although rural seniors have greater

need for prescription medications, they are more likely than urban

seniors to lack insurance coverage for prescription drugs. In 1995, 46

percent of rural elders lacked prescription coverage, compared to only

31 percent in urban areas.

(7)

Specific social welfare outcomes are also related to inadequate access
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and regulatory barriers. To the extent that child care funding is based

on population size and density, rural areas lose out. In addition,

smaller dispersed populations in rural areas and associated

transportation problems limit the feasibility of child care centers.

Nationwide, 30 percent of all children under age five are cared for in a

center setting. In rural areas, only 25 percent receive such care. The

remaining children are in family­run child care homes, in­home care or

relative care. While these settings may provide familial and community

connections, they are less likely to be regulated.

(40) Depending on

State policies, some of these settings may not be eligible to receive

subsidies through child care assistance programs such as the Child

Care and Development Fund.

"We also have a lot of children who could use a head

start program, within our community instead of shipping

the little guys thirty miles one way to have class." ­

Rural Resident

Rural low­income families are more likely than their urban counterparts

to work non­traditional hours. In addition, rural parents often have to

travel further to jobs, which means longer hours for their children in

care and increased child care costs. Few child care options are

available for parents who work evening or night shifts, or for the care of

a sick child. While Head Start is among the few programs that allows

for program funds to be used for the purchase, renovation or

construction of facilities under certain circumstances, there is no

targeted pool of funds for this purpose. Limited housing and affordable

facilities may lead rural grantees to struggle to find adequate child care

sites.

Poverty rates in rural areas are also higher than those in urban areas.

More than half of rural seniors have family incomes below 200 percent

of poverty, compared to roughly 40 percent of urban seniors.

(7) Over

half of rural children in female­headed households are in poverty (3.2

million children, 1996). In addition, 600 rural counties have the

designation "persistent poverty county," signifying that more than 20

percent of the residents experienced poverty between 1960­1990.

These counties are concentrated in the South, core Appalachia, the

lower Rio Grande Valley and on American Indian reservations. While

the largest numbers of rural poor are white, all minorities have much

higher rates of poverty in rural areas.

(7) The largest proportion of the

rural poor live in the South, where welfare benefits are the lowest and

where some of the more stringent welfare policies exist.

(41)

Conclusion

As these data underscore, access to health care and social services

remain critical rural issues. Also apparent is the interdependence of

health care, social services and economic development in rural

communities.

HHS' unique and important role in rural communities provides us with

an opportunity to redefine, with rural Americans, the meaning of a

healthy rural community and how HHS can organize and innovate its

services to correspond with this new definition. This redefinition will

recognize that, to be healthy, a community needs not only health care,

but a thriving economy, low levels of poverty and reliable social service

networks.
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The Task Force used this perspective of integrated, holistic services in

its analysis of and strategic plan concerning rural health and social

services. This new, invigorated understanding will enhance and unify

HHS' efforts in pursuing with energy and commitment the realization of

truly healthy communities throughout America.

One Department Serving Rural

Communities

The HHS Rural Task Force conducted a department­wide assessment

of how HHS programs currently serve rural and frontier communities.

During the course of this examination, the following key findings

emerged.

It is difficult to assess the Department's investment in rural

America.

HHS administers hundreds of programs that potentially support health

and human services in rural communities both directly and indirectly.

These programs are administered in myriad ways. In addition, the

areas and communities in which some programs serve are more

clearly defined as rural or urban than other programs' service areas.

For example, HHS administers grants directly to community­based

providers, groups or organizations. Medicare also makes payments

directly to health care providers. These investments can be easily

determined as either rural or urban.

Other program spending by the Department is not as easily identified

as rural or urban. For example, there are no mechanisms available to

consistently determine the proportion of rural funding in Stateadministered programs such as Medicaid, SCHIP, TANF, the Social

Services Block Grant and the Maternal and Child Health block grant.

Many HHS programs provide funds directly to State health

departments or local agencies that then redistribute those funds in a

variety of ways, some of which are categorical in nature. There are

other instances in which a central grantee such as a community health

center may receive an award and serve as the grantee of record.

However, many of these grantees also operate networks of satellite

clinics in both urban and rural locations. There is currently no means

for determining the proportion of this spending that benefits rural

areas.

HHS also funds a significant amount of health and human services

research. While some of these studies may focus on or at least

discuss some rural issues, most are not solely focused on rural issues.

This funding is typically awarded to universities, policy institutes or

individuals located in urban areas. Only HRSA's Office of Rural Health

Policy and NIH offer rural­specific services research.

Programs define how they serve rural in different ways.

The standard definition of rural used by the Office of Management and

Budget designates communities based on whether they are located in

metropolitan (i.e., urban) or non­metropolitan (i.e., rural) counties.

While this definition is used by the Medicare program and several of

the HRSA programs, it is not used by any of the other HHS agencies
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and offices.

Some agencies, such as the Administration on Aging (AoA), use their

own methodology based on specific program needs. Other programs

allow their grantees to designate themselves as rural if they claim to

serve rural residents. There are other HHS programs such as many of

those run by the Centers for Disease Control and Prevention that

categorically focus on specific diseases or health issues and fund both

rural and urban programs with no distinction between the two. Given

this variability, there is no easy way to determine the Department's

rural investment.

More that 225 HHS programs currently serve rural

communities.

Task Force members looked across their agencies and staff offices

and determined that rural communities are currently served by more

than 225 HHS­funded programs. These programs range from grants

targeted specifically to rural communities to State­based programs like

TANF and Medicaid.

All of the Agencies and staff divisions provide service to rural

individuals and communities. A summary of the key programs and their

impact on rural communities follows.

"It would be interesting to trace dollars from the national

level to the local level where services are actually

delivered. What percentage of those dollars actually

make it to 'where the rubber meets the road'?" ­

Program Director in Idaho

Agency Programs that Serve Rural Communities

Administration on Aging (AoA) ­ AoA supports a nationwide aging

network, providing services to the elderly, especially to enable them to

remain independent. AoA supports 291 million meals for the elderly

each year, including home­delivered "meals on wheels," provides

transportation and at­home services, supports ombudsman services

for the elderly and provides policy leadership on aging issues.

AoA's services in rural areas are administered principally through the

Older Americans Act Title II­C (Nutrition Services), Title III­E of that

act, the national Family Caregiver Support Program and through Title

VI, Part C ­ the Native American Caregiver Support Program.

Administration for Children and Families (ACF) ­ ACF is

responsible for numerous federal programs that promote the economic

and social well being of children, families, individuals and communities.

Actual services are provided by State, county, city and Tribal

governments, and public and private local agencies. Among its major

programs are the Temporary Assistance for Needy Families, the

nation's child support enforcement system, foster care and adoption

assistance, child care and child welfare services, child abuse and

neglect programs, assistance for people with disabilities and the Head

Start program.

It also administers a number of community and economic development

programs including several specifically for Native Americans. The

community services grant program provides essential funding to a
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network of more than 1200 community­based multi­service agencies

called community action agencies.

Agency for Healthcare Research and Quality (AHRQ) ­ AHRQ

supports research designed to improve the quality of health care,

reduce its costs, improve patient safety, address medical errors and

broaden access to essential services. The research sponsored,

conducted and disseminated by AHRQ provides evidence­based

information that helps health care decision makers ­ patients and

clinicians, health system leaders and policy makers ­ make more

informed decisions and improve the quality of health care services.

Last year, AHRQ supported a number of studies that examined issues

related to rural health, e.g., patterns of individual health plan coverage

among rural populations, quality care and error reduction in rural

hospitals and the rural response to Medicare+ Choice.

Agency for Toxic Substances and Disease Registry (ATSDR) ­

ATSDR works with States and other federal agencies to prevent

exposure to hazardous substances from waste sites. ATSDR conducts

public health assessments, health studies, surveillance activities, and

health education training in communities around waste sites on the

U.S. Environmental Protection Agency's National Priorities List.

Centers for Disease Control and Prevention (CDC) ­ CDC promotes

health and quality of life by preventing and controlling disease, injury

and disability. CDC seeks to accomplish its mission by working with

partners throughout the nation and world to monitor health, detect and

investigate health problems, conduct research to enhance prevention,

develop and advocate sound public health policies, implement

prevention strategies, promote healthy behaviors, foster safe and

healthful environments and provide leadership and training.

Centers for Medicare & Medicaid Services (CMS)­ CMS administers

the Medicare and Medicaid programs, which provide health care to

America's aged and indigent populations. These programs serve about

one in every four Americans, including more than 18 million children.

Medicaid also provides nursing home coverage for low­income elderly.

CMS also administers the State Children's Health Insurance Program

(SCHIP) that covered an estimated 4.6 million children in FY 2001.

Food and Drug Administration (FDA) ­ FDA assures the safety of

foods and cosmetics, and the safety and efficacy of pharmaceuticals,

biological products and medical devices. For FY 2001, FDA programs

do not have significant investments in rural communities. However, in

FY 2001, FDA supported Innovative Food Safety Projects and a

number of research grants that will benefit rural people.

Health Resources and Services Administration (HRSA) ­ HRSA's

programs provide the foundation for thesafety net of health care

services relied on by millions of Americans. In 2001, HRSA provided

preventive and primary health care to an estimated 10.5 million

Americans through its nationwide network of 773 health center

grantees, which includes community and migrant health centers and

primary care programs for the homeless and residents of public

housing, many of which are jointly funded. The agency administers

programs like the Ryan White Care Act, which give low­income people

with HIV/AIDS the medication and care they need to get better or stay

well, works with States to ensure that babies are born healthy and that

pregnant women and children have access to health care and
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oversees the Nation's organ transplantation system.

HRSA helps train physicians, nurses and other health care providers,

places them in communities where their services are desperately

needed and also works to build the health care workforce through the

National Health Service Corps. The Office of Rural Health Policy has

responsibility for coordinating rural efforts across HHS, examining HHS

policies on rural matters and currently administers eight grant

programs that address rural health needs.

Indian Health Service (IHS) ­ IHS supports a network of 49 hospitals,

214 health centers, 287 health stations, school health centers, satellite

clinics and Alaska village clinics and 34 urban Indian health centers to

provide services to 1.5 million American Indians and Alaska Natives of

558 federally recognized Tribes.

National Institutes of Health (NIH) ­ NIH, with 27 Institutes and

Centers, is the world's premier medical research organization and

supports some 35,000 research projects nationwide in diseases like

cancer, Alzheimer's, diabetes, arthritis, health ailments and AIDS. NIH

invests in research and care for rural communities, principally through

the National Cancer Institute, the National Institute on Drug Abuse and

the National Institute of Mental Health. Other NIH Institutes fund

smaller amounts of research directed toward rural communities.

Office of Intergovernmental Affairs (IGA) ­ IGA facilitates

communication regarding HHS initiatives as they relate to State, local

and Tribal governments. IGA is the Departmental liaison to State

governments and serves the dual role of representing the State and

Tribal perspective in the federal policymaking process as well as

clarifying the federal perspective to State and Tribal representatives. In

partnership with the US Department of Agriculture, IGA provides

support to the National Rural Development Partnership each year. IGA

also provides technical assistance and training on transportation

coordination, much of which serves rural areas.

Office of Public Health and Science (OPHS) ­ OPHS serves as the

focal point for leadership and coordination across the Department of

Health and Human Services (HHS) in public health and science.

OPHS provides direction to its program offices, including the Offices of

Women's Health, Minority Health, Population Affairs, and Disease

Prevention/Health Promotion. Additionally, OPHS provides advice and

counsel on public health and science issues to the Secretary.

OPHS invests in the improvement of health care and research,

principally through State and research institution­based programs

including Centers of Excellence and Community Centers of Excellence

in Women's Health, the Office of Population Affairs' Adolescent Family

Life and Family Planning Programs and the Office of Disease

Prevention/Health Promotion's Healthy People 2010.

U.S. Public Health Service Commissioned Corps (USPHS) ­ The

U.S. Public Health Service Commissioned Corps, a cadre of 5,628

health professionals, engineers, and scientists, is one of the seven

uniformed services of the United States. The mission of the

Commissioned Corps is to provide highly­trained and mobile

professionals who carry out programs to promote the health of the

nation, understand and prevent disease and injury, assure safe and

effective drugs and medical devices, deliver health services to federal

beneficiaries and furnish broad health expertise in time of war or other
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national or international emergencies.

The Office of Public Health and Science provides policy and leadership

for the Commissioned Corps through the Office of the Surgeon

General. The Program Support Center, through the Division of

Commissioned Personnel (DCP), provides day­to­day administration of

the Commissioned Corps. DCP is the centralized human resource

authority for all Commissioned Officers. Through participation in the

Rural Task Force, DCP has continued its efforts to evaluate

opportunities for Commissioned Officers to provide their exceptional

services to meet public health needs specific to rural America.

Commissioned Officers are presently assigned to all HHS agencies

and to a number of agencies outside HHS. Currently, 1422

Commissioned Officers (or roughly 34.2 percent) staff facilities in nonmetropolitan areas and 0.9 percent serve in Territories and

International areas. Analysis by provider­type showed that placement

in rural areas includes 230 dentists (43 percent of all dentists), 280

pharmacists (37 percent), 42 therapists (34 percent), 24 dieticians (32

percent), 304 nurses (28 percent), 107 engineers (26 percent), and

169 physicians (13 percent).

Program Support Center (PSC) ­ PSC, a service­for­fee organization,

utilizes a business enterprise approach to provide government and

support services throughout HHS as well as other Departments and

federal agencies. Administrative operations, financial management and

social resources are solution and custom­oriented.

In addition to the expansive array of support services to Federal

entities, PSC also is responsible for the distribution and management

of over 5,000 pharmaceutical items and health supplies worldwide. Its

Supply Service Center packages pharmaceuticals for hospitals, shipsat­sea and embassies around the world. All services are provided in

cooperation and sponsorship with National Institutes of Health and

other federal government agencies.

The Center's comprehensive program provides technical assistance,

inventory management, and logistical support to meet the packaging

and distribution requirements of clinical drug trials. Through interagency agreements with research programs, the Center participates

as the Drug Distribution Center for small to very large investigational

trials involving numerous clinical centers and is able to offer several

years of centralized experience in packaging, labeling, and distributing

investigational drugs for clinical trials.

In the area of rural health, the Supply Service Center provides

pharmaceutical and medical supplies to Indian Health Service and

Tribal run clinics. One of the products that is very useful in these rural

areas is our Pharmacy Unit of Use Prepacks, which are convenient,

prescription size, patient­ready units labeled for direct distribution to

patients by health care providers. Dispensing these unit­of­use

containers to patients is an economical and time saving alternative for

the small or remote locations that do not have a pharmacist.

Substance Abuse and Mental Health Services Administration

(SAMHSA) ­ SAMHSA is the lead federal agency for improving the

quality and availability of prevention and treatment services for

substance abuse and mental illness.

SAMHSA administers a combination of categorical, formula, and block
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grant programs and data collection activities through the Center for

Mental Health Services (CMHS); the Center for Substance Abuse

Prevention (CSAP); the Center for Substance Abuse Treatment

(CSAT); and the Office of Applied Studies (OAS).

These programs work in a coordinated manner to develop and apply

best mental health and substance abuse prevention and treatment

service practices. SAMHSA serves rural areas through grants to

States and community­based programs.

"We need a psychologist. There are a lot of issues that

people deal with out here in the sticks with no 'real' help.

Oh, sure you can go to your minister, but they too live in

this community and for too long and that becomes

uncomfortable." ­ Rural Resident

Barriers to Serving Rural

Communities

The HHS Rural Task Force identified a number of barriers to serving

rural individuals and families, but surprisingly few that were unique to

rural situations. Although rural communities share similar barriers with

urban America, the ways in which those barriers manifest themselves

in rural programs vary significantly. The barriers can be organized into

three categories: statutory, regulatory and administrative.

In general, statutory barriers are related to legislative requirements that

direct funding and payment policies. Other statutory barriers are a

result of what the statutes do not require, such as outreach or special

efforts to serve rural communities. Regulatory and administrative policy

barriers may stem from judgments made by federal staff with limited

knowledge of rural issues that unintentionally disadvantage rural

communities. Additionally, federal staff have little control over how

block grant funds are subsequently distributed at the State level.

Statutory Barriers

1. Requiring matching funds

Federal programs requiring a substantial match present challenges for

many grantees, but particularly for some rural constituencies with

limited resources. For example, the Office of Rural Health Policy's

State Office of Rural Health grant program requires States to provide

75 percent of funding to match the 25 percent provided by federal

grants. Rural constituencies often have fewer public and non­profit

entities from which to build the coalitions that can generate needed

match funding for initiation and maintenance of programs that benefit

rural communities.

2. Population­based formulas

Programs with allocation formulas based on numbers of clients or

anticipated costs may be biased against rural communities with small

numbers of participants and the inability to "spread costs" across a

larger client base. For example, the Ryan White CARE Act Title II

directs States to establish consortia for the delivery of HIV­related
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support and medical services within areas of the State "most affected

by HIV disease." Most rural communities have not had large numbers

of individuals with HIV.

3. Targeting and eligibility

Programs that provide funds through States may limit rural

communities' participation in these programs. For example, funds sent

to States in block grants may result in great variability in rural service,

as some States may target rural service areas while others do not.

Tribes' access to block grant dollars is also limited. Unless statutory

language specifically identifies rural or Tribal communities for service,

cost factors and lack of awareness lead States to direct funds to the

areas where there is greater perceived benefit for the expenditure.

4. The need for outreach

Authorizing statutes that do not require outreach efforts to providers or

families result in lack of awareness of services and limited

participation. Without rural outreach language, States may not be

encouraged to serve rural communities and these communities

frequently never learn of opportunities. For example, although ACF's

Child Care and Development block grant requires State plans to

include a consumer education component for parents of all eligible

children and quality initiative set­aside monies are available for rural

communities, there is not a specific rural outreach requirement. This

may contribute to the variability across States in the proportion of rural

families receiving child care services. Thus, the inclusion of rural

outreach language in this funding mechanism may be useful in

focusing State efforts on informing and assisting eligible geographically

isolated families to obtain needed access to child care services.

5. Data Collection Limitations

Concern about the undue burden of data collection and paperwork

reduction has led to significant limitations on the allowable collection of

data that would assist many programs to better understand and

respond to the needs of rural communities. For example, the lack of

available public transportation is uniformly recognized as a serious

barrier to accessing services in rural communities. However, there is

limited HHS program­specific information on the need for or costs of

transportation in rural communities. Particularly in social services

programs, little attention has been paid to defining the rural differential

in these programs.

There are unique statutory barriers that are not applicable across all

programs. For example, confidentiality protections limit data analysis

for smaller geographic areas for CDC's National Center for Health

Statistics. While providing important protections for citizens, this

hinders some in­depth rural analysis of national survey data that might

better inform policy making. Statutory language that requires HRSA's

Quentin Burdick interdisciplinary training grants to include a research

component presents barriers to smaller academic institutions that do

not sponsor significant research activities.

Regulatory Barriers

The Task Force identified a number of regulatory barriers, but few

unique to serving rural constituents. For example, the requirement for

individual plans, periodic reporting and comprehensive final reports
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can represent an overwhelming burden to small rural agencies with

limited staff, as they attempt to coordinate multiple funding sources.

1. Defining rural

The federal government has several ways of defining geographic

areas as either rural or urban ranging from the Office of Management

and Budget's (OMB) "Metropolitan­Non­metropolitan" system to the

Census Bureau's definition of urban and urbanized areas, as well as

several methodologies used by the Department of Agriculture. Some

HHS programs, however, use no definition at all and allow their

grantees to self­declare whether they serve rural communities.

The most widely used definition across the federal government and

HHS is the OMB methodology. This system designates counties as

either metropolitan (i.e., urban) or non­metropolitan (i.e., rural) areas.

Under this definition, any county not considered a metropolitan

statistical area (MSA) is considered rural. Metropolitan counties must

include one city with 50,000 or more inhabitants or an urbanized area

(defined by the Bureau of the Census) with at least 50,000 inhabitants

and a total Metropolitan Statistical Area (MSA) population of at least

100,000 (75,000 in New England). Under the OMB definition, any

adjacent counties in which at least fifty percent of the population is in

the urbanized area surrounding the largest city are also included in the

metropolitan area. Additional "outlying counties" are included in the

metropolitan area if a substantial proportion of the employed people in

the county commute to the central city or area.

Use of the OMB definition can affect application for, and awarding of,

grants for rural health and social services. This is largely due to the

use of counties in OMB urban/rural designations. There is great

variation in the size of counties across the country. One major problem

arises in the case of larger counties. Under OMB's county­based

geographic classification system, many counties with substantial rural

areas are designated as urban because they may contain an urban

area in one part of the county. For example, San Bernardino County in

California covers more than 20,000 square miles and contains a

portion of the greater Los Angeles area in its western corner but also

contains vast stretches of desert including Death Valley in its eastern

portion. Programs and services in San Bernardino County cannot

qualify for rural health and social service grants or special rural

Medicare payment protections, although they may serve communities

that are rural by every measure but that of the OMB.

The development of a new demographic classification system could

facilitate a more effective HHS response to rural communities as well

as a more precise assessment of HHS' service to rural communities.

"The health care system is highly regulated, and rural

providers are particularly feeling the effects of

regulation as they struggle with reimbursement and

workforce challenges." ­ Minnesota Rural Health

Association

2. Collecting data

As previously indicated, HHS programs do not routinely collect service

area and outcome data that describes how and precisely where they

serve rural people and communities. Sparse populations make the
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cost of conducting household­based representative surveys expensive

and limit HHS' ability to conduct rigorous quantitative research. The

diversity of rural areas and rural communities limits the generalizability

of research data; service area data is not collected by race, ethnicity

and disability, obscuring the diversity of rural communities. Narrow

reading of privacy statutes limits the ability of researchers to collect

data in rural areas because of smaller sample sizes. One notable

exception is SAMHSA's National Household Survey on Drug Abuse

which provides information on the prevalence of substance use in the

population and collects information on the socio­demographic

characteristics of users, including their place of residence.

3. Unique situations

There are a number of unique situations that are not addressed in

federal regulations. For example, a substantial proportion of rural

residents access drinking water exclusively through private water

wells. However, private well water is not regulated at the federal or

State level and can be a significant source of contaminants and

pathogens. Another example is an INS rule that mandates release of

parolees prior to completion of TB treatment. Difficulty tracking these

patients affects rural areas and contributes to the development of

multi­drug resistant TB. Program regulations do not address situations

where there may not be a road to the client, such as in Western

frontier areas. Confidentiality requirements take on very different

meanings in communities where there is limited anonymity.

Administrative, Policy and Resource Barriers

Most of the barriers identified were "resource" barriers, meaning that

resources were inadequate to address rural problems within the scope

of HHS' programs.

1. Categorical funding

Multiple agencies and constituents who responded to the Task Force's

request for comments expressed that categorical and limited funding

makes reaching remote populations difficult. Categories of funding

begin to define the need rather than the need defining the response.

Rural communities often lack the information, knowledge and capacity

to identify the range of funding sources, to redefine their needs to fit

the eligibility categories and to produce the reports required for

funding.

2. The regional nature of rurality creates challenges

In addition, the regional nature of rural America makes it hard to serve

rural residents. Frontier areas, populated largely by white Americans,

differ greatly in their health needs from Southeastern rural

communities, populated largely by African Americans. These

differences are evident when customizing prevention programs,

funding providers and measuring health status.

In some rural areas, regional identities are based on county and,

sometimes, State lines. The closest medical or social service may be

in the next county or the closest, larger city in another State.

3. Whom we consult

Another policy barrier internal to HHS is our interaction with constituent
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groups. HHS often uses national associations of State and local

government representatives as proxies for those governmental entities

in HHS regulatory and policy consultation processes. These

organizations may not have a rural focus and may exclude the rural

perspective unless specifically requested.

4. Working with States and communities

Working with States presents several challenges. The variability in

their responsiveness to rural issues and inadequate institutional

capacity at State and community levels limits sustained interventions.

For example, States may not have well­developed systems for tracking

service delivery and needs at sub­State levels.

"The health care infrastructure in many rural

communities is financially fragile and thus especially

sensitive to changes in Medicare's policies." ­ Clinic

Director in Wisconsin

5. Infrastructure barriers

Rural residents need better transportation to health and social

services, as well as to obtain and maintain employment. Communities

should ideally have affordable and accessible public transportation, yet

inadequate resources as well as poor transportation infrastructure limit

access.

Transportation for medical purposes and to serve individuals with

disabilities is especially lacking. Geographic distances, road conditions

and weather often limit service delivery, especially to rural elders.

Distance itself is a problem, as it raises the cost of delivering services.

Workforce shortages (health care providers, personal care) limit the

success of HHS' programs, where the workforce is inadequate in

number and training to deliver programs to rural populations. In

addition, time off from work for training is difficult, since small rural

staffs must ensure coverage. Related to workforce shortages is lack of

interpreters and translation services that present barriers to access to

quality health care and social services by persons with limited English

proficiency and persons with disabilities.

Technology, especially telemedicine, seen as a logical solution to

distance and workforce problems, presents problems to rural

communities which often lack the technological infrastructure to

support such options. Funds tend to support pieces of it but are not

available to support full participation in telemedicine programs. In

addition, a large proportion of telemedicine funds has gone to

academic medical centers, which, for the most part, are in urban

areas.

Many local health departments lack high speed continuous Internet

access (Only 48.9 percent have access); broadcast communications

capacity (44.9 percent have this capacity); and facilities and equipment

for distance­based training (e.g., satellite downlink, teleconferencing,

web­based training). This access may be especially limited in rural

health departments.

A final barrier related to infrastructure is the small number of

community­based organizations in rural areas. Without existing non­
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profit organizations in their communities, rural areas are less likely to

be eligible to apply for and receive federal or other health and human

services grants.

6. Costs of delivering care in rural areas

Higher costs for providing care in rural areas, without related higher

payments, are also a problem for rural communities. Rural

communities do not have sufficient use of services nor demand for

individual services to realize scaled cost savings. For example, rural

providers that have low numbers of low­income individuals and receive

a smaller percentage of State dollars through the ACF Community

Services Block Grant find the nature of rural poverty frequently

requires greater resources because of higher per client costs.

Providing services in rural areas often entails moving the client or the

service provider over great distances, using a limited provider network

and working with a client population often resistant to service. All of

these conditions raise the cost of providing service.

"The cost of running a medical practice is no less

expensive in a rural area than in an urban area. When I

buy a stethoscope, do I get a rural discount?" ­

Physician in Oregon

Statutory payment caps also disadvantage rural providers. For

example, the statutory payment cap for screening services at Medicare

rates, sufficient for many urban screening services, is not sufficient to

cover higher costs of delivering mobile mammography to rural women

through the National Breast and Cervical Cancer Early Detection

Program carried out by CDC.

7. Competing processes at the federal, State and local levels

Differing regulations ­ federal, State and local ­ are confusing to rural

communities. Effective health and social services program delivery

requires local agencies and service providers to weave a service

safety net from the often fragmented array of federal and State funding

options.

The ability to weave an effective net is directly related to the capacity

of the community and its organizations to acquire, understand,

integrate and respond to an enormous variety of program information

and requirements.

Larger communities may have the resources to employ full­time grant

writers and program administrators to address these formidable

information demands. This situation in essence constitutes a cycle in

which those that most need help are least likely to qualify. Even when

successful in obtaining funding, rural communities struggle with the

ability to produce the planning and reporting information required for

each individual funding source.

Research and Policy­Making Efforts

A number of HHS agencies have a role in conducting research and

supporting a rural perspective in policy and decision making. Much of
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this work is conducted to inform the public, Congress, State­level

leaders, Tribal leaders, local level leaders, as well as HHS leaders and

staff. The general public is also informed through these efforts. The

support of rural policy and decision making runs across the

Department ranging from targeted research studies to evaluation of

programs as well as national meetings and conferences.

The Office of Rural Health Policy serves as a focal point for rural

health issues within the Department. The Office, which was created in

1987, is charged in its authorizing language in the Social Security Act

with advising the Secretary and the Department on rural health issues.

ORHP reviews key Medicare and Medicaid regulations to assess the

impact on rural providers and beneficiaries and also funds rural

focused health services research. ORHP currently administers eight

grant programs designed to expand rural health capacity at the State

and local level.

HRSA, AHRQ, NIH, CMS, SAMHSA, ACF and the Office of the

Assistant Secretary for Planning and Evaluation all support health and

social services research on a variety of administration policies and

programs including Medicare, Medicaid, mental health, substance

abuse and TANF. Of these, only HRSA's Office of Rural Health Policy

and NIH offer rural­specific services research. Other HHS­supported

research projects tend to be more global in nature. CDC recently

produced a national chart book on rural and urban health indicators

that highlighted key differences in health status between rural and

urban populations.

Several of the HHS operating divisions are working to emphasize

flexibility in current programs to better meet rural needs. AoA has

emphasized creating flexibility in its funding streams to allow States

and local Agencies on Aging to tailor programs to local needs. AoA is

also working with States so that a substantial percentage of the

services in a new Alzheimer's Disease Demonstration grant program

are delivered to people living in rural areas.

HHS agencies and offices are also reaching out to rural constituency

groups on a variety of policy and programmatic

issues. CMS is currently sponsoring rural "listening sessions" with

providers and association representatives on key rural Medicare

issues. HRSA's Bureau of Primary Health Care annually convenes a

joint task force of members of the National Rural Health Association

and the National Association of Community Health Centers to discuss

issues that cut across both organizations.

The Office of Intergovernmental Affairs has represented the

Department on the National Rural Development Council and

participated in activities of the National Rural Development Partnership

since 1991. The Partnership consists of 40 State Rural Development

Councils as well as the Washington, DC based National Council. IGA

has worked with the Partnership to add health and social services

perspectives to their economic development strategies.

Developing HHS­Wide Goals and Strategies

To begin its Department­wide planning effort, the Rural Task Force

established five goals:
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Goal 1: Improving rural communities' access to quality health and

human services

Goal 2: Strengthening rural families.

Goal 3: Strengthening rural communities and supporting economic

development.

Goal 4: Partnering with State, local and Tribal governments to

support rural communities.

Goal 5: Supporting rural policy and decision­making and ensuring a

rural voice in the consultative process.

These goals were intended to broadly capture most of the

Department's rural programs and policy­making efforts. Each

agency and staff office was asked to develop a plan addressing

these five goals. Five goal workgroups used these as a basis for

developing an HHS­wide plan and making recommendations to the

Secretary.

Public Comment to Inform the Task

Force

Recognizing the value of input from people living in rural communities,

the HHS Rural Task Force invited public comment on the five goals of

the HHS Rural Initiative. Through a Notice in the Federal Register

published on August 29, 2001, the Task Force encouraged people at

the local, State, and Tribal levels to share their thoughts about how the

Department can better serve rural communities.

More than 450 individuals and organizations shared their insight and

experience. Comments ranged from people simply thanking Secretary

Thompson for his focus on rural services to technical comments about

the impact of particular HHS health care

financing regulations on small, rural providers. The comments received

were organized and analyzed in relation to the five goals of the HHS

Rural Initiative. The following are the common themes that supported

the work of the goal workgroups:

Goal 1: Improving rural communities' access to quality health and

human services.

Improve access to transportation services and increase vehicle

ownership so rural families can attend social services

appointments or medical visits, obtain and maintain employment

and more readily contribute to the life of the community.

Recruit and support more rural providers, particularly those

providing mental health, substance abuse or dental services.

Support better rural options for community­based care for

individuals with disabilities and elderly people.

Increase support for rural child care, telemedicine, Head Start,

EMS, HIV/AIDS services and rural health clinics.

Increase reimbursement for rural providers and minimize the

impact of geographic payment adjustments between rural and

urban providers.

Goal 2: Strengthening rural families.
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Support youth and adolescent opportunities through health and

social services career development, by increasing after­school

options and by partnering with rural youth organizations.

Support adult literacy and social capital through training and

educational programs to help people transition from welfare to

work.

Help families make better health, social and life­task decisions

through parenting education programs.

Increase support for rural caregivers and respite services.

Goal 3: Strengthening rural communities and supporting

economic development.

Increase technical assistance on HHS grant programs to rural

communities.

Partner with the US Department of Agriculture's Cooperative

Extension Services and Vocational Training Programs offered at

rural Community Colleges.

Support telemedicine, teleservices and rural infrastructure needs.

Provide a tax credit or expanded loan forgiveness for rural

providers as an incentive for serving rural America.

Goal 4: Partnering with State, local and Tribal governments to

support rural communities.

Support State or regional rural summits.

Build on the strength of existing partnerships with Community

Action Agencies, State Offices of Rural Health, etc. to better

connect HHS programs with the communities they serve.

Foster better relationships between Tribal governments and

State agencies who receive HHS funding.

Goal 5: Supporting rural policy and decision­making and

ensuring a rural voice in the consultative process.

Use a common definition of "rural" across HHS programs.

Recognize that GPRA measures that value the most people

served for the money may disadvantage rural communities

because of lower volume of people served.

Involve consumers in the policy­making process to attain a "true"

rural voice.

Form a new rural agency within HHS that looks at both social

services and health.

Integrate "rural" into Healthy People 2010 goals.

In addition to these themes, many comments offered agency specific

suggestions. These program specific recommendations are being

shared with the proper agency for future consideration. These

comments will be used to develop further strategies for improving rural

health and human services.

Cross­Cutting Recommendations:

One Department Serving Rural

America

Drawing from these public comments and from the individual goals
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submitted by each agency and staff division, the Task Force

developed a series of strategies to improve how HHS serves rural

communities. A number of proposals supported the Task Force's

concept of "One Department, Serving Rural America." These

strategies cut across all goals and most aspects of the Department

and require a fundamental change in our process. These goals were

pulled into a series of recommendations for restructuring the way HHS

works on rural issues as a Department and with State, local and Tribal

governments.

Effective, coordinated health care and social services are essential in

rural communities, where resources and providers are limited. The

Task Force's examination of HHS' rural support revealed that

improvements could be made in program coordination and policy. Our

current federal approach to providing rural services ­ through discrete

categorical funding ­ makes rural service providers "specialize" in an

attempt to meet grant requirements, despite the fact that many of

these programs serve the same clients. Our research and policymaking efforts have not been coordinated and in some instances have

been duplicative. The newly created HHS research coordination

council presents an opportunity to overcome these challenges and to

develop a Department­wide rural research agenda.

We also miss opportunities to inform policy­making by not

distinguishing data as rural or urban or by requiring data that describes

rural programs and outcomes. HHS could better serve rural

communities by making a fundamental change in its approach to

programs and policy­making affecting these communities. HHS needs

to integrate its own programs and policy making efforts, then help

States and rural communities do the same. The Rural Task Force

believes that we should characterize this as "One Department, Serving

Rural America."

1. Ways we can improve rural health and social services

coordination within HHS.

Create a formal structure within HHS with responsibility for

coordinating rural policy initiatives among HHS agencies and

staff divisions, as well as with external partners.

Based on the work of this Task Force, create a cross­HHS

workgroup that follows up on the proposed strategies. This

workgroup would meet quarterly with the Secretary, or the

Deputy Secretary, and report on HHS' progress toward achieving

the goals proposed by the Task Force.

"Social service agencies in certain parts of our region

continue to be underfunded with high [staff] turnover

rates." ­ Rural Provider in Pennsylvania

Enhance HHS budget documents to include a more thorough

consideration of rural issues.

Explore the feasibility of developing a rural impact analysis

statement to be included, as appropriate, in all proposed

regulations or regulatory changes.

Create opportunities for HHS staff and program managers to

learn about other programs that serve rural communities.
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Create a single point of entry or focal point to coordinate

assistance for rural communities with limited infrastructure as

they seek assistance from the Department of Health and Human

Services.

Ensure that central and regional HHS office grant officers receive

up­to­date information about HHS­funded projects at the

community level.

Create an "overlay" map of community­based programs that is

web­based and available to HHS staff, as well as State and

community­based health and social services providers.

Integrate the Department's technical assistance for new rural

grant seekers who do not currently receive funding from HHS.

Create a Department­wide plan for providing technical assistance

across health and human services to rural communities, rather

than a program by program approach.

Working with the newly created HHS research coordination

council, develop a coordinated research agenda to identify rural

needs and assess the impact of health and social services on

rural economies. Whenever possible, disaggregate rural/urban

data in research funded by HHS.

2. Ways we can support the integration of primary health care,

behavioral health and social services at the State level.

Sponsor Regional HHS­wide conferences to meet with State,

local and Tribal rural leaders to communicate department­wide

information to participants and to listen to State and local

concerns.

Support State­level rural health and social services workshops,

as part of that State's rural health meeting. At this workshop,

State­level health, behavioral health and social services staff

would examine the ways that they could integrate their services

with local rural providers.

Support two State­level demonstrations that would include an

evaluation component, assisting those States to develop a plan

to coordinate rural primary and behavioral health service

providers to address rural issues. Findings from these

demonstrations would be shared with federal and State staff and

rural providers.

3. Support the coordination of HHS' health and social services

programs at the community level.

Support two demonstrations in small rural communities that

would assist them in developing community­wide planning

efforts. For example, how can the local hospital, community

health center, public health and social services departments and

Head Start ensure they have adequate numbers of nurses, social

workers, front office staff, etc.

Work with the appropriate health and social services national

organizations to include workshops on service provision in rural

communities in their national or regional membership meetings,

emphasizing the need for the coordination of services in rural
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communities.

Build on earlier efforts by the Office of Rural Health Policy, the

Indian Health Service and the Centers for Medicare & Medicaid

Services to improve collaboration between local health providers

and the local Tribal health systems.

Identify ways to channel input from community leaders into HHS

program consultation processes and share with communities the

ways their input has been used.

Consider using Secretarial authority, under the newly proposed

State Program Integration Waivers, or other appropriate

mechanisms to consolidate program funds at the State or local

level.

Undertake two cross­cutting policy initiatives as models (one for

health services, one for social services) that seek to improve the

way the Department makes policy that relates to rural

communities. The health project could address health quality in

rural areas. The social services project could manage an

examination of whether the administrative systems (such as data

reporting and performance measurement systems) for TANF,

Head Start, Social Services Block Grant, Community Services

Block Grant or other social services programs support the

development of effective rural strategies.

Many of these proposals will be strengthened by partnerships with

other federal Departments, the private sector, foundations, and other

organizations. The Department will need to engage them and seek

their support as it goes forward to implement many of these strategies.

Other Administration Initiatives

In the course of the preparation of this report, it became clear that the

five goals of the Secretary's Initiative on Rural Communities reflect the

goals of several ongoing Presidential and Secretarial Initiatives,

including the New Freedom Initiative, the President's Blueprint for New

Beginnings, the Border Health Initiative, the Native American Initiative

and the Faith­Based Initiative. The President's Blueprint for New

Beginnings, which outlined the President's first budget, as well as the

New Freedom Initiative, set broad policy goals for improving the way

the Government does its business and doing so in a way that improves

access to needed services while also reaching out to State and local

governments in an ongoing partnership. Initiatives focusing on border

health and Native Americans as well as the Faith­Based Initiative echo

similar refrains about improving the way federal programs serve

Americans. Several consistent themes emerge: improving access to

needed services; reaching out to State and local governments to foster

more effective partnerships; and improving the responsiveness of

federal programs.

The Secretary's Rural Initiative relates to the HHS priorities of the

President's Blueprint for New Beginnings in several areas. Doubling

resources for NIH, strengthening the health care safety net, reforming

the National Health Service Corps' (NHSC) efforts to recruit and retain

health care providers, increasing access to drug treatment and
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supporting the Healthy Communities Innovation Initiative all coincide

with the Rural Initiative goal one of improving rural communities'

access to quality health and social services. Goal two, strengthening

rural families, relates to the President's Blueprint for New Beginnings

by promoting safe and stable families, creating after­school

certificates, promoting responsible fatherhood, supporting maternity

group homes, and providing an Immediate Helping Hand for

prescription drug benefits.

Two other current HHS initiatives also share some common goals with

the Rural Initiative by attempting to more directly meet the needs of

health care providers and the people they serve. The Secretary's

Regulatory Reform Initiative seeks to reduce regulatory burdens in

health care and respond faster to the concerns of health care

providers, State and local governments and individual Americans who

are affected by HHS rules. This activity has particular relevance for

rural providers who often lack the administrative resources to deal with

regulatory changes. CMS is also reaching out to the provider and

beneficiary community through its "Open Door" listening sessions in a

number of key areas, including rural health. The intent of this initiative

is to strengthen communication and information sharing between CMS

and beneficiary groups, plans, physicians and other providers.

The Border Health Initiative shares several common goals with the

Rural Initiative. These include improving rural communities' access to

quality health and social services, strengthening rural families,

strengthening rural communities and supporting economic

development and partnering with State, local and Tribal governments

to support rural communities. Specifically, the commitment to

community­based, culturally competent health care is a common

theme between these two initiatives.

HHS' emphasis on outreach to American Indians and the Rural

Initiative reflect common goals in improving access to quality health

and social services, specifically culturally appropriate services and

partnering with State, local and Tribal governments to support rural

communities.

The President's Faith­Based Initiative works to promote public/private

partnerships that level the playing field for all faith­based and

community organizations applying for federal grants. This Presidential

Initiative overarches all the Rural Initiative goals toward improving rural

communities' access to quality

health and social services, strengthening rural families, strengthening

rural communities and supporting economic development, and

partnering with State, local and Tribal governments to support rural

communities with particular emphasis on supporting rural policy and

decision­making and ensuring a rural voice in the consultative process.

Especially in rural America, faith­based organizations play a critical

role in the coordination of and provision of needed health and human

services.

Finally, the President's Anti­Bioterrorism Initiative and the Secretary's

Rural Initiative share the similar goal of improving rural communities'

access to quality health and social services. The need for

strengthening the capacity for medical response and emergency

services as well as creating partnerships and networks among public

health, medical and public safety entities to enhance preparedness

and response to threats of bio­terrorism is highlighted in both
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Initiatives.

Conclusion

Nowhere is the shared future of Americans more immediate and

present than in many rural communities where the needs of each

resident are often apparent. With this context as a setting, these

communities are the best place in which to make fundamental changes

and improvements in the operations and policies of HHS on a national,

regional and local level. The ideal of One Department is nowhere more

possible than in small communities around the country that need

unified, visionary leadership that no longer ideologically and

administratively separates the complementary services of HHS. Our

shared future depends in great measure on our ability to secure the

social and economic safety and health of all Americans. Now is the

time to embrace the future of rural America, essentially all of our

future, and our opportunity to lead the way in transforming the federal

government's response to those in need.

NOTES

1. This number is based on US Census Bureau data from 1990 with 2000

projections provided by the USDA Economic Research Service.

2. USDA Economic Research Service. "Rural Population and Migration:

Rural Population Change". 2000.

3. Ricketts, TC, Johnson­Webb, K, Randolph, RK. "Populations and Places in

Rural America" in Rural Health in the United States. New York: Oxford

University Press. 1999.

4. United States Census Bureau. "Estimates of the Population of Counties by

Age, Sex, Race and Hispanic Origin: 1990­1998.

5. Eberhardt MS, Ingram DD, Makuc DM, et al. Urban and Rural Health

Chartbook. Health, United States, 2001. Hyattsville, MD: National Center for

Health Statistics. 2001.

6. USDA Economic Research Service. "Rural Population and Migration: Race

and Ethnicity in Rural Areas". 2000.

7. Fluharty, Charles. "Rural America: Challenges and Opportunities".

Presentation to the NCSL Annual Meeting Assembly on Federal Issues

Committee on Agriculture and International Trade. San Antonio, Texas,

August 12, 2001.

8. Tickamyer A, White J, Tadlock B, Henderson D. "Where All the Counties

Are Above Average: Top­Down Versus Bottom­Up Perspectives on Welfare

Reform". Athens, OH: Paper prepared for Rural Dimensions of Welfare

Reform: A Research Conference on Rural Poverty, Welfare and Food

Assistance, Washington DC, May 5, 2000.

9. West Virginia Dept of Health and Human Services, West Virginia Works

Case Closure Study. 1999.

10. Economic Research Service, USDA. Rural Conditions and Trends. Vol. 9,

3. 1999.
11/19/2015 Rural Health Policy ­ ONE DEPARTMENT SERVING RURAL AMERICA

http://web.archive.org/web/20021207104442/http://www.ruralhealth.hrsa.gov/PublicReport.htm#challenge 33/34

11. Rural Policy Research Institute Center for Rural Health Policy Analysis.

Operation Rural Health Works Project Briefing. Vol 1, 1. 1999.

12. Pindus NM. " Implementing Welfare Reform in Rural Communities". The

Urban Institute and the Economic Research Service. 2001.

13. Weber B, Duncan G. "Welfare Reform Reauthorization and Rural

America: Implications of Recent Research". Joint Center for Poverty

Research. 2001.

14. Fitchen JM. Endangered Spaces, Enduring Places: Change, Identity, and

Survival in Rural America. Boulder: Westview Press. 1991.

15. Rural Policy Research Institute. "Welfare Reform in Rural America: A

Review of Current Research". 2001.

16. Fletcher C, Flora J, Gaddis B, Winter M, Litt J. "Small Towns and

Welfare Reform: Iowa Case Studies of Families and Communities". Paper

presented at the conference, Rural Dimensions of Welfare Reform: A

Research Conference on Poverty, Welfare and Food Assistance. Washington,

DC.: Georgetown University. May 4­5, 2000.

17. Centers for Disease Control and Prevention, National Center for Health

Statistics. National Health Interview Survey. 1997­1998.

18. Schur CL, Franco SL. "Access to Health Care" in Rural Health in the

United States. New York. Oxford University Press. 1999.

19. National Advisory Committee on Rural Health. "Medicare Reform: A

Rural Perspective". 2001.

20. Health Resources and Services Administration, Area File. 1998.

21. National Association of Social Workers. "Social Work in Rural Areas" in

Social Work Speaks, National Association of Social Workers, Washington

D.C. 1994.

22. Medicare Payment Advisory Commission. Report to the Congress:

Medicare in Rural America. 2001.

23. Holzer H. "Employer Demand for Welfare Recipients and the Business

Cycle: Evidence from Recent Employer Surveys." Discussion Paper No.

1185­1199. Madison, WI: Institute for Research on Poverty.

24. Substance Abuse and Mental Health Services Administration. National

Household Survey on Drug Abuse. 1999.

25. Centers for Disease Control and Prevention, National Center for Health

Statistics. National Health Interview Survey. 1997­1998.

26. Pearson TA, Lewis C. Rural epidemiology: Insights from a rural

population laboratory. Am J Epidemiology. 148(10): 949­57. 1998.

27. Newburger EC, Curry A. Educational attainment in the United States.

Current population reports: P­20, no. 528. US Census Bureau. 1999.

28. The National Center on Addiction and Substance Abuse at Columbia

University (CASA).No Place to Hide: Substance Abuse in Mid­ Size Cities

and Rural America. JAN 2000, Columbia University. New York, NY:

Columbia University.
11/19/2015 Rural Health Policy ­ ONE DEPARTMENT SERVING RURAL AMERICA

http://web.archive.org/web/20021207104442/http://www.ruralhealth.hrsa.gov/PublicReport.htm#challenge 34/34

29. Centers for Disease Control and Prevention, National Center for Health

Statistics. National Vital Statistics System. 1996­1998.

30. Lishner DM, Larson EH, Rosenblatt RA, Clark SJ. "Rural Maternal and

Perinatal Health" in Rural Health in the United States. New York: Oxford

University Press. 1999

31. National Center for Health Statistics. Public Use Data File

Documentation: Link Birth/Infant Death Data Set: 1991 Birth Cohort.

Hyattsville, MD. 1995.

32. National Center for Health Statistics. Vital statistics of the United States.

Volume II­Mortality, Part B. 1992.

33. National Association of County and Community Health Officials. "Local

Public Health Agencies: The Rural Experience." Presentation for the National

Rural Health Association Meeting, Dallas, TX, May 24, 2001.

34. National Advisory Committee on Rural Health. "Rural Public Health:

Issues and Considerations". June, 1999.

35. Centers for Disease Control and Prevention, National Center for Health

Statistics. National Vital Statistics System. 1996­1998.

36. Blatt J, Furman SM. Residence location of drivers involved in fatal

crashes. Accid Anal and Prev. 30(6): 705­11. 1998.

37. Toscano GA, Windau JA. Profile of fatal work injuries in 1996. Bureau of

Labor Statistics. Compensation and Working Conditions. 3(1): 37­45. 1998.

38. Kaplan MS, Geling O. Firearm suicides and homicides in the United

States: Regional variations and patterns of gun ownership. Soc Sci Med.

46(9): 1227­33. 1998.

39. Glaeser E, Glendon S. Who owns guns? Criminals, victims, and the

culture of violence. Am Econ Rev Papers and Proceedings. 458­62. 1998.

40. Beach B. Perspectives on Rural Child Care. ERIC Clearinghouse on Rural

Education and Small Schools. ERIC Digest, EDO­RC­96­9. 1997.

41. Zimmerman J, Garkovich L. The Bottom Line: Welfare Reform, the Cost

of Living, Earnings in the Rural South. (Information Brief No. 2). Mississippi:

Southern Rural Development Center. 1998.

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