Defining "Rural" Areas: Impact on Health

Care Policy and Research

July 1989

NTIS order #PB89-224646
FOREWORD

The

designed

problems of health care

to advance the Nation’s

in rural areas have long occupied a special niche in policies

health. Programs for recruitment, training, and deployment of

health care personnel, for constructing health-care facilities, and for financing health care often

have included special provisions for rural areas. These programs have often also included

attempts to mitigate the negative impacts on rural areas of policies primarily designed for and

responsive to the needs of urban areas. However, some rural areas continue to have high

numbers of hospital closures, ongoing problems in recruiting and retaining health personnel, and

difficulty in providing medical technologies commonly available in urban areas. Mounting

concerns related to rural residents’ access to health care prompted the Senate Rural Health

Caucus to request that OTA conduct an assessment of these and related issues. This Staff Paper

was prepared in connection with that assessment.

Rural definitions may greatly influence the costs and effects of health policies, because the

size and composition of the U.S. rural population and its health care resources vary markedly

depending on what definitions are used. There is no uniformity in how rural areas are defined

for purposes of Federal program administration or distribution of funds. This paper examines

dichotomous designations used to define rural and urban areas and discusses how they are

applied in certain Federal programs. In addition, several topologies are described that are useful

in showing the diversity that exists within rural areas. These topologies may be helpful in

identifying unique health service needs of rural subpopulations.

A second OTA paper, Rural Emergency Medical Services, will also precede the publication

of OTA’s full assessment on Rural Health Care.
Defining “Rural” Areas: Impact on Health Care Policy

and Research

by

Maria Hewitt

Health Program

Office of Technology Assessment

Congress of the United States

Washington, D.C. 20510-8025

July 1989

This Staff Paper is part of OTA’s assessment of Rural Health Care

Carol Guntow prepared this paper for desk-top publishing.

The views expressed in this Staff Paper do not

necessarily represent those of the Technology

Assessment Board, the Technology Assessment

Advisory Council, or their individual members.

For sale by the Superintendent of Documents, U.S. Government Printing Office

Washington, DC 20402
CONTENTS

Chapter Page

1.

2.

3.

4.

5.

6.

7.

8.

Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ........1

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...3

Delineating “Rural” and “Urban” Areas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5

U.S. Bureau of the Census . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

The Office of Management and Budget: Metropolitan Statistical Areas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Relationship Between Urban/Rural and

Metropolitan/Nonmetropolitan Designations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Understanding Diversity Within Rural Areas: Urban/Rural Topologies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Topologies Used To Describe Nonmetropolitan Areas. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Urbanization/Adjacency to Metropolitan areas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Adjacency to Metropolitan Areas/Largest Settlement Size . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

Population Density: Incorporation of the Frontier Concept . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

Urbanization/Population Density . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

Distance From an MSA or Population Center . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

Commuting-Employment Patterns . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

Economic and Socio-Demographic Characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

Availability of Vital and Health Statistics

for Nonmetropolitan Areas. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .27

Using OMB and Census Designations To Implement Health Programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35

Medicare Reimbursement Using MSAs To Define Urban and Rural Areas.....................35

The Rural Health Clinics Act . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37

Providing Services in “Frontier” Areas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38

Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...41

Appendix

A. Summary of the Standards Followed in Establishing

Metropolitan Statistical Areas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43

B. The Census Bureau’s Urbanized Area Definition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47

C. Census Geography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48

D. Rural Health Care Advisory Panel . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53

E. Acknowledgments. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56

Tables

Table

1. Urban and Rural Population by Size of Place (1980). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

2. Ten States With the Largest Rural Population (1980). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

3. States With More Than One-Half of Their Population Residing

in Rural Areas (1980) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

i i i
CONTENTS (cent’d)

Tables (cent’d)

Table Page

4.

5.

6.

7.

8.

9.

10.

11.

12.

13.

14.

15.

16.

17.

18.

19.

20.

Ten States With the Largest Nonmetropolitan Population (1986) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

States With More Than One-Half of Their Population Residing

in Nonmetropolitan Areas (1986) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Selected Federal Department/Agencies Using MSA Designations

for the Administration of Programs or the Distribution of Funds. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Population Inside and Outside of MSAs by Urban and Rural Residence (1980)................l5

Classification of Nonmetropolitan Counties by Urbanization and Proximity

to Metropolitan Areas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Nonmetropolitan County Population Distribution by Degree of Urbanization

and Adjacency to an MSA (1980) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

U.S. Population by County’s Largest Settlement and Adjacency

to an MSA (1980) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

Bluestone and Clifton County Classifications Based on

Urbanity and Population Density . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

Population-Proximity: A Measure of a County’s Relative Access

to Adjacent Counties’ Populations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

County Typology Based on Employment, Commuting, and

Population Characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

Distribution of U.S. Counties by Typology Based on Employment, Commuting,

and Population Characteristics (1986) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

Classification of Nonmetropolitan Counties by Economic and

Socio-Demographic Characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

Features of the Nine County-Based Topologies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

Proportion of the Population 65 and Older by

Metropolitan/Nonmetropolitan and Urban/Rural Residence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

Proportion of Nonmetropolitan Population Age 65 and Older by

Level of Urbanization and Adjacency to an MSA (1980). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

Nonmetropolitan Infant Mortality Rates by Urban Area and Race,

U.S. Total and Alabama (1986) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

Characteristics of Different Categories of U.S. Nonmetropolitan Counties. . . . . . . . . . . . . . . . . . . . . . . . . . 30

Figures

Figure Page

1. Urbanized Areas. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

2. Metropolitan Statistical Areas (June 30, 1986) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

3. The Relationship Between Metropolitan Statistical Areas (MSAs),

Urbanized Areas, and Urban and Rural Areas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

4. Map of California Counties: San Bernardino County . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

5. 1980 Population Distribution (United States). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

6. Areas With Cervical Cancer Mortality Rates Significantly Higher

Than the U.S. Rate, and in the Highest 10% of all SEA Rates

(White Females, 1970-1980) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

7. Death Rates Due to Unintentional Injury by County . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32

8. Death Rates Due to Motor Vehicle Crashes by County . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

9. Frontier Counties: Population Density of 6 or Less . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39

iv
1. SUMMARY

It is difficult to quantify rural health

problems and to make informed policy decisions without a clear definition of what and

where “rural” areas are. Small population,

sparse settlement, and remoteness are all features intuitively associated with “rural. ”

These features exist on a continuum, however, while Federal policies usually rely on

dichotomous definitions.

Urban and rural areas are often defined

using the designations of either the Office of

Management and Budget (OMB) or the

Bureau of the Census. Rural areas are the

remaining areas that are not captured in either OMB’s “metropolitan statistical area”

(MSA) designation or in Census’ urban or urbanized area definitions. Counties are the

building blocks of OMB’s MSAs and are easy

to use, because county-based data are readily

available. One or more counties form an

MSA on the basis of population size and

density, plus the degree of area-wide economic integration as reflected in commuting

patterns. The Census’ urban and urbanized

area definitions rely on settlement size and

density without following county boundaries,

making them more difficult to use. Both

methods identify about a quarter of the U.S.

population as rural or “nonmetropolitan,” but

these populations are not identical. For example, about 40 percent of the Censusdefined rural population live within MSAs,

and 14 percent of the MSA population live in

Census-defined rural areas. The Census’

rural population includes residents of small

towns and cities but excludes those living in

towns larger than 2,500, many of whom

might be considered rural. MSAs can include

areas that are sparsely populated and could be

considered rural, while nonmetropolitan areas

show significant within-area variation.

There is no uniformity in how rural

areas are defined for purposes of Federal

program administration or distribution of

funds. Different designations may be used

by the same agency. For example, Congress

directed the Health Care Financing Administration to use Census’ nonurbanized area

designation to certify health facilities under

the Rural Health Clinics Act, but to use

OMB’s MSA/nonMSA designations to categorized hospitals as urban or rural for purposes of hospital reimbursement under Medicare. In general, rural hospitals are reimbursed less than their urban counterparts.

While persistent differences between metropolitan and nonmetropolitan hospital costs

have been observed, hospital location may be

a correlate rather than a determinant of cost

differences. Therefore, hospital-specific

measures are being sought that might replace

the present MSA adjustments to the basic

prospective payment formula. Topologies

that categorize counties according to their degree of urbanization or their employment and

commuting patterns could be used to refine

the definition of labor market areas, an important component of the Medicare formula.

There have been calls to develop a standard rural typology that would capture the

elements of rural diversity and improve the

use and comparison of nationally collected

data. These topologies usually are based on

the following features: population size and

density; urbanization; adjacency and relationship to an MSA; and principal economic

activity. Although a standard typology may

be desirable, it will be difficult to arrive at,

because the different topologies have merit

for various purposes. Nevertheless, there

continues to be a need for a standardized

nonmetropolitan topology. It is especially

important to display vital and health statistics

in a standardized way, because markedly different conclusions can be reached, depending

on the definition of rural used. Better

measures of population concentration or dispersion within counties would be helpful--

especially for sparsely settled “frontier” areas

--to distinguish between urban and rural

areas within the same counties.
2. INTRODUCTION

Although there has been widespread concern regarding a “health care crisis” in rural

areas, there is little agreement as to what

rural areas are. How rural areas (or rural

populations) are defined is far from academic, since urban/rural designations are basic to

participation in certain Federal programs and

to payment rates from Federal sources. Indeed, the perceived magnitude of rural health

care problems and the impact of any change

in public policy depend on how rural is

defined.

The features most intuitively associated

with rurality are small populations, sparse

settlement, and remoteness or distance from

large urban settlements. Historically, rural

populations have been distinguished from urban ones by their dependence on farming occupations and by differences in family size,

lifestyle, and politics ( 13). However, because

of dramatic improvements in transportation

and communication, migration to and from

rural areas, and diversification of the rural

economy, these clear distinctions no longer

exist. The presence of farms, mining areas,

and forests in rural areas contribute to persistent differences, most notably lower population densities (1 3). By 1980, however, over

two-thirds of the work force

outside of metropolitan areas

in three industries--service,

and retail trade (49).

both inside and

were employed

manufacturing,

The purpose of this staff paper is to:

1.

2.

3.

4.

describe the principal “rural” definitions

applied by the Federal Government that

affect health programs and policies --

i.e., urban and rural areas (and populations) as defined by the Bureau of the

Census and metropolitan statistical areas

as defined by the Office of Management and Budget;

describe the classifications used to distinguish different types of rural areas;

discuss how Federal agencies have used

these definitions to compile vital and

health statistics and to implement programs; and

discuss the strengths and weaknesses of

rural definitions and classifications currently in use.

3
3. DELINEATING “RURAL” AND “URBAN” AREAS

The concepts of “rural” and “urban” now

exist as part of a continuum. While few

would argue about the extremes of that

continuum- - e.g., an isolated farming community in Texas at one extreme and New

York City at the other--where to draw the

line between urban and rural has become

more difficult. Many Federal policies, however, rely on dichotomous rural/urban designations. This section describes the two most

important dichotomous geographic designations: the Bureau of the Census’ urban and

rural areas (and populations), and the Office

of Management and Budget’s (O MB)

metropolitan statistical areas and residual

nonmetropolitan territory. Several geographic

classification schemes are then described that

portray the urban-rural continuum.

U.S. Bureau of the Census

According to the Census Bureau, urban

and rural are “type-of-area concepts rather

than specific areas outlined on maps” (50).

The urban population includes persons living

in urbanized areas (see below) and those

living in places with 2,500 residents or more

outside of urbanized areas. The population

not classified as urban comprise the rural

population; i.e., those living outside of urbanized areas in “places” with less than 2,500

residents and those living outside of “places”

in the open countryside. Census-recognized

“places” are either: 1) incorporated places such

as cities, boroughs, towns, and villages; or 2)

closely settled population centers that are outside of urbanized areas, do not have corporate limits, and have a population of at least

1,000.

1 The rural population is divided fur1 The minimum population of these unincorporated

areas, called census designated places, is lower in

Alaska and Hawaii.

ther into farm (see below) and nonfarm populations.

Urbanized areas consist of a central core

(a “central city or cities”) and the contiguous,

closely settled territory outside the city’s

political boundaries (the “urban fringe”) that

combined have a total population of at least

50,000 (48). The boundary of an urbanized

area is based primarily on a residential population density of at least 1,000 persons per

square mile (the area generally also includes

less densely settled areas, such as industrial

parks) (49). The boundaries of urbanized

areas are not limited to preexisting county or

State lines; rather they often follow the

boundaries of small Census-defined geographic units such as census tracts and

enumeration districts. Many urbanized areas

cross county and/or State lines (see figure 1).

Figure 1--- Urbanized Areas

Urbanized area

B

/

County D

SOURCE : U.S. Department of Comnerce, Bureau of the

Census, IICenSUS and Geography-Concepts and

Products, 08 Factf i rider CFF No. 8 (Washington, DC: U.S. Government Printing Office, August 1985).

5
6 ■ Defining “Rural” Areas: Impact on Health Care Policy and Research

Table 1--- Urban and Rural Population by Size of Place (1980)

Number Percent

of places Population of Us .

U.S. tota l

Urban areas

Places of 1,000,000 or more

Places of 500,000-999,99 9

Places of 250,000-499,99 9

Places of 100,000-249,99 9

Places of 50,000-99,99 9

Places of 25,000-49,99 9

Places of 10,000-24,99 9

Places of 5,000-9,99 9

Places of 2,500-4,99 9

Places of less than 2,500

Other urban areaa

Rural areas

Places of 1,000-2,49 9

Places under 1,000

Other rural are a

b

22,52 9

8,76 5

6

16

34

117

290

675

1,765

2,181

2,66 5

1,01 6

13,764

4,43 4

9,33 0

226,545,80 5

167,050,99 2

17,530,24 8

10,834,121

12,157,57 8

17,015,07 4

19,786,48 7

23,435,65 4

27,644,90 3

15,356,13 7

9,367,82 6

1,260,24 6

12,662,71 8

59,494,81 3

7,037,84 0

3,863,47 0

48,593,50 3

100.0%

73. 7

7 . 7

4 . 8

5 . 4

7 . 5

8 . 7

10. 3

12. 2

6 . 8

4 . 1

0 . 6

5 . 6

26. 3

3 . 1

1 . 7

21. 4

~Includes urban residents not living in Census-designated places.

Includes rural residents not living in Census-designated places and residents of the rural portion of ex -

tended cities.

SOURCE: 1980 Census of Population, Volume 1, Characteristics of the Population, 1981, table 5, p. 1-37 .

The 1980 Census identified 373 urbanized

areas in the United States and Puerto Rico

(52).2

The Census definition of urban areas has

changed considerably over time. Prior to

1900, the lower population limit for the size

of places considered urban was set at either

4,000 or 8,000. The limit was lowered to

2,500 residents in 1900(47). This definition

worked well until suburban development outside corporate boundaries became extensive.

To improve the definition, people living in

fairly densely populated areas (at least 1,000

z Since 1970, rural areas have been recognize d

~ithin certain cities whose corporate limits in -

clude large areas lacking urban development. The

rural portion of these Ilextended cities~ is a t

least 5 square miles in area and has a population

density of less than 100 persons per square mile.

Together, such areas must constitute at least 2 5

percent of the land area of the legal city or in -

clude at least 25 square miles (50). In 1980 there

were 87 extended cities with a total of 161,14 0

rural residents (41).

persons per square mile) in the immediate vicinity of cities of 50,000 or more population

were counted as urban instead of rural beginning in 1950 (21). With the exclusion of

these suburban residents, the size of the 1950

rural population dropped from 62 million to

54 million (47).

The rural population has been divided by

the Census Bureau into the farm and nonfarm

populations. The farm population includes

people living in rural-areas on properties of 1

acre of land or more where $1,000 or more of

agricultural products were sold (or would

have been sold) during the previous 12

months.

3 In 1987, the farm population was

3 From 1960 to the mid 1970s, the farm population

consisted of all persons living in rural territor y

on places of 10 or more acres, if at least $5 0

worth of agricultural products were sold frcnn th e

place during the preceding 12 months . Person s

living on places of under 10 acres were also in -

cluded if agricultural sales totaled $250 or mor e

(55) .
Defining “Rural” Areas: Impact on Health Care Policy and Research • 7

Table 2.--Ten States With The Largest Rural

Population (1980)

Rural population Percent

Stat e (in 1,000s ) of Stat e

Pennsylvania a

North Carolina

Texas

Ohio

Michigan

New York

Californi a

Georgia

Indiana

Illinoi s

3,64 3

3,05 9

2,89 6

2,87 9

2,711

2,70 0

2,06 0

2,05 4

1,96 5

1,90 8

30. 7

52. 0

20. 4

26. 7

29. 3

15. 4

8 . 7

37. 6

35. 8

16. 7

SOURCE: U.S. Department of Commerce, Bureau of the

Census, County and City Data Book: 198 3

(Washington, DC: U.S. Government Printing

Office, 1983) .

estimated at 4,986,000, or about 8 percent of

the rural population and 2 percent of the total resident U.S. population. In contrast,

farm residents represented 30 percent of the

population in 1920(55).

According to the 1980 Census, 73.7 percent of the U.S. population was urban, but

the proportion ranged from a low of 33.8

percent in Vermont to 100 percent in the

District of Columbia (51). Table 1 shows the

distribution of the 1980 urban and rural population by size of place. Over 85 percent of

the rural population live in places or areas

with fewer than 1,000 residents. Table 2

shows the ten States with the largest rural

populations. Table 3 shows the seven States

with more than one-half of their population

residing in rural areas.

The Census Bureau’s ‘urbanized” area

concept does not apply to towns, cities, or

population concentrations of less than 50,000.

Those living nearby, but outside of the limits

of smaller cities or towns are not counted as

being part of an “urbanized” area, even

though the “suburban” population may be

large and economically integrated with the

town. For example, the population surrounding the incorporated village of Hayward, Wisconsin (county seat of Sawyer County), exceeds the 1,456 population of Hayward. The

residents of the surrounding area us e

Hayward’s facilities such as a nursing home

and fire station but are not included in the

village population. This “undercount” has

hampered the village’s ability to obtain grants

to improve area services (13). Numerous

areas such as Hayward, that are considered

“rural” by virtue of the fact that they are outside of an urbanized area and have a population of 2,500 or less, would be considered urban if the population immediately surrounding the corporate area were included. Many

towns and villages have resolved this problem

by annexing surrounding developed territory

(12).

Table 3--- States With More Than One-Half

of Their Population Residing

in Rural Areas (1980)

Rural population Percent

State (in 1,000s ) of Stat e

Vermont 339 66. 2

West Virgini a 1,24 4 63. 8

South Dakota 370 53. 6

Mississippi 1,32 8 52. 7

Maine 591 52. 5

North Carolina 3,05 9 52. 0

North Dakota 334 51. 2

SOURCE: U.S. Department of Commerce, Bureau of the

Census, Count Y and City Data Book: 1983,

(Washington, DC: U.S. Government Printing

Office, 1983) .

The Office of Management and Budget:

Metropolitan Statistical Areas

A metropolitan statistical! area (MSA)4 is

an economically and socially integrated geographic unit centered on a large urban area.

In general terms, an MSA includes a large

population center and adjacent communities

that have a high degree of economic and so4 From 1959 to 1983, HSAS uere cal[ed Standar d

Metropolitan Statistical Areas (SMSAS) (53 F R

51175) . The term MSA is used throughout thi s

paper, even when referring to 1980 Census data.
8 • Defining “Rural” Areas: Impact on Health Care Policy and Research

cial integration with that center (54). This

contrasts with Census’ urban area, which is

defined solely on the basis of where people

reside (i. e., population size and density).

MSAs are defined by OMB5 and are used by

Federal agencies for collecting, tabulating,

and publishing statistical data. Some Federal

agencies also use MSA designations to implement programs and allocate resources although OMB does not define them with such

applications in mind. The business community uses MSA data and rankings extensively, for example to make investment

decisions and to assess the desirability of

markets (38).

The official standards that are used to

define MSAs are reviewed prior to each

decennial Census. 6 According to standards

adopted for the 1980 Census, an MSA must

have: 7

■ a city with 50,000 or more residents; or

■ an urbanized area (as defined by the

Census Bureau) with at least 50,000

people that is part of a county or

counties that have at least 100,000

people.

In most areas, counties are the building

blocks of MSAs. In the six New England

States, MSAs are composed of cities and

towns, rather than whole counties. 8 MSA s

s The metropolitan area concept appeared in U.S.

Census publications as early as 1910 but Has no t

widely incorporated or used until the 1950 censu s

when the concept was generalized to county line s

(12,47) .

6 The Office of Management and Budget’s Statistical

Pol icy Office, Office of Information and Regulatory

Affairs, reviews and revises MSAS with advice from

the interagency Federal Executive Committee o n

Metropolitan Statistical Areas (56).

7 See appendix A for a summary of the 1980 MSA

standards.

8 New England USA standards are based primarily on

population density and commuting patterns (56) .

The six New England States are Maine, New Hamp -

shire, Vermont, Massachusetts, Rhode Island, and

Connecticut.

often include more than one county; i.e., one

or more central counties containing the area’s

main population concentration and outlying

counties that have close economic and social

relationships with those central counties. To

be included in the MSA, the outlying counties must have a specified level of commuting

to the central counties and must also meet

certain standards regarding metropolitan

character, such as population density (see appendix A). Consolidated MSAs(CMSAs) are

large metropolitan complexes within which

individual components are defined, designated as primary MSAs (PMSAs) (see appendix A).

Problems in MSA classification may occur when county boundaries do not conform

closely to actual urban or suburban development. An MSA may inappropriately include

nonsuburban areas located in the outlying

sections of some counties. For example, in a

spatially large county with a concentrated

metropolitan area, a large, sparsely populated

area maybe included in the MSA. This

problem occurs more frequently in the West,

where counties are bigger than those in the

East. On the other hand, an MSA may exclude suburban areas just across the county

line. For example, a county with a suburban

population that commutes to a neighboring

MSA may be excluded from that MSA because it also includes a large, sparsely populated section and therefore has a low average

population density. 9 While these problems

occur, they occur infrequently (56).

About three-quarters (76.6 percent) of

the U.S. population lived in the 275 MSAs

designated as of 1983.

10 These MSA s

represent only 16.2 percent of the total U.S.

9 See appendix B for a description of criteria used

in including outlying counties in an USA.

10 By June 30, 1988, intercensal populatio n

estimates or special census population counts had

been used to add seven newly qualified HSAS and to

designate three new central cities within existing

MSAS (12) .
Defining “Rural” Areas: Impact on Health Care Policy and Research • 9

.
10 • Defining “Rural” Areas: Impact on Health Care Policy and Research

Table 4---Ten States With The Largest

Nonmetropolitan Population (1986)

Nonmetropolitan Percent

Stat e population (in 1,000s ) of Stat e

Texas

North Carolina

Ohio

Georgia

Illinoi s

Kentucky

Mississippi

Pennsylvania a

Michigan

Indiana

3,20 9

2,84 7

2,27 7

2,18 2

2,03 3

2,03 3

1,83 7

1,83 0

1,811

1,76 0

19. 2

45. 0

21. 2

35. 7

17. 6

54. 5

70. 0

15. 4

19. 8

32. 0

SOURCE : U.S. Bureau of the Census, Statistica l

Abstract of the United States: 1988, 108th

ed. (Washington, DC: 1987), table 33.

land area (figure 2.--MSA map). Seventyseven percent of U.S. counties (2,422 of 3,139

counties and county equivalents) are nonmetropolitan. 11 Table 4 shows the 10 States

with the largest nonmetropolitan populations.

Table 5 shows the 15 States with more than

one-half of their population residing in nonmetropolitan areas.

Before 1970, an MSA’s “recognized large

population nucleus” had to include a central

city of at least 50,000 population or twin

cities with a total population this large. Now

there is no minimum population size for an

MSA’s central city, and it is easier to include

contiguous populations in the urbanized area

(6). With the relaxation of MSA criteria,

some of the 58 MSAs designated following

the 1970 and 1980 censuses are demographically dissimilar from those MSAs meeting

earlier standards. For example, of the 33

MSAs newly designated after the 1980 census

that lacked a city of 50,000 or more residents, 25 had rural population percentages

that were closer to nonmetropolitan norms (62

percent) than metropolitan norms (15 percent)

(6). Furthermore, many of these do not have

facilities and services traditionally associated

11 There were 717 metropolitan comties (excluding

Ne~ England) as of June 30, 1988 (12).

Table 5--- States With More Than One-Half

of Their Population Residing in Nonmetropolitan Areas (1986)

Nonmetropolitan Percent

Stat e population (in 1,000s ) of Stat e

Idaho

Vermont

Montana

South Dakota

Wyoming

Mississippi

Maine

West Virgini a

North Dakota

Arkansas

Iowa

Alaska

Kentucky

Nebraska

New Mexico

416

619

508

361

1,83 7

1,21 7

426

1,43 9

1,62 9

2,03 3

848

776

80. 7

76. 9

75. 6

71. 8

71. 2

70. 0

63. 9

63. 4

62. 7

60. 7

57. 1

56. 0

54. 5

53. 1

52. 5

SOURCE: U.S. Bureau of the Census, Statistical Ab -

stract of the United States: 1988, 108t h

ed. (Washington, DC: 1987), table 33.

with metropolitan areas, such as hospitals

with comprehensive services, a 4-year college, a local bus service, a TV station, or a

Sunday paper (6).

A few counties that have not qualified

for MSA status on the basis of demographic

characteristics have become designated as

MSAs through the Federal legislative process.

Specifically, since 1983, one new MSA

(Decatur, Alabama) has been created (comprising two counties)12 and the boundaries of

two existing MSAs have been enlarged by

statute (62).13 The proponents of the bill to

create the Decatur, Alabama MSA argued that

“MSA status would encourage a measure of

economic recovery to this area... without any

additional financial burden on the Federal

Government” (45). Hospitals located in the

newly designated MSA of Decatur, Alabama

are expected to receive an additional $3 million per year in Medicare reimbursements beIZ Public Lau 100-258 .

13 Public Law 100-202, Sec. 530 and

PWlic Law 99-500.
Defining “Rural” Areas: Impact on Health Care Policy and Research Ž 11

cause of this change from nonmetropolitan

(rural) to metropolitan status. The increase in

Medicare outlays for these two counties

would in aggregate decrease reimbursement to

other hospitals because the total amount of

funding for the Medicare program was not

changed by this act (44).

The MSA definition is designed strictly

for statistical applications and not as a

general-purpose geographic framework. In

fact, according to official standards, “no Federal department or agency should adopt these

statistical definitions for a nonstatistical program unless the agency head has determined

that this is an appropriate use of the classification” (56). The OMB does not take into account or attempt to anticipate any nonstatistical uses that may be made of the MSA

definitions and will not modify the definitions to meet the requirements of any nonstatistical program (62). Nonetheless, Federal

agencies often use MSA designations to implement their programs. Table 6 contains a

partial list of Federal programs that use

MSAs for the administration of programs or

the distribution of funds.

Table 6--- Selected Federal Department/Agencies Using MSA Designations for

the Administration of Programs or the Distribution of Fundsa

Department of Agriculture

Farmers Home Administration

Rural Housing Assistance

Department of Education

Higher Education Assistance

Federal Impact Payments for Education

Sumner Food Service Program

Department of Health and Human Services

Federal Grants for Residency Training

Aid to Organ Procurement Organizations

Medicare Prospective Payment System

Juvenile Delinquency Treatment Grants

Provision of Services to Medicare Beneficiaries

by Health Maintenance Organizations (HMOs)

Department of Housing and Urban Development

Enterprise Zones

Public Housing Development

Community Development Block Grant Program

Urban Development Action Grants

Assisted Housing Fair Market Rents

Rental Rehabilitation Awards

Department of the Interior

Recreation Areas

Wastewater Treatment Works Grants

Department of Labor

Job Training Partnership Act

%ost USA applications listed Mere identified b y

searching the U.S. Code and the Code of Federal

Regulations (CFR) for the term 1’MSA. IC This lis t

is not caqwehensive.

SOURCE: Bea, K., llMetrwlitan Statistical Are a

Standards: Applications in Federal

Policy ,

w (CRS Draft), 1989; U.S. Department of Commerce, OFSPS, “Report on the

Inpct of Standard Metropolitan Statistical Areas on Federal Programs,ll 1978.
4. RELATIONSHIP BETWEEN URBAN/RURAL AND

METROPOLITAN/NONMETROPOLITAN DESIGNATIONS

Conceptually, the urban/rural and metro/

nonmetropolitan designations are quite different. Urban/rural are geographic designations based on population size and residential

population densities, while the MSA concept

embodies both a physical element (a city and

its built-up suburbs) and a functional dimension (a more-or-less unified local labor

market) (21 ). The Census-defined urban

population and the MSA population intersect

but are by no means identical; they are even

less congruent geographically. Common to

both are residents of most urbanized areas,

the densely settled area that forms the

nucleus of the MSA (see figure 3). 1 T h e

Census’ urban population includes the urbanized area population and those living

outside urbanized areas in places with 2,500

or more residents. The MSA population generally includes all those living in the county

or counties that contain the urbanized area

and the residents of additional counties that

are economically integrated with that metropolitan core. Forty percent of the 1980 rural

population lived in MSAs, and 14 percent of

the MSA population lived in rural areas (see

table 7). About one-fourth of farm residents

live in MSAs (55).

“Rural area,” “nonurbanized area, ” and

“nonmetropolitan area” have all been used to

display vital and health statistics or to implement Federal policies in health and other

areas. These “rural” definitions can be analyzed in terms of how well they include “rural

areas” and how well they exclude “urban

areas.” The Census-defined “rural area” is the

most specific measure, since it excludes urbanized areas and places with 2,500 residents

or more. Thus, few would argue that an area

designated as rural according to the Census

definition is really urban. However, some

might argue that the Census definition would

1 There are a few urbanized areas outside of MSAs.

z A sma[ 1 number of rural residents of extended

c i t i es are exc [ uded from the urban and urbanized

area population.

incorrectly classify as urban small towns

which are located far from a large population

center. In contrast, the “nonurbanized area”

definition includes as rural all territory outside of its densely populated area, regardless

of population size. Thus, while all “rural

areas” would be included, some cities and

towns of as large as 40,000 residents would

also be included, as well as some outer suburbs of large urban areas.

Figure 3---The Relationship Between

Metropolitan Statistical Areas (MSAs),

Urbanized Areas, and Urban and Rural Areas

●

●

Urban places

•

Rural areas

Counties 1 through 4 comprise the MSA.

Urbanized areas form the nucleus of the MSA and can

span tuo or more counties (e. g., counties 1 through

4 ) . There are a few urbanized areas i n non-MSA

counties (e. g., county 7).

Urban areas include urbanized areas and pl ace s

(e. g., cities and towns) with 2,500 or more residents. Such places are called urban places.

Rural places are located outside of urbanized areas

and have fewer than 2,500 residents.

Rural areas are the residential territory (shade d

gray) left after urbanized areas and urban place s

are excluded. The USA has rural areas within it.

SOURCE : Office of Technology Assessment, 1989.

13
14 • Defining “Rural” Areas: Impact on Health Care Policy and Research

Figure 4--- Map of California Counties: San Bernardino County

SOURCE : American Map Corporation, Business Control Atlas 1988 (Maspeth, New York: American Map Corporation, 1988). -
Defining ‘Rural” Areas: Impact on Health Care Policy and Research Ž 15

The nonMSA designation falls in between

the other two designations. If nonMSAs are

used to define rural areas, some large towns

and cities located outside of MSAS

3 would be

included as rural while small towns and sparsely populated areas within MSAs would be

excluded from the rural category. This exclusion is less a concern in the Eastern

United States, where counties are relatively

small, 4

and such towns would generally be

expected to be relatively close to an urbanized area. However, in some of the large

counties in the West, some areas within an

MSA are far from an urbanized area (e.g.,

San Bernardino County--figure 4).

3 There are at least 100 places with populations o f

25,000 or more wtside of MSAS.

d A typical county in the East has a land area o f

400 to 600 square miles. Uest of the Mississippi

River there are great variations, but the averag e

county land area is just over 1400 square mile s

excluding Alaska (29).

Table 7 .--Population Inside and Outside of

MSAs by Urban and Rural Residence (1980)

Percent of

Population MSA/nonMSA

U.S. tota l 226,545,80 5

Inside MSAs 149,430,623 100. 0

Urban 145,442,52 8 85. 8

Urbanized areas 137,481,71 8 81. 1

Central citie s 66,222,20 7 39. 1

Urban fringe 71,259,51 1 42. 1

Rural 23,988,09 5 14. 2

Outside MSAs 57,115,18 2 100. 0

Urban 21,608,46 4 37. 8

Rural 35,506,71 8 62. 2

SOURCE: U.S. Department of Commerce, Bureau of the

Census, 1980 Census of Population, Volume

1. Characteristics of the Population ,

1981, table 6, pp. 1-39.
5. UNDERSTANDING DIVERSITY WITHIN RURAL AREAS:

URBAN/RURAL TOPOLOGIES

Dichotomous measures of urbanity/

rurality not only obscure important differences between urban and rural areas but

also wide variations within rural areas. Consequently, there have been recommendations

to implement a standard rural typology that

would capture the elements of rural diversity

and improve use and comparison of data (14).

In the absence of such standardized data, it is

difficult to quantify rural health problems

and to make informed policy decisions.

In this section, several county-based

rural/urban topologies or classification

schemes are described that incorporate one or

more of the following measures:

■

■

■

population size and density;

proximity to and relationship with urban

areas;

degree of urbanization; and

principal economic activity.

Only county-based topologies are considered here, because the county is generally the

smallest geographic unit for which data are

available nationally. Counties also have

several other characteristics that make them

useful units of analysis: county boundaries are

generally stable; counties can be aggregated

up to the State level; and counties are important administrative units for health and other

programs. For small-area analyses and for

research purposes, ZIPCodes may be useful

units of analysis. However, ZIPCodes boundaries are not stable and sometimes cross

county lines.

Topologies Used To Describe

Nonmetropolitan Areas

Several topologies have been developed

to classify nonmetropolitan counties. Nine

county-based topologies are described below.1

These topologies are generally used for research purposes and have not yet been used

by Federal agencies to implement health

policies or to present vital and health

statistics. Before discussing specifi c

topologies, four geographic/demographic

measures common to most of the topologies

are briefly described: 1 ) population size, 2)

population density, 3) adjacency t o

metropolitan area, and 4) urbanization.

Population Size. --Population size can

refer to the total population of the county or

to the largest settlement in the county.

Presentation of an area’s population by settlement size helps to illustrate how the population is distributed. In 1980, 43 percent of the

U.S. population lived in places of less than

10,000 population or the open countryside

(see table 1). The Census Bureau’s urban

definition depends in part on population size

(i.e., those living in places of 2,500 or more

outside of urbanized areas).

Population Density.--Population density

is calculated by dividing the resident population of a geographic unit by its land area

measured in square miles or square kilometers. In 1980, half of the U.S. population

(excluding Alaska and Hawaii) lived in

counties with less than 383 persons per square

mile (21 ). Population density ranges from

64,395 persons per square mile in New York

County, New York (Manhattan) to 0.1 per

square mile in Dillingham Census Division,2

Alaska. Figure 5 shows how the U.S. population is distributed. Urbanized areas are

defined primarily by population density (i.e.,

territory with at least 1,000 residents per

square mile). One drawback of population

density is that it doesn’t describe how the

population is distributed within an area. For

example, a spatially large county that includes

both small, densely settled urban areas and

large, sparsely populated areas would have a

population density that masks such extremes.

1 Not al 1 rural topologies that have been proposed

are described i n this sect i on. Excluded from discussi on are severa 1 economic indices developed i n

the 1960s that associated economic underdevelopnent

ui th rural i ty.

z There are no counties in Alaska. The count y

equi vat ents are the organized boroughs and O1census

areas]’ (U. S. Dept. of Commerce, 1980 Census o f

Population, Volune 1, 1981).

17
18 • Defining “Rural” Areas: Impact on Health Care Policy and Research
Defining “Rural” Areas: Impact on Health Care Policy and Research ■ 19

Adjacency to Metropolitan Area. --A

county’s adjacency to a metropolitan area can

be measured geographically (e.g., sharing a

boundary) or functionally (e.g., proportion of

residents commuting to an MSA for work).

Many residents of these adjacent counties,

however, live some distance from an urban

center, particularly in large counties in the

West. Furthermore, natural geographic barriers or an absence of roads may impede access to metropolitan areas.

Urbanization --- Some topologies use various measures of the level of urbanization to

differentiate nonmetropolitan counties.

Sometimes, urbanization is measured by the

absolute or relative size of the Censusdefined urban population. For non -

metropolitan counties this generally means the

population living in places with 2,500 or

more residents or proportion of the county’s

population that is urban. In other topologies,

an urbanized county is defined by the size of

the county’s total population (e.g., counties

with 25,000 or more residents).

Urbanization/Adjacency to

Metropolitan areas

Analysts at the U.S. Department of Agriculture (USDA ) have classified nonmetropolitan counties on two dimensions: 1 )

the aggregate size of their urban population

and 2) proximity/adjacency to metropolitan

counties (see table 8) (22).3 The urban population follows the Census Bureau’s definition.

Urbanized counties are distinguished from

less urbanized counties by the size of the urban population (i.e., urbanized counties have

at least 20,000 urban residents and less urbanized counties have 2,500 to 19,999 urban

residents). A nonmetropolitan county’s adjacency to an MSA is defined both by shared

boundaries (i.e., touching an MSA at more

3 This classification also includes three types o f

met ropo 1 i t an count i es based on HSA tot a 1

popu 1 at i on- - sma 11 (under 250,000 popu 1 at ion), medium (250,000 to 999,999), and large ( 1 mi 1 I ion or

more).

Table 8--- Classification of Nonmetropolitan

Counties by Urbanization and Proximity

to Metropolitan Areas

(2,490 counties as of 1970)’

Urbanized adjacent (173 counties)

■ Counties with an urban population of at least

20,000 which are adjacent to a metropolita n

county.

Urbanized nonadjacent (154 counties )

■ Counties with an urban population

20,000 which are not adjacent to a

county.

Leas urbanized adjacent (565 counties)

■ Counties with an urban population

of at leas t

metropolita n

of 2.500 t o

19,999 which are adjacent to a metropolita n

count y.

Less urbanized nonadjacent (734 counties)

 Counties with an urban population of 2,500 t o

19,999 which are not adjacent to a metropolitan

county.

Rural adjacent (241 counties)

 Counties with no places of 2,500 or more population which are adjacent to a metropolitan county.

Rural nonadjacent (623 counties )

■ Counties with no places of 2,500 or more popu -

lation which are not adjacent to a metropolitan

count y.

a

Classification of nonmetropolitan areas using 198 0

Census data is forthcoming from the Department of

Agriculture (McGranahan, personal communication ,

1989) .

SOURCE : McGranahan et al., 1986, “Social and Economic Characteristics of the Population in

Metro and Nonmetro Counties, 1970-1980. 11

than a single point) and by commuting patterns (i.e., at least 1 percent of the county’s

labor force commutes to the centra l

county(ies) of the MSA) .

4 Nearly 40 percent

of the nonmetropolitan counties are adjacent

to MSAs, and just over one-half of the nonmetropolitan population resides in these adjacent counties (see table 9).

d The classification scheme Has introduced in 197 5

by Hines, Brown , and Zimner of USDA. Calvin Beal e

and David Broun, also at USDA, later modified th e

classification to include the 1 percent comnu t ing

requirement for adjacent counties (13). A 2 percent consnuting leve[ is used in a more recent version of the typology (5).
20 ■ Defining “Rural” Areas: Impact on Health Care Policy and Research

This typology still masks differences

among nonMSA counties. For example, both

a county with one town of 20,000 and a

county with eight towns of 2,500 would be

considered urbanized under this typology.

The county with several small towns is unlikely to have the level of services of a

county with its population concentrated into

larger towns.

Adjacency to Metropolitan Areas/Largest

Settlement Size

Another county typology groups nonmetropolitan counties by adjacency to MSAs

and by size of the largest settlement (21)

(table 10). Size of largest settlement is a useful parameter to include when analyzing

health services since large settlements are

more likely to have hospitals and specialized

health care providers. However, the presence

Table 9-- Nonmetropolitan County

Population Distribution by Degree of

Urbanization and Adjacency to an MSA

(1980)

Populatio n

a

Percent b

( 1,000s) of nonMSA

U.S. tota l

MSA counties

NonMSA counties

Urbanized

Adjacent to MSA

Not adjacent to MSA

Less urbanized

Adjacent to MSA

Not adjacent to MSA

Totally rura l

Adjacent to MSA

Not adjacent to MSA

226,54 6

163,526

63,02 0 100.0%

14,802 23. 5

9,59 4 15. 2

15,350 24. 4

15,52 9 24. 6

2,73 7 4 . 3

5,00 8 7 . 9

a

Total MSA/nonMSA populations differ from those in

table 7 because this typlogy relies on 1970 MSA

designations.

b

Percent does not sun to 100 due to rounding.

SOURCE: D. A., McGranahan, et al. , “Social an d

Economic Characteristics of the Popula -

tion in Metro and Nonmetro Counties ,

1970-1980.11

of a large town or city does not guarantee

easy access to facilities for all residents of a

spatially large county.

Population Density: Incorporation of the

Frontier Concept

The National Rural Health Association

(NRHA) has proposed a classification system

that includes four types of rural areas (27)

adjacent rural areas--counties contiguous

to or within MSAs which are very

similar to their urban neighbors;

urbanized rural areas--counties with

25,000 or more residents but distant

from an MSA;

frontier areas-- counties with population

densities of less than 6 persons per

square mile, which are the most remote

areas;

Table IO--- U.S. Population by County’s

Largest Settlement and Adjacency

to an MSA (1980)

Population Percen t

(1,000s ) of Us .

U.S. tota l 226,50 5

NonMSA counties 60,51 2

Counties not adjacent to an USA

Largest settlement

Under 2,500

2,500 to 9,99 9

10,000 to 24,999

25,000 or more

Counties adjacent to

Largest settlement

Under 2,500

2,500 to 9,99 9

10,000 to 24,999

25,000 or more

MSA counties

Largest settlement

Under 100,000

100,000 to 249,999

250,000 to 499,999

500,000 to 999,999

1,000,000 to 2,99 9

3,000,000 or more

an MSA

,99 9

4,54 3

10,255

7,12 0

4,12 4

3,15 7

13,23 6

12,46 7

5,61 0

165,994

3,61 1

18,461

24,88 3

28,64 0

50,52 4

39,87 5

100.0

26. 7

2 . 0

4 . 5

3 . 1

1 . 8

1 . 4

5 . 8

5 . 5

2 . 5

73. 3

1 . 6

8 . 2

11. 0

12. 6

22. 3

17. 6

SOURCE: Adapted from L., Long, and D., DeAre ,

llRepopu(ating the countryside: A 198 0

Census Trend ,

M Science, vol. 217, Sept .

17, 1982, pp. 111-116.
Defining “Rural” Areas: Impact on Health Care Policy and Research • 21

• countryside rural areas--the remainder

of the country not covered by other

rural designations.

This typology includes some important

concepts not covered by other topologies,

such as the concept of the “frontier” area.

This typo logy also differs from other

topologies because it includes some counties

within MSAs (i.e., in the adjacent rural area

category ). Since the categories are not

mutually exclusive, however, some counties

will fall into more than one group. For example, under this typology 3 of 14 counties

in Arizona would be both “urbanized rural

areas” and “frontier areas” because the

counties’ populations exceed 25,000 residents

and the population density is less than 6 persons per square mile. 5 County population size

is a poor indicator in the West because many

counties there are much larger than elsewhere.

Urbanization/Population Density

Two other rural topologies incorporate

population density and urbanization. The

first is a classification developed by

Bluestone 6 and the second is a modification

by Clifton of that classification (see table

11).7 Urbanization is defined in terms of the

proportion of the county that is urban (i.e.,

lives in towns of 2,500 or more). An advantage of using the percent of a county’s

population that is urban is that it is not influenced much by the size of the county, or

by a county’s including a large stretch of unpopulated territory. Density is heavily affected by these conditions. Combining mea5 The three Arizona counties are Apache, Coconino,

and Mohave.

6 Herman Bluestone, II FOCUS for Area Deve 10pment

Ana [ ys is: Urban Or ientat ion of Counties, Economi c

Development Di vision, Economic Research Service,

USDA as ci ted in Sinclair and Nanderscheid.

7 I very Clifton, Agricultural Economist, Economi c

Research Service, USDA, unpubl i shed manuscript as

ci ted by Sinclair and Manderscheid.

Table 11-- Bluestone and Clifton County

Classifications Based on Urbanization and

Population Density

Population

per square

Percent urban mil e

Bluestone classification

Metropolitan

Urban

Semi - isolated urban

Densely settled rural

Sparsely settled rural

with some

urban population

Sparsely settled rural

with no urban

population

Clifton's classificatio n

Urban

Semi - urban

Densely settled rural

Rural

GT 85 percent

GT 50 percent

LT 85 percent

GT 50 percent

LT 50 percent

LT SO percent

O percent

GE 50 percent

GE 50 percent

LT 50 percent

LT 100

GT 100

GT 500

100-500

LT 100

50-10 0

LT 50

LT 50

GE 200

30-20 0

GT 30

LT 30

ABBREVIATIONS: GT=greater than; GE=greater than or

equal to; LT=less than.

SOURC E: B., Sinclair, and L., Manderscheid, “ A

Comparative Evaluation of Indexes o f

Rurality--Their Policy Implications an d

Distributional Impacts, t

’ contract report,

Department of Agricultural Economics.

sures of urbanization and density provides

some indication of the degree of population

concentration or dispersion. However, as

with the USDA typology, a county with one

town of 20,000 and a county with eight towns

of 2,500 may not be distinguished under this

scheme.

Distance From an MSA or Population Center

Two rural indexes8 are based on distance

from an MSA or population center. Hathaway

et al., developed a size-distance index that

8 These rural indexes are different frun topologie s

in that they are continuous (e. g., a scale fr~ 1

to 100) rather than categorical measures.
22 ■ Defining “Rural” Areas: Impact on Health Care Policy and Research

includes two measures: miles from an MSA

and the population of that MSA (39). Smith

and Parvin considered three county characteristics in their rural index: populationproximity; population density; and employment in agriculture, forestry, or fisheries

(40,43). A county’s population-proximity indicates the relative access to adjacent

counties’ populations.

Population-proximity is measured as the

county population plus the size-distance ratio

of surrounding counties. 9 To illustrate, the

population-proximity for County A of size

20,000 surrounded by four counties B

through E is as follows:

Table 12--- Population-Proximity: A Measure

of a County’s Relative Access to Adjacent

Counties’ Populations

Distance between Ratio o f

County A and the population

indicated county to distanc e

count y population (miles )

a

(pop./mile )

A 20,00 0

B 15,000 30 5 0 :

c 60,00 0 1,50 0

D 250,00 0 100 2,50 0

E 100,000 10 10,000

Sun of ratios . . . . . . . . . . . . . . . . . . . . . . . . . . 14,500

Add population of County A.. . . . . . . . . . . . 20,000

Population-proximity for County A.... . . 34,500

aDistance is the number of miles between the county

seat of County A and the county seat of the indicated county.

SOURCE : Adapted from Select Committee on Aging, 1983

"Status of the Rural Elderly."

The combination of distance to adjacent

population centers and size of that population

in a typology is attractive because distance is

9 The population-proximity is “the sun of the total

population in the reference comty and the sun of

the ratios of the ntmber of persons in all countie s

within 125 miles of the reference county divided by

the distance in miles bet~een the county seat i n

the reference county and the county seat in each

county within the specified distance (43).U

a good access indicator and population size

indicates service availability. The topologies

incorporating these measures may be most informative for geographically small counties.

For large counties, however, the distance

from one county seat to the next is unlikely

to be applicable to those living at a distance

from the county seat.

Commuting-Employment Patterns

A relatively new county classification

system incorporates measures of population

size, urbanization, commuting patterns of

workers, and the relationships between workplace and place of residence (28). The classification criteria are shown in table 13 and the

distribution of U.S. counties according to this

typology is shown in table 14. The inclusion

of employment and commuting measures may

allow this typology to identify groups of

counties that are economically related such as

service and labor market areas.

Economic and Socio-Demographic

Characteristics

Nonmetropolitan counties have also been

classified according to their major economic

bases, land uses, or population characteristics

(table 15) (7).

10 Fifteen percent of nonmetropolitan counties (370 of 2,443 counties

in the 48 conterminous States) remain unclassified using this approach. Among the

counties that are classified, 70 percent fall

into only one of the seven categories; the

remaining 30 percent fall into two or more

categories (37).

Some of the data used to develop this

classification are now a decade old (e.g., farm

employment), and it is likely that with continued diversification of the rural economy

10 These represent the nonmetropolitan counties as

defined in 1974.
Defining “Rural” Areas: Impact on Health Care Policy and Research ■ 23

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24 ■ Defining “Rural” Areas: Impact on Health Care Policy and Research

Table 14--- Distribution of U.S. Counties by

Typology Based on Employment, Commuting,

and Population Characteristics (1986)

Number of Percent

count i es of Us .

Nonmetropolitan county trees 2393 23. 2

Centers 543 11.1

Satellite s 212 2 . 4

commuting counties with center 239 2 . 7

Small centers 565 3 . 7

Rural commuting counties 333 1 . 7

Rural counties 501 1 . 6

Metropolitan county type 745 76. 8

Metro centers 295 44. 7

Metro satellite s 91 10. 0

Metro commuting satellites 193 15. 0

Metro suburban 133 6 . 6

Metro dormitory 33 less than 1

SOURCE: J., Pickard ,

"An Economic Development

County Classification for the Unite d

States and its Appalachian County Types,"

Appalachian Regional Commission, Wash -

ington, DC June 1988.

since the late 1970s, even fewer counties 11

would be classified into one of these groups.

On the other hand, many rural economies

remain small and dependent on a single industry or occupation despite the economic

diversification(7).

Conclusion

In summary, several topologies for nonmetropolitan counties have been developed

incorporating measures of population size and

density, urbanization, adjacency and relationship to MSA, and principal economic activity (see table 16). While it is desirable to

have a standardized typology to portray the

diversity of rural areas, the potential uses of

11 If the classification scheme uere updated, th e

proportion of nonmetropolitan counties either no t

classified or falling into more than one grou p

would likely be greater than the present 43 percent.

topologies are varied and require inclusion of

different measures. For example, to study

the geographic variation of access to health

care, a typology that includes population size,

density, and distance to large settlements is of

interest. To study health personnel labor

market areas, however, a typology based on

economic areas, market areas, or worker

commuting patterns is preferable. On the

other hand, rural economists or sociologists

may be more interested in identifying

counties with economies dependent on farming, mining, or forestry.

While no one typology meets all potential

needs, there are several desirable features of

any typology. For example, for many purposes it is helpful to have topologies with

mutually exclusive (i.e., nonoverlapping) categories. The National Rural Health Association’s typology includes frontier (less than 6

persons per square mile) and urbanized rural

counties (population of 25,000 or more and

not adjacent to an MSA). Yet it is possible

for counties to meet both criteria.

The concept of urbanization is incorporated into several of the topologies. In

some cases, urbanization is determined by the

absolute or relative size of a county’s urban

population and in others, by the size of a

county’s largest settlement. When the size of

the urban population is used, a county with

one large city with the balance of the county

sparsely populated, would be indistinguishable

from a county with several smaller towns. As

level of resources are likely to be city-size

dependent, topologies using this measure of

urbanization may not discriminate well for

some applications. On the other hand, while

largest settlement size might be indicative of

level of services available in the county, it is

not informative of how remote those services

might be for all county residents. In geographically small counties, large settlements are

likely to be accessible to all county residents.

In the West, however, counties can be as

large as some Eastern States, and some

measure of proximity would be useful to indicate physical access. Measures of how
Defining “Rural” Areas: Impact on Health Care Policy and Research • 25

Table 15.--Classification of Nonmetropolitan Counties by Economic and

Socio-Demographic Characteristicsa

Farming-dependent counties

702 counties concentrated largely in the Plains portion of the North Central region.

Farming contributed a weighted annual average of 20 percent or more of total labor and proprietor income

over the five years from 1975 to 1979.

Manufacturing-dependent countie s

678 counties concentrated in the Southeast.

Manufacturing contributed 30 percent or more of total labor and proprietor income in 1979.

MNining-dependent countie s

200 counties concentrated in the West and in Appalachia.

Mining contributed 20 percent or more to total labor and proprietor income in 1979.

Specialized government counties

315 counties scattered throughout the country.

Government activities contributed 25 percent or more to total labor and proprietor income in 1979.

Persistent poverty counties

242 counties concentrated in the South, especially along the Mississippi Delta and in parts of Ap -

palachia.

Per capita family income in the county was in the lowest quintile in each of the years 1950, 1959, 1969,

and 1979.

Federal Lands counties

247 counties concentrated in the West.

Federal land was 33 percent or more of the land area in a county in 1977.

Destination retirement counties

515 counties concentrated in several northern Lake States as well as in the South and Southwest.

For the 1970 to 1980 period, net immigration rates of people aged 60 and over were 15 percent or more of

the expected 1980 population aged 60 and over. Retirement counties are disproportionately affected b y

entitlement programs benefiting the aged.

a

The nutr&er of nonmetropolitan counties does not add to the total n-r (2,443), because the categorie s

are not mutually exclusive and 370 counties do not fit any of the categories.

SOURCE: Bender, L.D., Green, B.L., Hady, T.F., et al., Economic Research Service, U.S. Department of Agriculture, The Diverse Social and Economic Structure of Nomnetrocmlitan America, Rural Develop -

ment Research Report No. 49 (Washington, DC: U.S. Goverrmnent Printing Office, Septenber 1985) .

Table 16--- Features of the Nine County-Based Topologies

Measures

Population

Typology siz e Densit y Urbanization Adjacency Distanc e Economy

USDA-l a . . . . ■

. . . .

Long and DeAre b

■

. . . . ■

. . . .

NRHAC ■ ■

. . . . . .

Blueston e

d . . ■

. . ■

. . . .

Clifto n

e . . . . ■

. . . .

Parvin and Smit h

f ■. . . . . .

Hathaway g

■

. . . . . . ■

. .

Pickar d

h

■

. . ■

. . . . ■

USDA-2i . . . . . . . . ■

~cGranahan, D.A. et al., USDA, 1986 .

Long, L. and DeAre, D., 1982.

~~~~~~~\~ural Health Association, as cited in pat~~ L., ,989 , H. as cited in Sinclair, B., and Mandersch&id, L.V. ,

.

1974.

~C[ifton, I. as cited in Sinclair, B., and Manderscheid, L.V., 1974.

Parvin, D.H. and Smith, B.J. as cited in U.S Congress, Hwse of Representatives, Task on the Rural Eldelry

of the Select Comnittee on Aging, 1983.

‘Hathaway, D.E. as Cited in Sinc[air, B., and Manderscheid, L.V., 1974.

‘Pickard, J. , Appalachia 21(3):19-24, Sumner, 1988.

IBender, L.D. et al., USDA, 1985.

SOURCE: Office of Technology Assessment, 1989.
26 ■ Defining “Rural” Areas: Impact on Health Care Policy and Research

evenly the population is distributed might

also be useful for large counties.12 Several of

the topologies incorporate an adjacent-toMSA measure, which is an indicator of access

to level of services. The proportion of a

county’s population that is urban is a useful

measure in large Western counties because

unlike population density, it is a measure that

is not influenced much by size of county or

by population distribution.

Nonmetropolitan county data can also be

disaggregate regionally by State or groups of

States (e.g., the four Census regions or nine

Census divisions), or by economic areas (e.g.,

Bureau of Economic Analysis Areas or

BEAs). The Bureau of the Census defines

“county groups” that are usually contiguous

counties that combined have a population of

100,000 or more. 13 These counties ar e

generally grouped according to meaningful

State regions such as planning districts (50).

A new category of nonmetropolitan area

called “micropolitan area” has recently been

described (42a). While not a typology, the

new category does distinguish non -

metropolitan areas that exert similar social

and economic influences on their regions as

metropolitan areas do on a larger scale. Most

micropolitan areas are single counties but a

few span two counties or are independent

cities. Micropolitan counties are relatively

large (40,000 or more residents) and include a

central “core city” with at least 15,000 residents. 14,15 Many micropolitan areas are COl- .

lege towns, sites of military bases, and retirement areas. More than 15 million people or

about one-quarter of nonmetropolitan residents live in the 219 identified micropolitan16

areas.

12 The Hoover index is a measure of population

concentration or dispersion. The index ranges from

zero, which indicates a perfectly uniform distribut ion in which each subarea has the same proportion

of total population as it does of land area, t o

100, which represents the concentration of all th e

population into a single subarea (21). To estimat e

county population dispersion, subcounty geographic

areas would be used. Other methods to measur e

population concentration or dispersion include th e

nearest-neighbor statistic or the quadrant technique, but both require a geographic information system incorporating longitude and latitude measure s

(9, 17,24) .

]3 These county groups are only defined in public

use data fi les.

14 If a nonmetropol itan city of 15,000 or mor e

residents has at least 40 percent of its population

in each of two counties, the micropol itan area in -

cludes both counties.

15 In four States (Maryland, Missouri, Nevada, and

Virginia) some cities (called independent cities )

have the sane status as counties and are considered

micropolitan if they have 15,000 or more resident s

and are larger than 15 square miles. If the cit y

is areally smaller, it is joined uith the adjacen t

county to form the area.

16 A list of micropolitan areas is available from

Niagara Concepts, P.O. Box 296, Tonauanda, New Yor k

14151”0296.
6. THE AVAILABILITY OF VITAL AND HEALTH STATISTICS

FOR NONMETROPOLITAN AREAS

Given the diversity of nonmetropolitan

areas, it is important to present vital and

health and statistics by State, region, or by

nonmetropolitan typology. Data from the

decennial Census and national vital statistics

(e.g., natality and mortality data) are published for nonmetropolitan areas by State and

degree of urbanization, but few other sources

of health information are published along

these dimensions. For example, the National

Center for Health Statistics does not publish

detailed nonmetropolitan data (e.g., crosstabulated by Federal region) in their reports

on National Health Interview and National

Medical Care Utilization and Expenditure

Surveys. Sometimes, limitations of the way

in which the data are collected (e. g., the

sample size or frame) limit the extent to

which nonmetropolitan data can be displayed.

In general, however, survey data files are

available for public use and can be analyzed

by area.

The choice of definition of “rural” used

to present demographic and health data can

make a substantive difference. For example,

whether a disproportionate number of rural

residents are elderly depends on how rural is

defined. Table 17 shows the proportion of

Table 17--- Proportion of the Population 65

and Older by Metropolitan/Non metropolitan

and Urban/Rural Residence

Percent age

Area U.S. population 65 and over

Metropolitan 169,430,57 7

Nonmetropolitan 57,115,22 8

Urban 167,054,63 8

Rural 59,491,16 7

Metropolitan

Urban 145,451,31 5

Central citie s 67,854,91 8

Not central cities 77,596,39 7

Rural 23,979,26 2

Nonmetropolitan

Urban 21,603,32 3

Rural 35,511,90 5

10. 7

13. 0

11. 4

10. 9

10. 9

11. 8

10. 2

9 . 0

14. 3

12. 2

SOURCE : U.S. Department of Commerce, Bureau of the

Census, 1980 Census: General Social and

Economic Characteristics.

the population aged 65 and older according to

metro/nonmetropolitan and urban/rural

designations. The elderly appear to make up

a larger proportion of the total population in

nonmetropolitan than metropolitan areas (13.0

v. 10.7 percent). Using the urban/rural categories, however, the opposite is true--there is

a greater proportion of elderly residents in

urban than rural areas (11.4 v. 10.9). The

explanation of this discrepancy appears to be

that there are proportionately more persons

65 and older living in urban nonmetropolitan

areas (14.3 percent) and fewer in rural

metropolitan areas (9.0 percent). Moreover,

when nonmetropolitan county MSA-adjacency

and size of the urbanized population are considered, the aged appear to be overrepresented in the less urbanized and nonadjacent counties (see table 18).

Table 18--- Proportion of Nonmetropolitan

Population Age 65 and Older by Level

of Urbanization and Adjacency

to an MSAa (1980) b

Percent

U.S. Population age 65

( 1,000s) and older

U.S. tota l

Metropolitan counties

Nonmetropolitan counties

Urbanized

Adjacent to metro are a

Not adjacent

Less urbanized

Adjacent to intro area

Not adjacent

Totally rural

Adjacent to metro area

Not adjacent

226,54 6

163,52 6

63,02 0

14,802

9,59 4

15,35 0

15,52 9

2,73 7

5,008

11. 2

10. 7

12. 8

11. 9

11. 0

13. 3

13. 5

13. 7

14. 6

~rbanized counties are those with an urban popu -

lation of at least 20,000; less urbanized countie s

are those with an urban population of betwee n

2,500 to 19,999; and totally rural counties ar e

those with no populations of 2,500 or more.

b1980 Census information is displayed using th e

1970 classification of counties.

SOURCE: D. A., McGranahan, et al. , “Social an d

Economic Characteristics of the Popula -

tion in Hetro and Nonmetro Counties ,

1970-80 ,

11 USDA, ERS, Rural Developmen t

Research report 58, appendix, table 2.

27
28 • Defining “Rural” Areas: Impact on Health Care Policy and Research

Infant mortality is also better understood

by looking beyond metropolitan/nonmetropolitan comparisons. Department of Health

and Human Services (DHHS) publishes data

on infant mortality for urban and “not urban”

places within metropolitan and non -

metropolitan counties (nonmetropolitan urban

places are defined as those with populations

of 10,000 or more). 1 Table 19 shows that

within U.S. nonmetropolitan areas ( 1985-

1986), white infant mortality rates were lower

in nonurban places than in urban places (9.3

versus 9.9). Black infant mortality, in contrast, is higher in non urban places (17.8

versus 16.5). In some nonmetropolitan areas

(e.g., Alabama), infant mortality is higher in

the more rural areas for both whites and

blacks (see table 19).

In summary, quite different conclusions

about the rural population may be reached by

changing the definition of rural areas. Furthermore, important within-area variations

are obscured when national data are not published for sub nonmetropolitan areas.

The problem of limited rural data is not

a new one for policy makers. In 1981, the

National Academy of Sciences addressed the

issue in a report, Rural America in Passage:

Statistics for Policy. A panel on Statistics for

Rural Development Policy comprised of agricultural economists, statisticians, geographers,

sociologists, and demographers made a number of recommendations to improve the perceived poor availability and quality of rural

statistical databases. The panel recommended

that the Federal Government “take a more active role in the coordination of statistical activities and in developing and promulgating

common definitions and other statistical standards that are appropriate for implementation

at the Federal, State, and local levels.” The

panel concluded that a single definition of

“rural” is neither feasible nor desirable but

1 DHHS defines urban places in USA counties a s

those with populations of 10,000 or more but les s

than 50,000 . This urban definition differs fro m

the Bureau of the Census definitions of urban or

urbanized areas.

Table 19.--Nonmetropolitan Infant Mortality

Rates by Urban Area and Race, U.S. Total

and Alabama (1986)

Infant mortality rate (no. deaths )

(deaths under age 1 per 1,000 births )

United

State s Alabama

Nonmetropolitan

Urban placesa

White

Black

Other

Balance of area

White

Black

Other

10.4 (17,926 )

10.8 (4,075 )

9.9 (3,019 )

16. 5 (958 )

7 . 1 (98 )

10.3 (13,851 )

9.3 (10,644 )

17.8 (2,632 )

10. 7 (575 )

12.7 (553 )

10.9 (115 )

7.4 (47 )

16.3 (67 )

7 . 6 ( 1 )

13.3 (438 )

10.5 (228 )

19.2 (210 )

. . ( o )

aUrban places in nonMSA counties are those wit h

populations of 10,000 or more.

SOURCE : Department of Health and Human Services,

Public Health Service, Vital Statistics o f

the U. S.: 1986, 1985, Vol. 1, Natal ity,

Pub. No. 88-1123, 88-1113 (Washington, DC:

U.S. Government Printing Office, 1988 ,

1987); 1986, 1985, Vol. 2, Mortality, Pub.

No. 88-1114, 88-1102 (Washington, DC: U.S.

Govermnent Printing Office, 1988, 1987).

recommended that data be organized in a

building-block approach so that different

definitions and topologies could be constructed. The panel recognized the need for

a common aggregation scheme for counties.

It recommended the development of a standard classification of nonmetropolitan

counties related to the level of urbanization.

The panel recommended that if possible, the

county classification should be supplemented

by a distinction between urban and rural

areas within counties (13).

The lack of consistent county coding

poses difficulties for those interested in developing county-based definitions and

topologies. Unique county identifiers called

county FIPS (Federal Information Processing

Standards) codes are provided by the National

Institute of Measurement and Technology

z The National Institute of Measurement and Tech -

nology was formerly the Bureau of National Stan -

dards.
Defining “Rural” Areas: Impact on Health Care Policy and Research Ž 29

but are not universally used (8). The panel

recommended that Federal and State data be

recorded with such county codes to permit

tabulations for individual counties and groups

of counties. Adherence to a county coding

system would facilitate aggregation of information regardless of how rural is defined.

Since the report was issued in 1981, few of

its recommendations have been implemented

(8).

The relative merits of the county-based

topologies for health service planning and research can be evaluated using the Area

Resource File (ARF), a county-level data

base maintained by the Health Resources and

Services Administration (61). The file contains data necessary for the Bureau of Health

Professions to carry out its mandated program

of research and analysis of the geographic

distribution and supply of health personnel.

Population, economic, and mortality data, and

measures of health personnel, health education, and hospital resources, are included in

the file (61).

The ARF has been used to show how the

availability of physician and hospita l

resources varies by type of nonmetropolitan

area (table 20) ( 18). For example, when

physician availability is examined by typeof-county, wide variations in physician-topopulation ratios are evident. The average

physician-to-population ratio is 64 per

100,000 in nonmetropolitan counties 3 but it

ranges from 131 per 100,000 in high-density

counties to a low of 45 per 100,000 in persistent poverty counties (see table 20). Somewhat surprisingly, there appear to be relatively more physicians in nonadjacent than adjacent nonmetropolitan counties (67 compared

to 59 per 100,000). A possible explanation is

that physicians serving many of the residents

of the adjacent nonmetropolitan counties are

3 This analysis was ( imi ted to nonmetropolitan

count i es of 1 ess than 50,000 population i n 1985.

Only physicians engaged in patient care are inC 1 Uded.

preferentially locating in the outlying suburban areas of MSAs.

Maps effectively illustrate geographic

variation in health status and access to health

care resources. U.S. cancer atlases have been

published at the county level providing a

visualization of geographic patterns of cancer

mortality not apparent from tabular data

(60).

4 Rural women in the lower socioeconomic classes have high rates of cervical

cancer and for white women, maps show

concentrations of cervical cancer throughout

the South, especially in Appalachia (see figure 6).

Maps of the United States by county

show higher death rates due to unintentional

injury (e.g., housefires and drownings) and

motor vehicle crashes in rural areas, particularly in Western, sparsely populated counties

(see figures 7-8). The large volume of travel

on major routes traversing rural areas does

not account for the high rural death rates.

Instead, road characteristics, travel speeds,

seat-belt use, types of vehicles, an d

availability of emergency care are factors that

may contribute to the excess of motor vehicle

crash deaths in rural areas (3).

Maps of nonmetropolitan county variation in health indicators (e. g., infant

mortality) and the distribution of health care

resources (e.g., physicians, hospitals) will soon

be published in the Rural Health Atlas.5 A

typology of rural medical care is being developed for the Atlas, which incorporates

measures of access to primary care physicians

and health facilities. Such a typology will

help identify isolated communities with

limited access to health care (35).

d The U.S. Cancer Atlas maps cancer mortality b y

county groupings called State Economic Areas (SEA).

506 SEAS were delineated by the Bureau of th e

Census in 1960. SEAS are geographic units ~ith

sirni lar demographic, climatic, physiographic, an d

cultural features (60) .

J The atlas is scheduled to be published by re -

searchers at the University of North Carolina b y

October, 1989 (35).
30 ■ Defining “Rural” Areas: Impact on Health Care Policy and Research

Table 20.--Characteristics of Different Categories of U.S. Nonmetropolitan Counties

(2,092 nonmetropolitan counties of less than 50,000 population in 1985)8

1985 1986 1986 1980 1979

Category M.D.+ hospital hospital Age X in

(numbet of counties) DO/100,000 beds/1,00 0 days per 1,000 over 65 povert y

U.S. total (2092 )

Urbanized (83)

Less urban (1239)

Rural (770 )

MSA adjacent (751)

MSA nonadjacent (1341)

1980 population density

3 or less (194 )

>3 and < 6 (181)

>6 and < 9 (123)

>9 and < 50 (1235)

>50 and < 100 (320)

more than 100 (39)

East (59)

South Atlantic (324 )

South (624)

Central (799 )

West (286)

Agricultural only (464 )

Agricultural total (680 )

Manufacturing only (290)

Manufacturing total (500 )

Mining only (97)

Mining total (183 )

Federal Lands only (35)

Federal lands total (210 )

Government only (75)

Government total (246)

Poverty only (41)

Poverty total (238 )

Retirement only (140)

Retirement total (420 )

64. 2

113. 7

71. 9

46. 5

58. 6

67. 3

48. 9

59. 2

63. 4

60. 5

80. 5

130. 5

115. 7

60. 7

54. 4

64. 9

75. 4

52. 2

49. 1

68. 3

62. 4

61. 2

57. 1

106. 8

75. 8

76. 5

66. 6

45. 3

43. 0

79.1

67. 5

5 . 0

6 . 4

5 . 5

4 . 1

4 . 3

5 . 4

4 . 9

7 . 2

6 . 1

4 . 6

4 . 9

7 . 7

5 . 5

4 . 2

4 . 3

5 . 9

5 . 1

5 . 7

5 . 1

4 . 5

4 . 3

5 . 1

4 . 3

3 . 8

3 . 9

9 . 9

7 . 0

3 . 4

3 . 3

4 . 5

4 . 0

962

1421

1081

721

858

1021

1382

1035

858

1053

1959

1443

1193

942

1o11

944

847

824

774

689

698

643

2382

1603

535

575

841

743

14. 2

12. 5

13. 9

15.1

13. 9

14. 8

13.1

14. 7

15. 9

14. 8

12. 5

11. 4

13. 5

12. 7

14. 8

16. 0

11. 5

16. 6

15. 9

13. 2

13. 4

12. 2

11. 8

10. 0

11. 4

13. 4

13. 2

13. 5

13. 6

16. 9

15. 6

17. 6

15. 2

16. 7

19. 3

16. 4

18. 2

17. 9

16. 5

16.1

18. 5

15. 7

12. 0

12. 8

20. 7

22. 0

14. 3

14. 3

17.1

18. 8

15. 2

16. 8

16. 0

16. 5

12. 0

14. 8

18. 0

19. 4

29. 9

28. 3

16. 0

17. 6

a

2 8 2 nomtetropolitan counties uith 50,000 or more population were excluded from analyses.

SOURCE: Kindig, D.A., et al., llN~tropo(itan County Typology and Health Resources;ti unpublished manuscript, Dec. 15, 1988.
Defining “Rural” Areas: Impact on Health Care Policy and Research ■ 31

Figure 6--- Areas With Cervical Cancer Mortality Rates Significantly Higher

Than the U.S. Rate, and in the Highest 1OO

/o of all SEA Rates

(White Females, 1970-1980)

SOURCE: U.S. Department of Health and Human Services, Public Health Service, National Institutes of Health,

Atlas of U.S. Cancer Mortality Among Whites: 1950-1980, DHHS Pub. No. (NIH) 87-2900 (Bethesda, MD:

1987).
32 ■ Defining “Rural” Areas: Impact on Health Care Policy and Research

Figure 7---Death Rates Due to Unintentional Injury by County

0.00 —

I I

38.16 —

72.07 —

90.44 — 429.00

SOURCE : Baker, S. P., Uhitfield, R. A., and O]Nei 11, B . , qwty Mapping of Injured Mortal ity, ” The Journal

of Trauna 28(6):741-745, Jme 1988 .
Defining “Rural” Areas: Impact on Health Care Policy and Research • 33

Figure 8--- Death Rates Due to Motor Vehicle Crashes by County

57.28– 1465.20

SOURCE : Baker, S. P., Uhitfield, R.A., and O’Neill, B. , llGeOgr@ic variations in Mortality From Motor

Vehicle Crashes, U New England Journal of Medicine 316(22):1384-1387, May 28, 1987.
7. USING OMB AND CENSUS DESIGNATIONS

TO IMPLEMENT HEALTH PROGRAMS

There is no uniformity in how rural

areas are defined for purposes of Federal

program administration and distribution of

funds. Even within agencies different

definitions maybe used. This may occur

when agencies implement programs or

policies for which rural areas have been

defined legislatively. For example, the

MSA/nonMSA designations are used to categorize hospitals as urban or rural areas for

purposes of hospital reimbursement under

Medicare. On the other hand, in the case of

clinics certified under the Rural Health

Clinics Act, “rural” is defined as Census

Bureau-designated nonurbanized areas.

Certified clinics receive cost-based reimbursement from Medicare and Medicaid.

These two examples of how the MSA and

Census designations are used are described in

more detail in the following section. Finally,

the definition of “frontier” areas is described

as it is used by the Department of Health and

Human Services (DHHS).

Medicare Reimbursement: Using MSAs To

Define Urban and Rural Areas

Several geographic designations affect

hospital reimbursement under Medicare’s

prospective payment system (PPS). Different

reimbursement rates are calculated for hospitals located in rural, large urban (population

of more than a million),l and other urban

areas. Under PPS, Congress directed the

Health Care Financing Administration

(HCFA) to define “rural” and “urban” hospitals as those located in nonmetropolitan and

metropolitan areas, respectively. 2 On average, urban hospital per-case payments are 40

percent higher than those of rural hospitals

because of differences in urban and rural

standardized amounts, average wage and

case-mix indexes, and other factors.

Rural hospitals designated as “sole community hospitals” are not subject to the same

reimbursement methods as other rural hospitals. 3 These hospitals are “by reason of factors such as isolated location, weather conditions, travel conditions, or absence of other

hospitals, the sole source of inpatient hospital

services reasonably available in a geographic

area to Medicare beneficiaries.” An exception is also made for large nonmetropolitan

hospitals that serve as “rural referral centers”

for Medicare patients. These hospitals are

reimbursed at the same rate as urban hospitals

(58).

The rural/urban reimbursement differential has not been well-accepted by some hospitals. In some cases, the concerns of nonmetropolitan hospitals have prompted legislators to change the designation of the county

in which the hospital is located from nonmetropolitan to metropolitan. The HCFA

metropolitan/nonmetropolitan hospital reimbursement standards were modified by the

Omnibus Reconciliation Act of 1987.4 Some

hospitals located in nonMSAs were reassigned

to the urban (MSA) category. Accordingly, a

hospital located in a nonmetropolitan county

adjacent to one or more metropolitan area is

treated as being in the metropolitan area to

which the greatest number of workers in the

county commute, if:

■ the nonMSA county would otherwise be

considered part of an MSA area but for

the fact that the nonMSA county does

not meet the standard relating to the

1 I n Neu Engl and County Metropol i tan Area s

(MECMAs), a large urban area includes a population

of more than 970,000.

L Certain nornnetropol itan New England counties were

deemed to be parts of metropol i tan areas for purposes of PPS.

3 The prospective payment rates for sole cmnun i ty

hospitals -al 75 percent of the hospital-specifi c

base payment rate plus 25 percent of the ap -

propriate regional prospective payment rate (58).

4 Pub(ic Law 100-203 Sec. 4005.

35
36 ■ Defining “Rural” Areas: Impact on Health Care Policy and Research

■

rate of commutation between the non

MSA county and the central county or

counties of any adjacent MSA; and

either 1) the number of residents of the

non MSA county who commute for

employment to the central county or

counties of any adjacent MSA is equal

to at least 15 percent of the number of

residents of the nonMSA county who are

employed; or 2) the sum of the number

of residents of the nonMSA county who

commute for employment to the central

county or counties of any adjacent MSA

and the number of residents of any adjacent MSA who commute for employment to the nonMSA county is at least

equal to 20 percent of the number of

residents of the nonMSA county who are

employed.

Thirty-nine non MSA counties meet these

standards (53 FR 38498).

Some hospitals dissatisfied with the

rural/urban reimbursement differential have

resorted to lawsuits in order to receive urban

rates. For example, 28 hospitals in Missouri

nonMSAs have sued DHHS, contending that

MSA designations are not related to the costs

of providing medical care and that DHHS

underpays for the services provided to

Medicare patients. Under the current regulations, a hospital in Jefferson City, for example, is paid less than a hospital in Columbia

30 miles away, because the first hospital is

located outside an MSA ( 15). The National

Rural Health Association has filed a class action suit against DHHS, charging that rural

hospitals’ Fifth Amendment rights to due

process are being violated on two counts related to “unreasonably low reimbursement for

rural hospitals” (16).

In a congressionally mandated study,

DHHS examined the feasibility and impact of

phasing out or eliminating separate urban and

rural payment rates, retaining regional or

hospital-specific rates, refining the wage index, and other alternatives to separate urban/rural rates (58). The study suggests that

the PPS formula should be refined so that

continuous measures are used to adjust a

single reimbursement rate. HCFA is examining the feasibility of using severity measures

as a more sensitive alternative to geographically based separate rates (65).

The Prospective Payment Assessment

Commission (ProPAC), a body formed to

make recommendations to the Congress on

PPS, has stated that before it can make a

recommendation to either maintain or

eliminate separate urban and rural rates, it

must better understand why there is an approximate 40 percent difference in average

Medicare cost per case between urban and

rural hospitals. This cost difference was

present when the PPS rates were first established and has persisted through at least the

first three years of PPS. The PPS rural/urban

payment differential reflects poorly understood geographic practice pattern variations that cannot be attributed to measurable

differences in patient characteristics, quality

of care, or market area features. The issue is

complicated by the unknown relationship between practice pattern variations, revenues,

costs, and quality (34).

Defining Rural Labor Market Areas ---

The PPS formula includes a wage index adjustment that takes into account geographic

differences in labor costs. A different wage

index is applied to urban and rural labor

market areas. Labor market areas are rather

precisely defined for urban areas--each MSA

is defined as a labor market area. In contrast, there is one rural labor market area

defined for each State, which includes all

nonMSA counties in that State.

Recognizing wide variation in hospital

wage levels within these broadly defined

labor markets, ProPAC has recommended that

rural hospital labor market areas be redefined

to distinguish between urbanized rural

counties and other rural counties within each

State. Accordingly, urbanized rural counties

would be defined as counties with a city or

town having a population of 25,000 or great-
Defining “Rural” Areas: Impact on Health Care Policy and Research • 37

er

5 (33). Analyses of 1982 data show average

hospital wages in State’s “urbanized rural

counties” to be 8.5 percent higher than wages

in “other rural counties” ($7.54 v. $6.95) (32).

DHHS asserts that wage differentials are already taken into account to some degree

through other PPS adjustments (i.e., the indirect medical education and disproportionate

share adjustments) and the special treatment

for rural referral centers (53 FR 38498).

ProPAC has also recommended (31,32,33)

that definitions of urban hospital labor

market areas be modified to include a distinction between an MSA’s central urban and

outlying areas. They suggest that urbanized

areas within an MSA, as defined by the

Bureau of the Census, could be distinguished

from nonurbanized areas. DHHS has rejected

this proposal, in part because of the difficulty

of assigning a hospital to an urbanized area,

the boundaries of which are defined below

the MSA level. Determining whether or not

a hospital is inside or outside of an urbanized

area involves pinpointing the hospital location

in terms of the smallest units of Census geography (the block or block group). In a study

conducted for ProPAC ( 1), a process is described whereby the location of a hospital can

be specified in terms of Census geography

and then mapped to urbanized area boundaries. According to DHHS, however, defining labor markets below the county level

would be confusing and difficult to administer.

The Rural Health Clinics Act

Ambulatory services can be reimbursed

on an at-cost basis by Medicare and Medicaid

if facilities and providers meet certification

requirements of the Rural Health Clinics Act

(Public Law 95-210). To be certified, a

practice must be located in a rural area that

is designated either as a health manpower

shortage area (HMSA) or a medically undeserved area (MUA). The practice must

use a mid-level practitioner (physician assistant or nurse practitioner) at least 60 percent of the time that the practice is open.

There has been renewed interest in this Act

following an increase in the ceiling of reasonable costs reimbursed by Medicare and

Medicaid programs. The payment cap is indexed to the Medicare Economic Index (36).6

Rural areas, for purposes of the Rural

Health Clinics Act, are ‘areas not delineated

as urbanized areas in the last census conducted by the Census Bureau.” Nonurbanized

areas encompass a larger area than either the

non MSA or Census-defined rural areas.

Therefore, Rural Health Clinics can be located within an MSA (see figure 3) or in a

nonMSA town with a population of 2,500 or

more (such a town is urban according to the

Census Bureau).

In summary, for purposes of hospital

reimbursement under Medicare, the MSA

designation is used (with certain specific exceptions) to distinguish urban from rural hospitals. Persistent MSA/nonMSA hospital cost

differences have been noted since the PPS

rates were first established, but it is likely

that MSA location is an indirect measure of

hospital cost. Hospital-specific measures are

being sought to replace the MSA adjustment

in the PPS formula.

Geographic designations are also used to

define urban and rural labor market areas.

Dissatisfaction with having only one rural

labor market area per State (i.e., one labor

market for all non MSA counties) has led

ProPAC to recommend two labor market

areas for nonMSA counties. They have suggested recognizing as urbanized, nonMSA

counties with a city or town with a population of 25,000 or greater (33). The average

5 This definition of an urbanized rural count y

should not be confused u i th the Bureau of th e

Census definition of an urban or urbanized area.

6 These changes to the Rural Health Clinics Ac t

uere contained i n the Budget Reconc i 1 i at i on Act of

1987.
38 • Defining “Rural” Areas: Impact on Health Care Policy and Research

hospital wage is 8.5 percent higher in urbanized rural counties than in nonurbanized

rural counties (32). There are less than 125

nonMSA towns with 25,000 or more population, so few of the 2,393 nonMSA counties

would be classified as urbanized (49). In

fact, this distinction would create only 37

new areas (32).

Although HCFA has chosen not to use

urbanized areas to refine labor market areas,

HCFA does use urbanized area designations

when certifying hospitals and clinics under

the Rural Health Clinic Act. Rural Health

Clinics must be located in nonurbanized areas

that are designated as either a health manpower shortage area or a medically undeserved area. This liberal interpretation of

“rural” (e. g., it includes some areas within

MSAs) seems appropriate, given the requirement that the area must also be medically undeserved. This allows some medically undeserved areas within MSAs--but isolated

from an urbanized area by factors other than

distance--to be certified.

Providing Services in “Frontier” Areas

Health services may be difficult to provide in large, sparsely populated areas. Areas

with a population density of 6 persons per

square mile or less, called “frontier” areas, are

common West of the Mississippi river (30)

(figure 9). In 1980, by this definition, there

were at least 378 frontier counties with a total population of nearly 3 million persons

(42). It may take an hour or more for residents of frontier areas to reach health providers and facilities. Frontier physicians tend

to be generalists, solely responsible for a large

service area, and have limited access to hospitals and health care technology (1 1).

Recognizing the unique characteristics of

frontier areas, 7 DHHS in early 1986 agreed to

use different criteria to evaluate Community

7 The Frontier Task Force of the National Rural

Health Association (established in 1985) uas in -

strumental in documenting the unique health car e

needs of rural areas (63).

Health Center (CHC) grantees (and new applicants for CHC support) and National

Health Service Corps sites. 8 Frontier areas

were defined as (59):

Those areas located throughout the country

which are characterized by a small popu -

lation base (generally 6 persons per square

mile or fewer) which is spread over a considerable geographic area.

To be eligible for Bureau of Health Care

Delivery and Assistance (BHCDA) support as

a frontier area, the following service area

criteria must be met (59):9

Service Area: a rational area in the frontier will have at least 500 residents within

a 25-mile radius of the health services

delivery site or within the rationally established trade area. Most areas will have

between 500 to 3,000 residents and cover

large geographic areas.

Population Density: the service area will

have six or fewer persons per square mile.

Distance: the service area will be such

that the distance from a primary care

delivery site within the service area to the

next level of care will be more than 45

miles and/or the average travel time more

than 60 minutes. When defining the “next

level of care,” we are referring to a facility with 24-hour emergency care, with 24-

hour capability to handle an emergency

caesarean section or a patient having a

heart attack and some specialty mix to include at a minimum, obstetric, pediatric,

internal medicine, and anesthesia services.

8 The 1988 authorizing legislation for Publi c

Health Service programs of assistance for prinmry

health care included reconunendations for DHHS t o

support primary health care planning, development,

and operations in frontier areas (46).

!) If the eligibility criteria are not strictly met ,

an organization may justify any unusual circum -

stances which may qualify them as frontier, fo r

example, geography, exceptional economic conditions, or special health needs (59).
Defining “Rural” Areas: Impact on Health Care Policy and Research • 39

Figure 9--- Frontier Counties: Population Density of 6 or Less

(

A—-

+ — ,~

.

SOURCE : U.S. Department of Health and Human Services, Public Health Service, Health Resources and Services

Administration, Bureau of Health Professions, Office of Data and Management, Area Resource File,

June 16, 1986.
40 • Defining ‘Rural” Areas: Impact on Health Care Policy and Research

Some State Health Departments have had

trouble identifying service areas meeting

these criteria (26). Whole counties can be

identified as frontier areas on the basis of

population density, but available sub-county

geographic units are sometimes inadequate for

identifying health service areas. Population

data from the 1980 Census are available for

sub-county areas such as Census County

Divisions (CCDs), and Enumeration Districts

(EDs) (see appendix D) but these areas can be

large and may not represent a rational health

service area.10 ZIpCode s

11 may be a g-

gregated to form a rational service area, but

this poses some technical difficulties (19).

Following the 1990 Census, Block Numbering

Areas will be available for all nonurbanized

areas (see appendix D.--1980 Census geography). 12

10 Some States have defined primary care service

areas (e. g., Neu York) .

11 population data from the Census are available by

Z I PCode. Some investigators have used ZIPCodelevel census data to describe three types of rural

area based upon density within zip code: semi-rural

(density of 16 to 30 per square mile); rura l

(density 6 to 15 per square mile; and frontie r

(density less than 6 per square mile) (10).

12 In 1980, Block Nunbering Areas were only available for nonurbanized places ~ith over 10,000 pop -

ulation .

It is useful to distinguish frontier area

counties with evenly distributed small settlements from counties with one or two large

population settlements and large areas with

little or no settlement. For example, the

health service needs of two frontier counties

in New Mexico with similar population

densities differ because of the way the populations are distributed. One county has a total population of approximately 8,000, of

whom about 6,000 live in one town. In contrast, the other county has a total population

of 2,500 living in six widely dispersed towns.

If suitable sub-county areas were available,

the Hoover Index, which measures population

concentration or dispersion, could be used to

distinguish between these counties. An automated geographic information system called

TIGER (Topologically Integrated Geographic

Encoding and Referencing System) has been

developed

13 that will enhance the ability ‘ 0

conduct spatial analyses of population data

from the 1990 decennial census (23).

13 TIGER has been developed jointly by the U.S.

Geological Survey and the U.S. Bureau of th e

census.
8. CONCLUSIONS

The concepts of “rural” and “urban” exist

as part of a continuum, but Federal policies

generally rely on dichotomous urban/rural

differences based on designations of the Office of Management and Budget (OMB) or

the Bureau of the Census. OMB’s MSA

designation includes a large population center

and adjacent counties that have a high degree

of economic and social integration with that

center. Census’ urban areas include densely

settled “urbanized areas” plus places with

populations of 2,500 or more outside of urbanized areas. “Rural” areas are designated

by exclusion: i.e., those areas not classified as

either MSA or urban. About one-quarter of

the U.S. population resides in nonMSAs and

Census’ rural areas. The identified populations are different but overlapping. Forty

percent of the 1980 Census’ rural population

lived in MSAs, and 14 percent of the MSA

population lived in rural areas.

“Nonmetropolitan area,” “rural area,” and

“nonurbanized area” have all been used to

display vital and health statistics or to implement Federal policies. These “rural” definitions can be analyzed in terms of how well

they include “rural areas” and how well they

exclude “urban areas.” For example, we intuitively associate farming with “rural” but

about one-fourth of farm residents live in

MSAs (55). Some might argue that isolated

towns with just over 2,500 residents are inappropriately excluded from the Census’ rural

definition. Others may argue that when nonMSAs are defined as rural, over 100 towns

with populations of 25,000 or more are inappropriately included. Moreover, when

MSAs are used to define “urban” in spatially

large counties, small towns that are far from

an urbanized area are inappropriately called

urban.

Dichotomous measures of urbanity/

rurality obscure important differences between urban and rural areas and wide variations within a rural area. Consequently, there

have been recommendations to implement a

standard rural typology that would capture

the elements of rural diversity and improve

use and comparison of data. Nine countybased rural/urban topologies or classification

schemes that incorporate one or more of the

following measures are reviewed in this

paper: population size and density; proximity

to and relationship with urban areas; degree

of urbanization; and principal economy.

While a standard typology may seem desirable, it will be difficult to arrive at, because

the different topologies are designed and

have merit for various purposes, some of

which conflict.

For purposes of health services planning

and research, a typology based on largest

settlement size is useful, because the level of

available health resources is likely to be related to the size of a city. In spatially small

counties, large settlements are likely to be

quite accessible to all county residents. In

the West, however, counties can be several

times as large as in the East, and some

measure of proximity would be useful. A

measure of population concentration and dispersion, or distance to a large settlement,

could serve as an indicator of access to those

services. Of the topologies reviewed in this

paper, the one likely to best measure both

level of and access to services is a typology

that incorporates a county’s largest settlement

and the county’s adjacency to an MSA.

Other topologies that categorize counties according to employment and commuting patterns could be used to refine the definition of

labor market areas, an important component

of the Medicare prospective payment system

(PPS) formula.

Rural areas are not defined uniformly

for purposes of Federal program administration or distribution of funds. Different

designations may, in fact, be used by the

same agency. For example, Congress has

directed the Health Care Financing Adminis41
42 • Defining “Rural” Areas: Impact on Health Care Policy and Research

tration to use OMB’s MSA designations to

categorize hospitals as urban or rural for purposes of hospital reimbursement under Medicare, but to use Census’ nonurbanized area

designation to certify health facilities under

the Rural Health Clinics Act.

The relative merits of county-based

topologies for particular applications can be

evaluated by using the Area Resource File

(ARF), a county-level data base maintained

by the Health Resources and Services Administration. In addition, visual aids such as

maps can effectively serve as an analytic

device to illustrate geographic variation in

health status and access to health care

resources and could further the development

and evaluation of topologies. In the spatially

large Western counties, sub-county geographic units need to be employed to help

identify health service areas with special

characteristics such as those that are ‘frontier”

(i.e., have 6 or fewer persons per square

mile).

The choice of definition for “rural” that

is used to present demographic and health

data can make a substantive difference. For

example, whether a disproportionate number

of rural residents are elderly depends on how

rural is defined. Furthermore, wide variations in health status indicators within nonmetropolitan areas will not be apparent unless

nonmetropolitan data are disaggregate by

region, urbanization, proximity to urban

areas, or other relevant factors.
APPENDIX A: SUMMARY OF THE STANDARDS FOLLOWED IN

ESTABLISHING METROPOLITAN STATISTICAL AREAS

This statement summarizes in nontechnical language the official standards for designating and defining metropolitan statistical

areas. It omits certain exceptions and unusual

situations that are covered in the standards

themselves or in the detailed statement of the

procedures followed in applying the standards.

Population Size Requirements for

Qualification (Section 1)

To qualify for recognition as a metropolitan statistical area, an area must either

have a city with a population of at least

50,000 within its corporate limits, or it must

have a U.S. Bureau of the Census urbanized

area of at least 50,000 population, and a total

metropolitan statistical area population of at

least 100,000. A few metropolitan statistical

areas that do not meet these requirements are

still recognized because they qualified in the

past under standards that were then in effect.

The Census Bureau defines urbanized

areas according to specific criteria, designed

to include the densely settled area around

each large city. An urbanized area must have

a population of at least 50,000. The urbanized area criteria define a boundary based

primarily on a population density of at least

1,000 persons per square mile, but also include some less densely settled areas within

corporate limits, and such areas as industrial

parks, railroad yards, golf courses, and so

forth, if they are adjacent to dense urban development. The density level of 1,000 persons per square mile corresponds approximately to the continuously built-up area

around the city, for example, as it would appear in an aerial photograph.

Typically, the entire urbanized area is

included within one metropolitan statistical

area; however, the metropolitan statistical

area is usually much larger in areal extent

than the urbanized area, and includes territory where the population density is less than

1,000 persons per square mile.

Central County(ies) (Section 2)

Every metropolitan statistical area has

one or more central counties. These are the

counties in which at least half the population

lives in the Census Bureau urbanized area.

There are also a few counties classed as central even though less than half their population lives in the urbanized area because they

contain a central city (defined in Section 4),

or a significant portion (with at least 2,500

population) of a central city.

Outlying Counties (Section 3)

In addition to the central county(ies), a

metropolitan statistical area may include one

or more outlying counties. Qualifications

an outlying county requires a significant level

of commuting from the outlying county to

the central county(ies), and a specified degree

of “metropolitan character.” The specific requirements for including an outlying county

depend on the level of commuting of its resident workers to the central county(ies), as

follows:

1.

2.

3.

4.

Counties with a commuting rate of 50

percent or more must have a population

density of at least 25 persons per square

mile.

Counties with a commuting rate of 40

to 50 percent can qualify if they have a

density of at least 35 persons per square

mile.

Counties with a commuting rate of 25

to 40 percent typically qualify through

having either a density of at least 50

persons per square mile, or at least 35

percent of their population classified as

urban by the Bureau of Census.

Counties with a commuting rate of 15

to 25 percent must have a density of at

least 50 persons per square mile, and in

43
44 Ž Defining “Rural” Areas: Impact on Health Care Policy and Research

addition must meet two of the following four requirements:

■

■

■

■

the population density must be at

least 60 persons per square mile;

at least 35 percent of the population

must be classified as urban;

population growth between 1970 and

1980 must be at least 20 percent; and

a significant portion of the population (either 10 percent or at least

5,000 persons) must live within the

urbanized area.

There are also a few outlying counties

that qualify for inclusion in a metropolitan

statistical area because of heavy commuting

from the central county (ies) to the outlying

county, or because of substantial total commuting to and from the central counties.

Central Cities (Section 4)

Every metropolitan statistical area has at

least one central city, which is usually its

largest city. Smaller cities are also identified

as central cities if they have at least 25,000

population and meet certain commuting requirements.

In certain smaller metropolitan statistical

areas there are places between 15,000 and

25,000 population that also qualify as central

cities, because they are at least one-third the

size of the metropolitan statistical area’s

largest city and meet commuting requirements.

Most places that qualify as central cities

are legally incorporated cities. It is also possible for a town in the New England States,

New York, or Wisconsin, or a township in

Michigan, New Jersey, or Pennsylvania to

qualify as a central city. The town or

township must, however, be recognized by

the Bureau of the Census as a “census designated place” on the basis of being entirely urban in character, and must also meet certain

population size and commuting requirements.

Consolidating or Combining Adjacent

Metropolitan Statistical Areas

(Sections 5 and 6)

These two sections specify certain conditions under which adjacent metropolitan

statistical areas defined by the preceding sections are joined to form a single area. Section 5 consolidates adjacent metropolitan

statistical areas if their commuting interchange is at least 15 percent of the number

of workers living in the smaller of the two

areas. To be consolidated under Section 5,

each of the metropolitan statistical areas must

also be at least 60 percent urban, and the total population of the consolidated metropolitan statistical area must be at least a million.

Section 6 provides for combining as a

single metropolitan statistical area those adjacent metropolitan statistical areas whose

largest cities are within 25 miles of each

other, unless there is strong evidence, supported by local opinion, that they do not constitute a single area for general social and

economic purposes.

Levels (Section 7)

This section classifies the prospective

metropolitan statistical areas defined by the

preceding sections into four categories based

on total population size: Level A with a million or more; Level B with 250,000 to a million; Level C with 100,000 to 250,000; and

Level D with less than 100,000.

Under this section, the metropolitan

statistical areas in Levels B, C, and D (those

with a population of less than 1 million)

receive final designation as metropolitan

statistical areas.

Area Titles (Section 8)

This section assigns titles to the metropolitan statistical areas defined by the

preceding sections.
Defining “Rural” Areas: Impact on Health Care Policy and Research ■ 45

Primary and Consolidated Metropolitan

Statistical Areas (Sections 9 through 11)

Within the metropolitan statistical areas

classified as Level A, some areas may qualify

for separate recognition as primary metropolitan statistical areas. A primary metropolitan statistical area is a large urbanized

county, or cluster of counties, that demonstrates very strong internal economic and social links, in addition to close ties to the

other portions of the Level A metro-politan

statistical area.

Section 9 through 11 provide a framework for identifying primary metropolitan

statistical areas within metropolitan statistical

areas of at least 1 million population. A

metropolitan statistical area in which primary

metropolitan statistical areas have been identified is designated a consolidated metropolitan statistical area.

Metropolitan Statistical Areas

in New England (Sections 12 through 14)

These sections provide the basic standards for defining metropolitan statistical

areas in New England.

Qualification for recognition as a metropolitan statistical area in New England is on

much the same basis as in the other States. A

few modifications in the standards are necessary because cities and towns are used for the

definitions. In New England each Census

Bureau urbanized area of at least 50,000

normally has a separate metropolitan statistical area, provided there is a total metropolitan statistical area population of at least

75,000 or a central city of at least 50,000.

The total metropolitan statistical area population requirement is lower than the 100,000

required in the other States because the New

England cities and towns used in defining

metropolitan statistical areas are much smaller

in areal extent than the counties used for the

definitions in the other States. This makes it

possible to define New England metropolitan

statistical areas quite precisely on the basis of

population density and commuting.

For users who prefer definitions in terms

of counties, a set of New England County

Metropolitan Areas is also officially defined.

However, the official metropolitan statistical

area designations in New England apply to

the city-and-town definitions.

In order to determine the cities and

towns which could qualify for inclusion in a

New England metropolitan statistical area,

section 12 defines a central core for each

New England urbanized area, consisting essentially of cities and towns in which at least

half the population lives in the urbanized

area or in a contiguous urbanized area.

Once the central core has been defined,

Section 13 reviews the adjacent cities and

towns for possible inclusion in the metropolitan statistical area. An adjacent city or

town with a population density of at least 100

persons per square mile is included if at least

15 percent of its resident workers commute to

the central core. Towns with a density between 60 and 100 persons per square mile

also qualify if they have at least 30 percent

commuting to the central core. However, the

commuting to the central core from the city

or town must be greater than to any other

central core, and also greater than to any

nonmetropolitan city or town.

If a city or town has qualifying commuting in two different directions (e.g., to a central core and to a nonmetropolitan city) and

the commuting percentages are within five

points of each other, local opinion is solicited

through the appropriate congressional delegation before assigning the city or town to a

metropolitan statistical area. Some New England communities also qualify for inclusion in

a metropolitan statistical area on the basis of

reverse commuting or total commuting.

Once the qualifying outlying towns and

cities have been determined, Section 14

qualifies the resulting area as a metropolitan

statistical area provided it has a city of at
46 • Defining “Rural” Areas: Impact on Health Care Policy and Research

least 50,000 or a total population of at least metropolitan statistical areas. It follows the

75,000. This section also specifies that same general approach as is used for

several of the standards used in the other identifying such areas outside New England

States are also applied to the New England (Section 9). Finally, Section 16 provides that

States: level and titles for New England primary and

1.

2.

3.

consolidated metropolitan statistical areas are

The central cities of each area are determined by much the same standards as

determined by Section 4. for the remaining States.

Two adjacent New England metropolitan statistical areas may be consolidated under Section 5.

New England areas are categorized into

levels according to Section 7A. Those

in Levels B, C, and D are given final

designation as metropolitan statistical

areas, and are assigned titles according

to Section 8.

Primary and Consolidated Metropolitan

Statistical Areas in New England

(Sections 15 and 16)

Section 15 is used to review each Level

A metropolitan statistical area in New England for the possible identification of primary

Note: OMB is reviewing the MSA standards

and will publish them with some revisions before Apr. 1, 1990 (12).

SOURCE: Excerpt from “The Metropolitan

Statistical Area Classification:

1980 Official Standards and Related Documents, ” The Federal

Committee on Standard Metropolitan Statistical Areas.
APPENDIX B: THE CENSUS BUREAU’S

URBANIZED AREA DEFINITION

The major objective of the Census

Bureau in delineating urbanized areas is to

provide abetter separation of urban and rural

population and housing in the vicinity of

large cities. An urbanized area consists of a

central city or cities and surrounding closely

settled territory or “urban fringe.”

There are 366 urbanized areas delineated

in the United States for the 1980 census.

There are seven urbanized areas delineated in

Puerto Rico.

The following criteria are used in

determining the eligibility and definition of

the 1980 urbanized areas.1

An urbanized area comprises an incorporated place2 and adjacent densely settled

surrounding area that together have a minimum population of 50,000. 3 The densely

settled surrounding area consist of:

1. Contiguous incorporated places or

census-designated places having:

■ a population of 2,500 or more; or

■ a population of fewer than 2,500 but

having either a population density of

1,000 persons per square mile, closely

settled area containing a minimum of

50 percent of the population, or a

cluster of at least 100 housing units.

2. Contiguous unincorporated area which

is connected by road and has a popula-

] All references to population counts and densitie s

relate to data from the 1980 census.

z In Hawaii , incorporated places do not exist in

the sense of functioning local governmental units.

Instead, census-designated places are used i n

defining a central city and for applying urbanized

area criteria .

3 The rural portions of extended cities, as defined

in the Census Bureauts extended city criteria, ar e

excluded from the urbanized area. In addition, for

an urbanized area to be recognized, it must include

a population of at least 25,000 that does no t

reside on a military base.

3.

4.

tion density of at least 1,000 persons

per square mile.4

Other contiguous unincorporated area

with a density of less than 1,000 persons per square mile, provided that it:

■

■

■

eliminates an enclave of less than 5

square miles which is surrounded by

built-up area;

closes an indentation in the boundary

of the densely settled area that is no

more than 1 mile across the open end

and encompasses no more than 5

square miles; and

links an outlying area of qualifying

density, provided that the outlying

area is:

--connected by road to, and is not

more than 11⁄2 miles from, the main

body of the urbanized area; and

--separated from the main body of

the urbanized area by water or

other undevelopable area, is connected by road to the main body

of the urbanized area, and is not

more than 5 miles from the main

body of the urbanized area.

Large concentrations of nonresidential

urban area (e.g., industrial parks, office

areas, and major airports), which have

at least one-quarter of their boundary

contiguous to an urbanized area.

d Any area of extensive nonresidential urban land

me, (e.g., railroad yards, airports, factories,

parks, golf courses, and cemeteries) is excluded in

computing the population density.

Note: The Census Bureau is reviewing the

urbanized area rules and will publish

them with some revisions by 1990.

SOURCE: Excerpt from 1980 Census of

Population Vol. 1, Characteristics

of the Population, Appendix A.

Area Classifications.

47
APPENDIX C: CENSUS GEOGRAPHY

CENSUS GEOGRAPHY-CONCEPTS

INTRODUCTION

It is important for anyone using census data to be aware of the geographic

concepts involved in taking the census

and allocating the statistics to States,

counties, cities, and smaller areas down

to the size of a city block. Preparing for

and taking a census also results in a

number of geographic tools or products

that are helpful to the data user as well

as to the Census Bureau, in activities

such as computerized location coding,

mapping, and graphic display. They also

allow users to interrelate local and census statistics for a variety of planning

and administrative purposes. This Factfinder explains the Census Bureau’s

geographic concepts and products.

Except where noted, the definitions

and references below are those used for

the 1980 Census of Population and

Housing. Figure 10 on page 6 summarizes the geographic areas for which

data are available from other Bureau

censuses and surveys.

Data summarizes are presented in

printed reports m , microfiche m, and

computer tapes @ and flexible diskettes K , based on tabulations for the

geographic and statistical levels

discussed below. Maps El are als o

available. The symbols ● and +, keyed

to the legend on page 3, indicate how to

obtain the items described in this

brochure.

REPORTING AREAS

There are a number of basic relationships, illustrated below, among the

geographic areas the Census Bureau

uses as “building blocks” in its reports.

Some of the areas are governmental

unite, i.e., legally defined entities, while

other areas are defined specifically for

statistical purposes. (The statistical

areas are italicized in the diagrams; all

others are governmental.)

United States-The 60 States and the

District of Columbia. (Data also are

collected separately for Puerto Rico

and the outlying areas under U.S.

sovereignty or jurisdiction.)

Regions/divisions-There are four

Census regions defined for the United

States, each composed of two or more

geographic divisions. The nine divi48

Figure 1. CENSUS REGIONS AND GEOGRAPHIC DIVISIONS

OF THE UNITED STATES

● The Midwest Region was designated as the

North Central Region until June 1984.

sions are groupings of States. (See

fig. 1.)

•

●

●

Governmental units of the Nation—

States (50) and the District of

Columbia

Counties and their equivalents (3,139,

plus 78 in Puerto Rico)

Minor civil divisions (MCD’s) of counties, such as towns and townships

(approximately 25,000)

Incorporated places (about 19,100),

e.g., cities and villages

census county divisions (CCD’s)-In

20 States where MCD’s are not adequate for reporting subcounty census

statistics, Bureau and local officials

delineated 5,512 CCD’s (plus 37 census subareas in Alaska) for this

purpose.

•Census designated places (CDP’s)–

Formerly referred to as “unincorporated places,” CDP’s (about 3,500)

are closely settled population centers

without legally established limits,

delineated with State and local

assistance for statistical purposes,

and generally have a population of at

least 1,000.

Figure 2. NATIONAL GEOGRAPHIC

RELATIONSHIPS

Nation

I Regions

Divisions

places’ designated

places”

Counties

Minor civil census

divisions

/

county

divisions

districts

or block

groups

a Note that places (incorporated and census

designated] are not shown within the county

and county subdivision hierarchy, since

places may cross the boundaries of these

areas. A few census reports and tape series

do show places within MCD or CCD within

county, but in these cases data pertain only

to that part of a place which is within a

Particular higher-level area. Enumeration

district and block-group summaries do racognize place boundaries, making ED’s and

BG’s important as the Iotwrst common de

nominator for the higher-lwel entities.
Defining “Rural” Areas: Impact on Health Care Policy and Research Ž 49

●

●

●

●

●

●

●

Census tracts –These statistical subdivisions of counties (approximately

43,350, including 463 in Puerto Rico),

average 4,000 inhabitants. They are

delineated (subject to Census Bureau

standards) by local committees for

metropolitan areas and roughly 200

other counties.

Blocks–Generally bounded by

streets and other physical features,

blocks (approximately 2.5 million) are

identified (numbered) in and adjacent

to urbanized areas, most incorporated places of 10,000 or more

population, and other areas that contracted with the Census Bureau to

collect data at the block level. (Fig.

8 illustrates the extent of blockstatistics coverage in part of a State.)

Five States are completely blocknumbered.

Block-numbering areas (BNA’s)–

Areas (approximately 3,400, including over 100 in Puerto Rico)

defined for the purpose of grouping

and numbering blocks where census

tracts have not been established.

Block groups (BG’s)–Subdivisions

of census tracts or BNA’s, BG’s

(about 200,000) comprise all blocks

with the same first digit in a tract or

BNA. Averaging 900 population,

BG’s appear in areas with numbered

blocks in lieu of ED’s (see below) for

tabulation purposes.

Enumeration districts (ED’s)–An

ED is a Bureau administrative area

assigned to one census enumerator.

ED’s (about 100,000 nationwide)

were used for census tabulation purposes where census blocks were not

numbered. ED size varies considerably, but averages 500

inhabitants.

Metropolitan Areas

Standard metropolitan statistical

areas (SMSA‘s)-An SMSA (defined

by the Office of Management and

Budget) comprised one or more counties around a central city or urbanized area with 50,000 or more inhabitants. Contiguous counties were

included if they had close social and

economic links with the area’s

population nucleus. There were 323

SMSA’s, including 4 in Puerto Rico.

Standard consolidated statistical

areas (SCSA‘s)--SCSA’s (17, including 1 in Puerto Rico) were composed of two or more adjacent

SMSA’s having a combined population of 1 million or more, and with

close social and economic links.

After the relationships between central

urban core(s) and adjacent counties were

Figure 3. GEOGRAPHIC

RELATIONSHIPS IN AN MSA

MSA

I Metropolitan

groups districts

I

Blocks

a In New England, MSA’S are defined in

terms of towns and cities, rather than munties

(as in the rest of the country),

b Cen5us tr~ts subdivide moat MSA

counties as wel I as about 20I3 other cou ntiea,

As tracts may cross MCD and place boundaries, MCD’S and places are not shown in

this hierarchy,

analyzed on the basis of the 1980

population census and a revised set of

criteria, these areas were redefined and

the word “standard” was dropped from

the titles. Thus, on June 30, 1983,

SMSA’s and SCSA’s were redesignated

as

. Metropolitan statistical areas

(MSA'S)

● Consolidated MSA's (CMSA's)

and

● Primary MSA (PMSA's)

As the 1982 Economic Censuses

covered calendar year 1982, prior to the

June 1983 date for adopting the

changes, the 1982 SMSA and SCSA

designations and nomenclature were retained for those censuses. Some data

from the 1980 Census of Population and

Housing were retabulated by MSA and

issued in special reports, and the new

definitions were used in preparing

population and migration estimates and

in presenting current statistics from

1983 onward.

●

●

●

Urbanized areas (UA's)–A UA (them

are 373, including 7 in Puerto Rico)

consists of a central city and

surrounding densely settled territory

with a combined population of 50,000

or more inhabitants. (See fig. 5)

Metropolitan/nonmetropolitan–

“Metropolitan” includes all population within MSA’s; “nonmetropolitan” comprises everyone elsewhere.

Urban/rural-The urban population

consists of all persons living in urbanized areas and in places of 2,500

or more inhabitants outside these

areas. All other population is

classified as rural. The urban and

rural classification cuts across the

Figure 4. URBAN/RURAL

GEOGRAPHIC RELATIONSHIPS

/

ALL AREAS

Urban

/ \

Urbanized Other Rural Rural

Central Urban Rural Other

cities fringe places’ rural

nonfarm

a Includes both governmental and statistical units.

other hierarchies; there can be both

urban and rural territory within

metropolitan as well as nonmetropolitan areas.

There are other geographic units for

which data may be obtained from the

1980 Census of Population and Hous-

 ing. Some appear in regular publications

and data files: American Indian reservations (278, both State and Federal, including 3 administered by or for more

than one tribe), Alaska Native villages

(209), congressional districts (435), and

election precincts in some States. Data

are prepared for neighborhoods in

almost 1,300 areas and by ZIP Code

areas nationwide. Data for other areas

are generated in special tabulations

prepared at cost, for example, school

districts.

Two types of areas are defined

specifically for the economic censuses:

● central business districts (CBD’s)

CBD’s are areas of high land value,

traffic flow, and concentration of

retail businesses, offices, theaters,

hotels, and service establishments. In

the 1982 Census of Retail Trade, 456

CBD’s were defined in (1) any SMSA

central city and (2) any other city

with a population of 50,000 or more

and a sufficient concentration of

economic activity. CBD’s also are

shown in place -of-work data from the

1980 Census of Population and

Housing.

● Major retail centers (MRC’s)-MRC’O

are concentrations of retail stores

located in SMSA’s, but outside the

CBD’s. For 1982, 1,545 MRC’s were

defined areas with at least 25 retail

establishments and one or more large

general merchandise or department

stores.
50 • Defining “Rural” Areas: Impact on Health Care Policy and Research

Figure 6. GEOGRAPHIC HIERARCHY INSIDE AND OUTSIDE URBANIZED AREAS (UA’s)

(See figures 7-10 for maps exhibiting most of these features.)

MSA

aThe entire MSA is subdlvlderl intO census tracts.

bB10ck5 and biock 9rouPs do not have symbolized boundaries as do the other areas, but are

identified by number. (see discu=ion on pa- 2.)

SOURCE : U.S. Department of Commerce, Bureau of the Census, "Census and Geography-Concepts and Products,"

Factfinder CFF No. 8 (Rev.) Washington, DC: U.S. Government Printing Office, August 1985).
Defining “Rural” Areas: Impact on Health Care Policy and Research • 51

The Bureau collects and publishes data

for two kinds of sub-state areas:

Governmental, such as--

incorporated places (e.g., cities, villages)

and minor civil divisions (MCDs) of

counties (e.g., townships),

congressional districts and election

precincts, and

American Indian reservations and Alaska

Native villages.

Statistical, including--

standard metropolitan statistical areas

(SMSAs) and standard consolidated

statistical area (SCSAs) were used in the

1980 decennial and 1982 economic

censuses. In 1983, SMSAs and SCSAs

were replaced by metropolitan statistical

areas (MSAs), primary MSAs (PMSAs),

and consolidated MSAs (CMSAs);

census county divisions (CCDs) in States

where MCD boundaries are not satisfactory for statistical purposes;

census-designated places (formerly called

“unincorporated places”);

urbanized areas;

census tracts (subdivisions of counties,

primarily in metropolitan areas) and

block numbering areas (BNAs), averaging about 4,000 people each;

census blocks- -generally equivalent to

city blocks in cities, but are very large

in rural areas;

enumeration districts (EDs)--census administrative areas, averaging around 700

inhabitants, used where block statistics

are not available;

block groups (BGs)--counterparts to EDs

averaging 900 population, in areas with

census blocks;

neighborhoods --subareas locally defined

by participants in the Bureau’s Neighborhood Statistics Program; and

ZIPCodes--Postal Service administrative

areas independent of either governmental or other statistical units.

In the 1982 Census of Retail Trade, the

Bureau published data for central business

districts (CBDs) and major retail centers

(MRCs) outside CBDs; in the Census of Governments, for school districts and other special districts; and in foreign trade and international research, for countries and world

areas.

Generally, survey data are published only

for the larger areas, such as the United

States, its regions, and some States, while

census data are made available for smaller

areas as well.

Population and Housing

The decennial census of population and

housing is the most important source of data

for small communities, not only on a wide

variety of subjects but in finer geographic

detail than from any other statistical base. It

provides a uniform set of data for intercommunity comparisons as well.

Table A-1 shows the items collected in

the census. The basic data, called “complete

count” or “100 -percent,” come from the questions asked for every person and housing

unit. Other items are obtained only at a

sample of households and housing units in

order to keep response burden to a minimum.

The 100-percent data provide the basic

population and housing counts and certain

characteristics -- e.g., age, sex, and race for

people; and value or rent, and vacant or occupied status for housing units--for all tabulation areas, even down to census blocks.

Since they are estimates rather than complete

counts, the sample statistics for small communities must be used with caution.

In general, the higher the geographic or

statistical level of tabulation, the greater

amount of detail there is available in the

census reports. With respect to small communities, more data usually are contained in

the printed reports at the county level than

for the county subdivisions and places. (This

difference seldom occurs on summary tape

files or selected microfiche). Only limited

county- and subcounty-level data are available on flexible diskettes and through

CENDATA.
52 • Defining “Rural” Areas: Impact on Health Care Policy and Research

Table A-1.--Items Collected in the 1980 Census

100-percent population items

Household relationship

Sex

Race

Age

Marital statu s

Spanish/Hispanic origin or descent a

Sample population items

School enrollment

Education attainment

State or foreign country of birth

Citizenship and year of immigration

Current language and English proficiency

Ancestry b

Place of residence 5 years ago

Activity 5 years ago

Veteran status and period of service

Presence of disability or handicapa

Children ever born

Marital histor y

Employment status last week

Hours worked last week

Place of work

Travel time to work b

Means of transportation to worka

Persons in carpool b

Year last worked

Industr y

Occupation

Class of worker

Amount of income by source in 1979a

Work in 1979 and weeks looking for work in 1979a

100-percent housing items

Number of housing units at address

Complete plumbing facilitie s

Number of rooms in unit

Tenure (whether the unit is owned or rented)

Condominium identification

Value of home (for owner-occupied units and condominiums)

Rent (for renter-occupied units )

Vacant for rent, for sale, etc., and period of vacanc y

Sample housing items

Number of units in structure

Stories in building and presence of elevator

Year unit built

Year moved into this housea

Source of water

Sewage disposal

Heating equipment

Fuels used for home heating, water-heating, and cooking

Costs of utilities and fuel s

a

Complete kitchen facilities

Numbet of bedrooms and bathrooms

Telephone

Air conditioning

Number of automobiles

Number of light trucks and vans

b

Homeowner shelter costs for mortgage,

real estate taxes, and hazard insurance b

~Changed relative to 1970.

Neu item for 1980.

Derived items (illustrative examples)

Familie s Household size

Family type and size Persons per room (“overcrowding")

Family income Institutions and other group quarter s

Poverty status Farm residence

Population density

Note: This information pertains to the 1980 census and does not reflect changes in data presentation and

availability following the 1990 census.

SOURCE: Adapted from "Data for Small Communities,” U.S. Bureau of the Census--FACTFINDER for the Nation,

CFF No. 22 (Rev.) January 1986.
APPENDIX D: RURAL HEALTH CARE ADVISORY PANEL

James Bernstein, Panel Chair

Director, Office of Health Resources Development

North Carolina Department of Human Resources

Robert Bergland

Executive Vice President and General Manager

National Rural Electric

Cooperative Association

Washington, D.C.

James Coleman

Executive Director

West Alabama Health Services, Inc.

Sam Cordes

Professor& Head

Department of Agricultural Economics

University of Wyoming

Elizabeth Dichter

Senior Vice President for Corporate Strategies

Lutheran Health Systems

Denver, Colorado

Mary Ellis

Director

Iowa Department of Public Health

Kevin Fickenscher

Assistant Dean and Executive Director

Michigan State University

Center for Medical Studies

Kalamazoo, Michigan

Roland Gardner

President

Beaufort-Jasper (South Carolina)

Comprehensive Health Center

Robert Graham

Executive Vice President

American Academy of Family Physicians

Kansas City, Missouri

Alice Hersh

Executive Director

Foundation for Health Services Research

Washington, D.C.

David Kindig

Director

Programs in Health Management

University of Wisconsin - Madison

Advisory Panel members provide valuable

However, the presence of an individual on the

agrees with or endorses the conclusions of this

T. Carter Melton, Jr.

President

Rockingham Memorial Hospital

Harrisonburg, Virginia

Jeffrey Merrill

Vice President

Robert Wood Johnson Foundation

Princeton, New Jersey

Myrna Pickard

Dean

School of Nursing

University of Texas - Arlington

Carolyn Roberts

President

Copley Health Systems, Inc.

Morrisville, Vermont

Roger Rosenblatt

Professor& Vice Chairman

Department of Family Medicine

University of Washington

Peter Sybinsky

Deputy Director for Planning,

Legislation, and Operations

Hawaii Department of Health

Fred Tinning

President

Kirksville College of

Osteopathic Medicine

Kirksville, Missouri

Robert Vraciu

Vice President

Marketing& Planning

HealthTrust, Inc.

Nashville, Tennessee

Robert Walker

Chairman

Department of Family and

Community Health

Marshall University School of Medicine

Huntington, West Virginia

guidance during the preparation of OTA reports.

Advisory Panel does not mean that individual

particular paper.

53
APPENDIX E: ACKNOWLEDGMENTS

The author would like to express her appreciation to the following people for providing information and assistance.

Paul Anderson

Bureau of Emergency Medical Services

Boise, Idaho

Susan Baker

The Johns Hopkins University

School of Hygiene and Public Health

Baltimore, Maryland

Keith Bea

Congressional Research Service

Washington, DC

Calvin Beale

Economic Research Service

U.S. Department of Agriculture

Washington, DC

Viola Behn

New York Department of Health

Albany, New York

Richard Bohrer

Division of Primary Care Services

Health Resources and Services Administration

Rockville, Maryland

James T. Bonnen

Department of Agricultural Economics

Michigan State University

East Lansing, Michigan

Don Dahmann

Population Division

U.S. Bureau of the Census

Washington, DC

Robert Dawson

National Rural Health Network

National Rural Electric Cooperative Association

Washington, DC

Diana DeAre

Population Division

U.S. Bureau of the Census

Washington, DC

Denise Denton

Rural Health Office

University of Arizona

Tucson, Arizona

Terry Dimon

Memorial Hospital of Laramie County

Cheyenne, Wyoming

Gar Elison

Community Health Services

Utah Department of Health

Salt Lake City, Utah

Bob Erikson

Department of Geography

University of Maryland, Baltimore County

Baltimore, Maryland

Richard L. Forstall

Population Division

U.S. Bureau of the Census

Washington, DC

George Garnett

National Association of EMS Physicians

Soldotna, Alaska

Wilbert Gesler

Department of Geography

University of North Carolina

Chapel Hill, North Carolina

Maria Gonzales

Office of Management and Budget

Washington, DC

54
Defining “Rural” Areas: Impact on Health Care Policy and Research • 55

Mary Goodwin

Department of Agriculture

Austin, Texas

Rena Gordon

Phoenix Rural Health Office

Phoenix, Arizona

John Johnson

Porter Memorial Hospital

Valparaiso, Indiana

Harvey Licht

New Mexico Health and

Environment Department

Santa Fe, New Mexico

David McGranahan

Economic Research Service

U.S. Department of Agriculture

Washington, DC

Carol Miller

Mountain Management

Ojo Sarco, New Mexico

Steven Phillips

National Governor’s Association

Washington, DC

Jerome Pickard

Appalachian Regional Commission

Washington, DC

Stuart A. Reynolds

Northern Montana Surgical Associates

Havre, Montana

Steven Rosenberg

Salinas, California

Howard V. Stambler

Bureau of Health Professions

Health Resources and Services Administration

Rockville, Maryland

Jack L. Stout

The 4th Party Inc.

Miami, Florida

Elsie M. Sullivan

Division of Primary Care Services

Health Resources and Services Administration

Rockville, Maryland

Tom Swan

Rural E.M.S. Development Service

Crested Butte, Colorado

Robert T. Van Hook

National Rural Health Association

Kansas City, Missouri

John Wardwell

Washington State University

Pullman, Washington

Barbara Wynn

Bureau of Eligibility, Reimbursement,

and Coverage

Health Care Financing Administration

Baltimore, Maryland

Thomas C. Ricketts

Health Services Research Center

University of North Carolina

Chapel Hill, North Carolina
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0