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| Setup             Instructions |   | ONE DEPARTMENTSERVING RURAL AMERICA
HHS Rural Task ForceReport to the Secretary
July 2002

**Contents**
Executive Summary
Section 1:  Introduction- Secretary Thompson's Challenge to the Task Force   Rural America in 2001: Challenges and Opportunities
Section 2:  Rural Task Force Findings - One Department, Serving Rural Communities:	Overview of the Federal Role  Barriers to Serving Rural CommunitiesResearch and Policy-Making Efforts
Section 3:  Task Force Goals, Strategies and Recommendations- Public Comment to Inform the Task Force  Cross-Cutting Recommendations:One Department, Serving Rural America
Section 4:  Implications for Administration-Wide Activity- Other Administration Initiatives   Notes

**Executive Summary**
On July 25, 2001, Secretary of Health and Human Services Tommy G. Thompson charged all HHS agencies and staff offices to examine ways to improve and enhance health care and human services for rural Americans. As the former governor of a predominantly rural State, Secretary Thompson recognizes the unique characteristics and needs of rural America and the important role HHS plays in ensuring healthy rural communities.
There are 65 million Americans who live in rural areas. Health care and social service programs in rural communities provide needed support of communities' well-being and represent a significant segment of local economies. Health care can represent up to 20 percent of a community's employment and income. In some lower income communities, federal support may account for as much as 50 percent of income in the community through funding for social and health services. These same programs, however, experience difficulties related to inadequate funds, personnel and support networks. 
These challenges may compromise the effectiveness of service to rural residents. The loss or reduction of these services may adversely affect entire communities which suffer greater poverty, poorer health and less solvent economies. Ensuring the health and welfare of rural Americans is an essential part of a national policy that promotes the self-sufficiency of all Americans.
**HHS Rural Task Force**
In response to the Secretary's charge, HHS created a Rural Task Force to bring together representatives from each of the HHS agencies and staff offices. While members represented their respective agencies, the work of the Task Force was a unified effort and represented diverse perspectives as well as the central goals of HHS.  Task Force members examined current program investment, regulatory policy and barriers to providing services, and developed strategies to improve HHS services in rural communities. 
Recognizing the value of input from people living in rural communities, the Task Force invited public comment through a notice in the Federal Register published in August 2001. The Task Force encouraged people at the local, State, and Tribal level to share their thoughts about how the Department can better serve rural communities.  More than 450 individuals and organizations shared their insight and experience.  Comments ranged from people simply offering thanks to Secretary Thompson for his focus on rural services to technical comments about the impact of particular HHS health care financing regulations on small rural providers.  Highlights from these public comments are featured throughout this report. 
The Rural Task Force found that while there are statutory, regulatory and resource-related barriers that impede HHS' work in rural communities, there are also innovative strategies, both immediate and long-term, that the Department can implement to better serve rural communities.  
**Three Important Findings**
The Rural Task Force's efforts resulted in three important findings:- HHS lacks a common definition of "rural" or set of definitions that are used by all agencies and staff offices and that accounts for the gradient between metropolitan and rural areas.  As a result, it is difficult to target grants, evaluate services, develop policy and quantify HHS' investment in rural and frontier communities.
More than 225 HHS programs currently serve rural communities. Despite the breadth of support, rural communities struggle to access resources because individual programs have unique application, implementation and evaluation requirements.  This lack of coordination in HHS is amplified at the State and local levels.
The HHS policy development process does not consistently consider rural concerns. As a result, HHS policy decisions may have negative consequences for rural areas or fail to capitalize on opportunities to improve rural health and social services. 
**Recommendations to Improve Rural Health and Social Services Coordination**
The Rural Task Force identified several actions that could improve the way that HHS manages rural policy development and services delivery.  These actions have the potential to better integrate HHS' rural efforts and create "One Department, Serving Rural America."
- Create a formal structure within HHS with responsibility for coordinating rural policy initiatives among HHS agencies and staff divisions, as well as with external partners.
Based on the work of this Rural Task Force, create an interagency workgroup that follows up on the proposed strategies. This workgroup would meet quarterly with the Secretary, or the Deputy Secretary, and report on HHS' progress towards achieving the goals proposed by the Task Force. It would update this plan periodically.
Ensure that the annual HHS budget development,                 legislative and Government Performance and Results Act (GPRA)                 processes include a specific focus or crosscutting discussion                 about serving rural America.
Develop a common methodology for determining                 HHS' investment in specific communities and populations. 
**Five Task Force Goals**
 The Rural Task Force set five goals to improve               key areas of the provision of health care and human services in               rural areas and developed strategies and activities for each goal               area. The goals are: 
**Goal 1: Improving rural communities'               access to quality health and human services.              Goal 2: Strengthening rural families.              Goal 3: Strengthening rural communities and supporting economic               development.              Goal 4: Partnering with State, local and Tribal governments to support               rural communities.              Goal 5: Supporting rural policy and decision-making and ensuring               a rural voice in the consultative process.**
 These goals were intended to broadly capture               most of the Department's rural programs and policy-making efforts.               Each agency and staff office was asked to develop a plan addressing               these five goals. Five goal workgroups used these as a basis for               developing an HHS-wide plan and making recommendations to the Secretary.               
**HHS Rural Task Force Report**
 This report describes the current health and               social services challenges facing rural America, outlines HHS components               whose programs currently serve rural and frontier communities, discusses               the barriers that Task Force members identified, shares the common               themes from the 450 public comments and details a number of strategies               for improving health care and human services in rural communities.               
 The Rural Task Force drew from the experiences               of rural leaders, existing literature and from the lessons shared               through the public comments to frame the discussion under the "Rural               America in 2001: Challenges and Opportunities." The strategies presented               in this report represent a broad range of actions that could be               taken. The next step in this effort will be to review these strategies               and establish priorities. HHS' action on these suggestions can make               an important and discernible difference in the lives of rural Americans.               This report is a first step towards achieving this goal.

**Secretary Thompson's Challenge to the Task Force
**F**or the 65 million people living in rural America(1), the US Department of Health and Human Services' (HHS)mission to protect health and to provide help to those who need assistance is especially relevant. Health careand social service programs in rural communities provide needed support of communities' well-being andrepresent a significant segment of the local economies. These programs, however, frequently lack adequatefunds, personnel and support networks.  

Public health financing programs such as Medicare, Medicaid and the State Children's Health InsuranceProgram (SCHIP) and social welfare programs such as Temporary Assistance for Needy Families (TANF), childcare and child welfare also play a key role in rural communities, yet many rural service providers perceive thatthey work under regulations designed specifically for urban and suburban providers. This challenge maycompromise the effectiveness and availability of service to rural residents. Concurrently, the loss or reduction ofthese services adversely affects entire communities who suffer greater poverty, poorer health and weakereconomies. 

On July 25, 2001, recognizing the unique characteristics and needs of rural communities and the relevance ofHHS' mission to these communities, the Secretary of Health and Human Services, Tommy G. Thompson,issued a charge to all HHS divisions to improve and enhance the provision of health care and social services torural Americans. 
**"As former governors of States with large rural populations, President Bush and I know how important it is for people outside of urban centers to have access to quality health care and social services.  We have carried that understanding to the White House and HHS."Secretary Tommy Thompson**
The HHS Rural Task Force was created under the leadership of the Health Resources and ServicesAdministration's Office of Rural Health Policy and the Department's Office of Intergovernmental Affairs. TheRural Task Force brought together representatives from each of the HHS agencies and staff offices. TaskForce members contributed specialized expertise about how their programs serve rural areas. With theseunique perspectives, members examined program investment and regulatory policy in rural America as well asbarriers to providing services. In addition, the Task Force asked for public input through a notice in the FederalRegister. This report to the Secretary is the result of a multi-faceted analysis of all HHS programs and publiccomments. Highlights from these public comments are featured throughout this report. 

The Task Force focused on improving five key areas:  access to services; the strength of rural families; ruraleconomic development; relationships with State, local and Tribal governments; and policy and research toinform decision-makers concerning rural communities. 

**Rural America in 2001:  Challenges and Opportunities
Rural America today is significantly different from rural America in the mid-twentieth century or even ruralAmerica of the 1980's. It is also very different from the stereotypes that still characterize America's perceptionsof its rural areas. These differences create formidable challenges for federal government agencies, programsand policy makers. Consideration of these differences, as well as important distinctions between rural andurban/suburban areas, is essential for understanding and improving health and social service programs in ruralAmerica. 

**Demographics**

Significant and uneven rural population shifts have occurred throughout the last decade. The 1990 Censusindicated that 61 million people lived in rural America.  Projections for the year 2000 estimate that an increaseof 3.9 million people occurred over the last 10 years in rural areas. Data collected by the USDA EconomicResearch Service show that 70 percent of rural counties grew in population from 1990 to 1999; in this sametime period, 2.2 million more Americans moved from the city to the country than from the country to the city.

However, much of the rural population growth was largely concentrated in only 40 percent of rural counties. Inaddition, the number of rural counties with decreasing population rose from 600 in 1990-1995 to 855 in 1995-1999. Mining and farming dependent counties had the greatest relative fall off in population growth rates.Significant rural population declines continue in the Great Plains, the Appalachian coalfields and other areas where job losses in mining and farming persist.(2)

Population shifts throughout the last decade have included changes in many communities' racial and ethnicmakeup. Many growing rural counties are experiencing concurrent growth in the diversity of residents. Onesource of increasing diversity is the change in immigration patterns in response to employment opportunities inrural areas. Many immigrants, especially Hispanic and Asian immigrants, are increasingly settling in the ruralUS.  As with other characteristics, each region within the US has distinct patterns of racial and ethnic makeup.In general, non-metropolitan immigrants are concentrated in the Western and Southern US.(3)
**"As a member of the Rural Caucus of the Texas Legislature, you can be assured that I am well aware of the problems andchallenges of the rural areas of this great state. I applaud your efforts to identify and eliminate the regulatory barriers thathinder the efficient delivery of programs to rural areas."  - Member of the Texas Legislature**
In the South, non-Hispanic Black Americans accounted for more than 18 percent of the population in the most rural counties in 1998. In the West, American Indians and Alaska Natives constituted nine percent of the population and people of Hispanic origin constituted 11 percent in the most rural counties.(4)(5) "Rural minorities often live in distinct communities where poverty is high, opportunity is low, and the economic benefits derived from more education and training are limited."(6)

The age distribution of rural communities' residents is also important for understanding the demography ofthese communities.  In general, rural areas have a higher proportion of elderly residents. This trend is mostdramatic in the South and Midwest(4). From the perspective of HHS, this is significant in that the elderly usemore health services than the non-elderly and use a significant proportion of social services. This contributes toa trend in which rural health care systems are increasingly dependent on Medicare as a primary fundingsource. Exacerbating the age differences between rural and metropolitan areas is that many of the youngestand most highly educated people are moving away from rural areas.(7)
**Economics**
The economies of rural communities have profoundly changed in the last fifty years.  Most importantly, ruralareas' economies are not one-dimensional, characterized only by agricultural activity.  Rather, agriculture is asmall segment of rural economies, accounting for only 7.6 percent of rural employment.(7) Rural communitiesalso experience challenges in remaining economically competitive. These challenges include the inability toattract new investments, significant numbers of working poor and difficulty in achieving economies of scale indelivering health care, social services, education and training.(8)  In addition, the "rural digital divide" continuesto compromise educational, social service and economic opportunities. While some States have createdStatewide infrastructures that enhance access to technology, many rural areas lack access to many of thecommunication and information technologies that urban and suburban areas have.  For example, Internetaccess is not readily available in many rural areas. This inaccessibility has negative implications for aninformation technology-based "new economy" in rural areas.
Rural workers are nearly twice as likely as urban and suburban workers to earn the minimum wage. Ruralworkers also remain more likely to be under-employed and are less likely to improve their employmentcircumstances over time. Rural poor families are more likely to be employed and still poor.(7)
Between 1990 and 1996 there was a negligible               change in non-metropolitan job earnings, remaining more or less               around $22,493 (1996) per year per job.(10)               The largest percent growth in non-metropolitan earnings between               1990 and 1996 occurred in the finance, insurance and real estate               segments of the economy. The largest percent decline in earnings               during this same time period occurred in agricultural services,               forestry and fishing.(10)
**Rural Areas Differ By Region**
When considering rural America, it is important to remember that as each rural community is distinct, each USregion has distinct characteristics that help define its rurality. For example, small towns and cities mark theNortheast US, particularly the New England area. This area's economy is largely dependent on fisheries andtimber and has a predominantly white population. Thus, job decline in the fishery and timber industries hasprofoundly affected the economies of many of these communities. 
The rural South is marked by high rates of poverty and racial diversity (with a high proportion of AfricanAmericans) and a rural economy dominated by low-tech manufacturing. The Midwest and Great Plains Stateshave a higher percentage of rural elderly with shrinking communities. This region also relies heavily onagriculture and recent economic circumstances have included an increase of meat-packing and renderingoperations accompanied by an influx of mostly Hispanic employees. The Southwestern border States see ahigh influx of immigrant workers. The West has vast frontier areas in which much of the land is federal park andForest Service land. Consequently, the tax base is extremely limited.
**Health and Social Services in Rural Communities**
Effective, coordinated health care and social               services in rural communities are essential for the health of these               communities and well-being of their residents. The necessity of               these services lies not only in their more obvious and immediate               benefits, but also in their central role in local economies. Health               care provides and generates up to 15 to 20 percent of jobs in many               rural communities.(11) Social services               also creates jobs and contributes to the health of local economies.               In addition, twenty percent of total personal income in rural America               comes from Federal transfers to rural residents, including Social               Security and Temporary Assistance for Needy Families payments.(7)               In addition, the presence of effective social services increases               the likelihood that businesses will locate to these communities               and further bolster the economy. Despite their importance, rural               health care and social services struggle to remain viable because               of inadequate service coordination and funding, workforce challenges,               barriers and characteristics inherent to rural areas and residents               they serve (e.g., relatively smaller and more dispersed populations).

**Coordination of Services**

The strong relationship between adequate income,               sufficient food, strong social networks and good health necessitates               coordination among various health care and social service agencies.               This coordination is especially important in rural communities,               where services and providers are limited in numbers. In many rural               communities, service providers often make alliances with one another               and exhibit extraordinary resourcefulness and resilience.(12)               In some cases, rural providers facilitate a better response to people               in need than urban providers because of smaller office size and               more familiarity with clients. When given the opportunity, local               administrators are often energized by the increased responsibility               to attempt innovations in social service provision.(13)
**"Our seniors are literally dying on the farm, slowly starving trying to live on toast and coffee, because they are so lonely, andthey don't know how to reach out." - Rural Resident**
However, coordination in rural communities is               difficult for a number of reasons. Some services are becoming more               fragmented as rural service providers specialize in an attempt to               simplify administrative responsibilities and to meet federal grant               requirements.(14)

In addition, State and federal authorities,               often make decisions regarding funding for specific programs based               on cost. Cost-based decisions invariably disadvantage rural areas               because it costs more to serve a dispersed population than a concentrated               one.(14) Possibly the most important               factor in fragmentation and lack of coordination in rural areas               is the continuing conceptual and practical separation among primary               health care, behavioral health care and social services. Although               health and social welfare are strongly associated with one another,               in many cases federal, State and local planning efforts continue               to address them separately.

**Rural American Culture**

The culture of rural America also plays an important               role, both positive and negative, in the delivery of health and               social services. Because rural communities have relatively small               populations, strong social networks often exist accompanied by a               sense of familiarity, or of knowing people in the community. Such               phenomena provide supportive safety nets and empathy with those               in need of services. Conversely, this familiarity may create a sense               of limited privacy and stigma associated with certain services,               like mental health and substance abuse treatment. The strong ethos               of reliance on informal rather than formal institutions, independence               and individualism in many rural communities may also hinder the               effectiveness of these services as they limit rural residents' willingness               to use them. Rural residents may also perceive that certain social               welfare issues (i.e., substance abuse among TANF recipients) are               urban issues and will not support services that address such issues               in their communities.(14)

**Access**

Two central issues predominate when considering               health and social services in rural communities: lack of access               and, related to this lack of access, poorer health and greater poverty.               A number of factors inherent to rural areas affect rural residents'               access to health care and social services. Geography plays an important               role in limiting rural residents' access because they often must               travel longer distances to see health care and social services providers.(15)               Service providers are frequently located in county seats or other               population centers and often do not provide sufficient outreach               to less populated areas. This reality often makes services much               less accessible for all residents, but particularly those with special               needs such as people with developmental disabilities who may need               personnel assistance, home health services and respite care for               their care givers. Complicating the longer travel distances is the               scarcity of public transportation in rural areas. With limited public               transportation, rural residents without reliable private transportation               have fewer options for accessing these services. This dearth of               transportation options also makes finding and maintaining employment               difficult.(12)(15)               In addition, most government programs designed to address these               issues have a specific population focus, like children with special               health care needs or elderly. Many rural communities do not have               a critical mass of these populations to qualify for specialized               funding or to make the effort to apply worthwhile. 

Rural residents in need of health care and social               services may not have access to these services because there are               no services in their communities, there is limited access to appropriate               transportation or telephone services or because they cannot pay               for them. Research has illustrated that rural residents have less               access to job training and education, health care, childcare, social               services for the elderly and emergency services.(16)               One study of 12 rural counties in four different States showed that               public transportation, workforce development services, shelters,               rehabilitative services and 24 hour childcare (an important service               in some rural counties, where shift work is common) were available               in few counties.(12) Such a lack               of services limits rural residents' economic options. Service availability               in rural communities varies by State. Thus, State policies and State               spending priorities influence the location and availability of services.               

An inability to pay for health care also compromises               access to these services. Rural residents are less likely to have               health insurance, a significant factor in their ability to access               health services. In 1997, between 18 and 20 percent of central metropolitan               and non-metropolitan county residents lacked health insurance, compared               to 12 percent of suburban residents.(5)(17) One cause of lower rates of               insurance in rural areas is the prevalence of industries less likely               to insure. There are also more part-time workers in rural areas               than in urban areas. Rural residents are also less likely to have               other benefits, like paid sick leave, than their urban counterparts.(18)               One factor in this disparity is the prevalence of small businesses               in rural areas. Many small businesses do not have the resources               to provide health insurance.

Another important influence on the quality of               rural health care and social services is the presence of qualified               professionals. As of 2001, only 9 percent of the nation's physicians               practiced in rural areas while roughly 20 percent of the nation's               population lived in rural areas.(19)Currently, 22 million rural residents               live in federally-designated Health Professions Shortage Areas (HPSAs),               or Medically Underserved Areas (MUAs).(7)               Mid-level health care providers, including physician assistants,               nurse practitioners, counselors and certified nurse midwives, provide               outstanding care in many rural communities. Nevertheless, varying               State regulations regarding these practitioners' independence limits               their use in many rural areas. Moreover, the supply of dentists               in relation to population is as low as 29 per 100,000 in the most               rural counties compared to 61 per 100,000 in metropolitan counties.(5)(20) Recruitment and retention of               social welfare professionals to rural areas are also often difficult.               Most social work education programs focus on urban issues and pay               relatively little attention to rural populations. Thus, many agencies'               staff are provided little or no professional training specific to               rural issues.(21) Rural agencies               frequently offer lower salaries and require less education than               their urban counterparts.

**Statutory and Regulatory Barriers Related to Rural Health and Social Services**

In addition to difficulties related to access,               federal regulations have limited the effectiveness of rural health               and social services.(19) One example               of such a regulatory impediment is federal health care financing               policy. Health care financing in rural areas exacerbates difficulties               associated with accessing health care and provider shortages.(19)               Medicare remains the primary source of health care reimbursement               in rural areas with Medicare patient expenses in 1998 accounting               for 47 percent of total patient care expenses for rural hospitals,               compared to 36 percent for urban hospitals.(22)               The transition to prospective payment and fee schedules beginning               with legislation in 1983 and most recently in 1997 and 1999 has               threatened rural hospitals.(19)               Because rural hospitals have lower volumes of patients with higher               fixed costs, they often require special payment arrangements under               prospective payment systems. Furthermore, poor financial status               limits a hospital's ability to recruit and retain qualified health               care providers, access needed capital and maintain other services               like home health and skilled long-term care.(19)

Another example of federal legislation without explicit               considerations of rural communities is the 1996 Personal Responsibility               and Work Opportunity Reconciliation Act (PRWORA), the act that reformed               welfare. Inherent in this legislation authorizing the TANF program               were four central assumptions. The first was that welfare recipients               in all communities would move from welfare to work.(7)               The federal government provided States significant flexibility in               developing programs that would meet communities' diverse needs.               Welfare to work policies mixed with a strong economy helped move               a significant number of welfare recipients off of welfare. However,               during a recession, States need to be aware that their rural areas               may be at an increased risk of unemployment and may require additional               supports. 

A second assumption of welfare reform was that               as workers transition off welfare, they can better support their               families.(7) While many families               have increased their capacity to support themselves, many jobs obtained               by rural welfare recipients pay the minimum wage.(12)               The average weekly salary of a non-metro woman with less than a               high school education is 213 dollars.(7)               In addition, family median income is typically lower in rural areas,               with no rural districts in the top 100 family median income districts.(7)
**"Typically, funding formulas for federal funds favor highly populated states, creating a variety of challenges for rural areas."- Aging Program Director**
Third, with the implementation of welfare reform, many state welfare programs provided welfare-to-workparticipants with supplementary services to enter the workforce, e.g., child care, transportation and substanceabuse and mental health services. Because of the geography of rural communities, these services are difficultto provide and access. This lack of adequate services may impede successful employment. 

Lastly, while States have flexibility in establishing work requirements under TANF, a limited range of activitiescount as work in determining State participation rates. The TANF rules and the High Performance Bonusmeasures encourage States to support families as they move into jobs and to help recipients retain andadvance in jobs. Because rural residents often do not have access to formal employment, States may need tofocus more proactively to help these residents find and obtain jobs that can more easily meet the participationrate standards.

TANF also provides a good example of a program administered through State block grants. Block grantsprovide States the opportunity to design programs that address the unique needs of their communities includingflexibility to prescribe the amount or scope of services to rural communities. Programs administering HHS blockgrants may want to consider providing technical assistance on the specific needs of rural health and socialservice providers.

**Health and Social Service Outcomes in Rural America**

Rural residents experience relatively poorer               health and social welfare outcomes. The most dramatic health-related               disparities between rural and urban residents are in the areas of               mental health, substance abuse, public health outcomes and oral               health.(5) Human services-related               disparities include greater poverty and higher rates of unemployment.(7)

Some of the greatest rural/urban health disparities               are in tobacco and illicit drug use. In 1999, adolescents living               in the most rural counties had the highest percentage of cigarette               use (19 percent compared to 11 percent of urban adolescents).(5)(24) In addition, adults living               in the most rural counties are the most likely to smoke (27 percent               of women and 31 percent of men in 1997-1998).(5)(25) Higher rates of smoking in               the most rural counties may reflect two factors--delayed access               to the medical and media resources that help change unhealthy behaviors,(5)(26) and lower educational attainment,               which is strongly associated with smoking.(5)(27) Use of illicit drugs is also               more prevalent in rural areas. In 1999, rural eighth graders were               more likely to have used marijuana, cocaine, crack, methamphetamines               and alcohol than urban eighth graders. In the case of methamphetamines,               rural eighth graders were twice as likely to have used them than               urban eighth graders.(28)

Some of these disparities may be related to               inadequate access to mental health care, substance abuse treatment               and youth development programs in rural communities. Difficulties               include a shortage of mental health professionals and less funding               for the community mental health system(14)               that provides a substantial proportion of rural mental health services.               The stigma of mental health care and substance abuse as well as               concerns regarding confidentiality also limit rural residents' use               of these services. With limited budgets, mental health care providers               in rural areas are forced to focus on acute mental illness to the               detriment of prevention programs.(14)

Also of concern are continued low rates of early               prenatal care among rural women, especially those from certain minority               groups and high rates of childbearing among rural teenagers.(29)(30)(31)               Postneonatal death rates are also higher in rural areas.(32)

Better health insurance coverage and improvement               of the public health service system could reduce some of these issues.               However, rural public health programs and agencies also struggle               because of budget restrictions and shortages of professionals. Non-metropolitan               local public health agencies rely to a much greater extent on reimbursement               for services (22 percent of their income is reimbursement, compared               to 8.5 percent for urban public health agencies).(33)               When confronted with budget shortages, local public health agencies               often sacrifice services like family planning, mental health services               and chronic disease monitoring, which have less obvious impact on               the community's overall health.(33)               Non-metropolitan public health agencies also rely more heavily than               metropolitan public health agencies on health care providers because               of small staffs and budget restrictions.(34)               This reliance can create difficulties as a result of the perpetual               provider shortage in rural America.

Rural public and mental health services have               the potential to address higher rates of unintentional death, injury               and suicide in rural areas. Nationally, the age-adjusted unintentional               injury and death rate increases significantly as counties become               less urban.(35) The excess risk               of unintentional injury and death in rural areas is associated with               the higher incidence of fatal motor vehicle crashes and to some               extent with more hazardous occupations such as commercial fishing,               timber cutting and farming.(5)(36)(37) The higher incidence of fatal               crashes is related to poorer road conditions in rural areas and               also to lower rates of seat belt and child safety seat use, a situation               that could be remedied with public health programs. Also important               in increasing the rural fatal crash rate are long emergency medical               services response times and lack of medical emergency and trauma               care facilities.(5) Suicide rates               for men also increase as urbanization declines. Possible factors               in this increase include more increased firearm ownership in rural               areas and fewer treatment options for mental illness. (5)(38)(39)

Elderly rural residents also experience poorer               health than their urban counterparts. For example, the age-adjusted               edentulism (total tooth loss) prevalence among seniors generally               increases as urbanization declines.(5)(25) This urban-rural increase in               total tooth loss is consistent with the urban-rural decrease in               the number of dentists per population.(5)               Rural seniors also purchase more prescription medications than urban               seniors. Although rural seniors have greater need for prescription               medications, they are more likely than urban seniors to lack insurance               coverage for prescription drugs. In 1995, 46 percent of rural elders               lacked prescription coverage, compared to only 31 percent in urban               areas.(7)

Specific social welfare outcomes are also related               to inadequate access and regulatory barriers. To the extent that               child care funding is based on population size and density, rural               areas lose out. In addition, smaller dispersed populations in rural               areas and associated transportation problems limit the feasibility               of child care centers. Nationwide, 30 percent of all children under               age five are cared for in a center setting. In rural areas, only               25 percent receive such care. The remaining children are in family-run               child care homes, in-home care or relative care. While these settings               may provide familial and community connections, they are less likely               to be regulated.(40) Depending on               State policies, some of these settings may not be eligible to receive               subsidies through child care assistance programs such as the Child               Care and Development Fund. 

**"We also have a lot of children who could use a head start program, within our community instead of shipping the little guys thirty miles one way to have class." - Rural Resident**
Rural low-income families are more likely than their urban counterparts to work non-traditional hours. Inaddition, rural parents often have to travel further to jobs, which means longer hours for their children in careand increased child care costs. Few child care options are available for parents who work evening or nightshifts, or for the care of a sick child. While Head Start is among the few programs that allows for program fundsto be used for the purchase, renovation or construction of facilities under certain circumstances, there is no targeted pool offunds for this purpose. Limited housing and affordable facilities may lead rural grantees to struggle to findadequate child care sites.  

Poverty rates in rural areas are also higher               than those in urban areas. More than half of rural seniors have               family incomes below 200 percent of poverty, compared to roughly               40 percent of urban seniors.(7) Over               half of rural children in female-headed households are in poverty               (3.2 million children, 1996). In addition, 600 rural counties have               the designation "persistent poverty county," signifying that more               than 20 percent of the residents experienced poverty between 1960-1990.               These counties are concentrated in the South, core Appalachia, the               lower Rio Grande Valley and on American Indian reservations. While               the largest numbers of rural poor are white, all minorities have               much higher rates of poverty in rural areas.(7)               The largest proportion of the rural poor live in the South, where               welfare benefits are the lowest and where some of the more stringent               welfare policies exist.(41)

**Conclusion**

As these data underscore, access to health care and social services remain critical rural issues. Also apparentis the interdependence of health care, social services and economic development in rural communities. 

HHS' unique and important role in rural communities provides us with an opportunity to redefine, with ruralAmericans, the meaning of a healthy rural community and how HHS can organize and innovate its services tocorrespond with this new definition. This redefinition will recognize that, to be healthy, a community needs notonly health care, but a thriving economy, low levels of poverty and reliable social service networks. 

The Task Force used this perspective of integrated, holistic services in its analysis of and strategic planconcerning rural health and social services. This new, invigorated understanding will enhance and unify HHS'efforts in pursuing with energy and commitment the realization of truly healthy communities throughoutAmerica.  

**One Department Serving Rural Communities
The HHS Rural Task Force conducted a department-wide assessment of how HHS programs currently serverural and frontier  communities. During the course of this examination, the following key findings emerged. 
- ***It is difficult to assess the Department's investment in rural America.*** **

HHS administers hundreds of programs that potentially support health and human services in ruralcommunities both directly and indirectly. These programs are administered in myriad ways. In addition, theareas and communities in which some programs serve are more clearly defined as rural or urban than otherprograms' service areas. For example, HHS administers grants directly to community-based providers, groupsor organizations. Medicare also makes payments directly to health care providers. These investments can beeasily determined as either rural or urban. 

Other program spending by the Department is not as easily identified as rural or urban. For example, there areno mechanisms available to consistently determine the proportion of rural funding in State-administeredprograms such as Medicaid, SCHIP, TANF, the Social Services Block Grant and the Maternal and Child Healthblock grant.

Many HHS programs provide funds directly to State health departments or local agencies that then redistributethose funds in a variety of ways, some of which are categorical in nature. There are other instances in which acentral grantee such as a community health center may receive an award and serve as the grantee of record.However, many of these grantees also operate networks of satellite clinics in both urban and rural locations.There is currently no means for determining the proportion of this spending that benefits rural areas. 

HHS also funds a significant amount of health and human services research. While some of these studies mayfocus on or at least discuss some rural issues, most are not solely focused on rural issues. This funding istypically awarded to universities, policy institutes or individuals located in urban areas. Only HRSA's Office ofRural Health Policy and NIH offer rural-specific services research. 
- ***Programs define how they serve rural in different                 ways.***

The standard definition of rural used by  the Office of Management and Budget designates communities based  on whether they are located in metropolitan (i.e., urban) or non-metropolitan (i.e., rural) counties. While this definition is used by the Medicare program and several of the HRSA programs, it is not used by any of the other HHS agencies and offices. 
Some agencies, such as the Administration on Aging (AoA), use their own methodology based on specificprogram needs. Other programs allow their grantees to designate themselves as rural if they claim to serverural residents. There are other HHS programs such as many of those run by the Centers for Disease Controland Prevention that categorically focus on specific diseases or health issues and fund both rural and urbanprograms with no distinction between the two. Given this variability, there is no easy way to determine theDepartment's rural investment.  
- ***More that 225 HHS programs currently serve rural communities.***

Task Force members looked across their agencies and staff offices and determined that rural communities arecurrently served by more than 225 HHS-funded programs.  These programs range from grants targetedspecifically to rural communities to State-based programs like TANF and Medicaid. 

All of the Agencies and staff divisions provide service to rural individuals and communities. A summary of thekey programs and their impact on rural communities follows.

**"It would be interesting to trace dollars from the national level to the local level where services are actually delivered.  Whatpercentage of those dollars actually make it to 'where the rubber meets the road'?" - Program Director in Idaho**
**Agency Programs that Serve Rural Communities**

***Administration on Aging********(AoA)*** - AoA supports a nationwide aging network, providing services to the elderly,especially to enable them to remain independent. AoA supports 291 million meals for the elderly each year,including home-delivered "meals on wheels," provides transportation and at-home services, supportsombudsman services for the elderly and provides policy leadership on aging issues. 

AoA's services in rural areas are administered principally through the Older Americans Act Title II-C (NutritionServices), Title III-E of that act, the national Family Caregiver Support Program and through Title VI, Part C -the Native American Caregiver Support Program.  

***Administration for Children and Families (ACF)***** - ACF is responsible for numerous federal programs thatpromote the economic and social well being of children, families, individuals and communities. Actual servicesare provided by State, county, city and Tribal governments, and public and private local agencies. Among itsmajor programs are the Temporary Assistance for Needy Families, the nation's child support enforcementsystem, foster care and adoption assistance, child care and child welfare services, child abuse and neglectprograms, assistance for people with disabilities and the Head Start program. 

It also administers a number of community and economic development programs including several specificallyfor Native Americans. The community services grant program provides essential funding to a network of morethan 1200 community-based multi-service agencies called community action agencies.

***Agency for Healthcare Research and Quality (AHRQ)***** - AHRQ supports research designed to improve thequality of health care, reduce its costs, improve patient safety, address medical errors and broaden access toessential services. The research sponsored, conducted and disseminated by AHRQ provides evidence-basedinformation that helps health care decision makers - patients and clinicians, health system leaders and policymakers - make more informed decisions and improve the quality of health care services.

Last year, AHRQ supported a number of studies that examined issues related torural health, e.g., patterns of individual health plan coverage among rural populations, quality care and errorreduction in rural hospitals and the rural response to Medicare+ Choice.  

***Agency for Toxic Substances and Disease Registry (ATSDR)***** - ATSDR works with States and other federalagencies to prevent exposure to hazardous substances from waste sites.  ATSDR conducts public healthassessments, health studies, surveillance activities, and health education training in communities around wastesites on the U.S. Environmental Protection Agency's National Priorities List.  

***Centers for Disease Control and Prevention (CDC)*** - CDC promotes health and quality of life by preventingand controlling disease, injury and disability. CDC seeks to accomplish its mission by working with partnersthroughout the nation and world to monitor health, detect and investigate health problems, conduct research toenhance prevention, develop and advocate sound public health policies, implement prevention strategies,promote healthy behaviors, foster safe and healthful environments and provide leadership and training.

***Centers for Medicare & Medicaid Services (CMS)***- CMS administers the Medicare and Medicaid programs,which provide health care to America's aged and indigent populations. These programs serve about one inevery four Americans, including more than 18 million children. Medicaid also provides nursing home coveragefor low-income elderly.  CMS also administers the State Children's Health Insurance Program (SCHIP) thatcovered an estimated 4.6 million children in FY 2001.

***Food and Drug Administration (FDA)*** - FDA assures the safety of foods and cosmetics, and the safety andefficacy of pharmaceuticals, biological products and medical devices. For FY 2001, FDA programs do not havesignificant investments in rural communities. However, in FY 2001, FDA supported Innovative Food SafetyProjects and a number of research grants that will benefit rural people.

***Health Resources and Services Administration (HRSA)*** - HRSA's programs provide the foundation for thesafety net of health care services relied on by millions of Americans. In 2001, HRSA provided preventive andprimary health care to an estimated 10.5 million Americans through its nationwide network of 773 health centergrantees, which includes community and migrant health centers and primary care programs for the homelessand residents of public housing, many of which are jointly funded. The agency administers programs like theRyan White Care Act, which give low-income people with HIV/AIDS the medication and care they need to getbetter or stay well, works with States to ensure that babies are born healthy and that pregnant women andchildren have access to health care and oversees the Nation's organ transplantation system.  

HRSA helps train physicians, nurses and other health care providers, places them in communities where theirservices are desperately needed and also works to build the health care workforce through the National HealthService Corps. The Office of Rural Health Policy has responsibility for coordinating rural efforts across HHS,examining HHS policies on rural matters and currently administers eight grant programs that address ruralhealth needs. 

***Indian Health Service (IHS)*** - IHS supports a network of 49 hospitals, 214 health centers, 287 health stations,school health centers, satellite clinics and Alaska village clinics and 34 urban Indian health centers to provideservices to 1.5 million American Indians and Alaska Natives of 558 federally recognized Tribes. 

***National Institutes of Health (NIH)*** - NIH, with 27 Institutes and Centers, is the world's premier medicalresearch organization and supports some 35,000 research projects nationwide in diseases like cancer,Alzheimer's, diabetes, arthritis, health ailments and AIDS. NIH invests in research and care for ruralcommunities, principally through the National Cancer Institute, the National Institute on Drug Abuse and theNational Institute of Mental Health. Other NIH Institutes fund smaller amounts of research directed toward ruralcommunities.

***Office of Intergovernmental Affairs (IGA)*** - IGA facilitates communication regarding HHS initiatives as theyrelate to State, local and Tribal governments. IGA is the Departmental liaison to State governments and servesthe dual role of representing the State and Tribal perspective in the federal policymaking process as well asclarifying the federal perspective to State and Tribal representatives. In partnership with the US Department ofAgriculture, IGA provides support to the National Rural Development Partnership each year. IGA also providestechnical assistance and training on transportation coordination, much of which serves rural areas.

***Office of Public Health and Science (OPHS)*** - OPHS serves as the focal point for leadership andcoordination across the Department of Health and Human Services (HHS) in public health and science.  OPHSprovides direction to its program offices, including the Offices of Women's Health, Minority Health, PopulationAffairs, and Disease Prevention/Health Promotion.  Additionally, OPHS provides advice and counsel on publichealth and science issues to the Secretary. 

OPHS invests in the improvement of health care and research, principally through State and researchinstitution-based programs including Centers of Excellence and Community Centers of Excellence in Women'sHealth, the Office of Population Affairs' Adolescent Family Life and Family Planning Programs and the Office ofDisease Prevention/Health Promotion's Healthy People 2010. 

***U.S. Public Health Service Commissioned Corps (USPHS)*** - The U.S. Public Health Service Commissioned Corps, a cadre of 5,628 health professionals, engineers, andscientists, is one of the seven uniformed services of the United States.  The mission of the CommissionedCorps is to provide highly-trained and mobile professionals who carry out programs to promote the health of thenation, understand and prevent disease and injury, assure safe and effective drugs and medical devices,deliver health services to federal beneficiaries and furnish broad health expertise in time of war or othernational or international emergencies.  

The Office of Public Health and Science provides policy and leadership for the Commissioned Corps throughthe Office of the Surgeon General.  The Program Support Center, through the Division of CommissionedPersonnel (DCP), provides day-to-day administration of the Commissioned Corps.  DCP is the centralizedhuman resource authority for all Commissioned Officers. Through participation in the Rural Task Force, DCPhas continued its efforts to evaluate opportunities for Commissioned Officers to provide their exceptionalservices to meet public health needs specific to rural America.

Commissioned Officers are presently assigned to all HHS agencies and to a number of agencies outside HHS. Currently, 1422 Commissioned Officers (or roughly 34.2 percent) staff facilities in non-metropolitan areas and0.9 percent serve in Territories and International areas. Analysis by provider-type showed that placement inrural areas includes 230 dentists (43 percent of all dentists), 280 pharmacists (37 percent), 42 therapists (34percent), 24 dieticians (32 percent), 304 nurses (28 percent), 107 engineers (26 percent), and 169 physicians(13 percent).

***Program Support Center (PSC)*** - PSC, a service-for-fee organization, utilizes a business enterprise approachto provide government and support services throughout HHS as well as other Departments and federalagencies.  Administrative operations, financial management and social resources are solution and custom-oriented.  

In addition to the expansive array of support services to Federal entities, PSC also is responsible for thedistribution and management of over 5,000 pharmaceutical items and health supplies worldwide. Its SupplyService Center packages pharmaceuticals for hospitals, ships-at-sea and embassies around the world. Allservices are provided in cooperation and sponsorship with National Institutes of Health and other federalgovernment agencies. 

The Center's comprehensive program provides technical assistance, inventory management, and logisticalsupport to meet the packaging and distribution requirements of clinical drug trials. Through inter-agencyagreements with research programs, the Center participates as the Drug Distribution Center for small to verylarge investigational trials involving numerous clinical centers and is able to offer several years of centralizedexperience in packaging, labeling, and distributing investigational drugs for clinical trials. 

In the area of rural health, the Supply Service Center provides pharmaceutical and medical supplies to IndianHealth Service and Tribal run clinics. One of the products that is very useful in these rural areas is ourPharmacy Unit of Use Prepacks, which are convenient, prescription size, patient-ready units labeled for directdistribution to patients by health care providers. Dispensing these unit-of-use containers to patients is aneconomical and time saving alternative for the small or remote locations that do not have a pharmacist.  

***Substance Abuse and Mental Health Services Administration (SAMHSA)*** - SAMHSA is the lead federalagency for improving the quality and availability of prevention and treatment services for substance abuse andmental illness.

SAMHSA administers a combination of categorical, formula, and block grant programs and data collectionactivities through the Center for Mental Health Services (CMHS); the Center for Substance Abuse Prevention(CSAP); the Center for Substance Abuse Treatment (CSAT); and the Office of Applied Studies (OAS). 

These programs work in a coordinated manner to develop and apply best mental health and substance abuseprevention and treatment service practices. SAMHSA serves rural areas through grants to States andcommunity-based programs.

**"We need a psychologist. There                   are a lot of issues that people deal with out here in the sticks                   with no 'real' help. Oh, sure you can go to your minister, but                   they too live in this community and for too long and that becomes                   uncomfortable." - Rural Resident**

**Barriers to Serving Rural Communities
The HHS Rural Task Force identified a number of barriers to serving rural individuals and families, butsurprisingly few that were unique to rural situations.  Although rural communities share similar barriers withurban America, the ways in which those barriers manifest themselves in rural programs vary significantly. Thebarriers can be organized into three  categories:  statutory, regulatory and  administrative. 

In general, statutory barriers are related to legislative requirements that direct funding and payment policies.Other statutory barriers are a result of what the statutes do not require, such as outreach or special efforts toserve rural communities. Regulatory and administrative policy barriers may stem from judgments made byfederal staff with limited knowledge of rural issues that unintentionally disadvantage rural communities.Additionally, federal staff have little control over how block grant funds are subsequently distributed at the Statelevel.

**Statutory Barriers**

*1. Requiring matching funds*

Federal programs requiring a substantial match present challenges for many grantees, but particularly for somerural constituencies with limited resources. For example, the Office of Rural Health Policy's State Office ofRural Health grant program requires States to provide 75 percent of funding to match the 25 percent providedby federal grants. Rural constituencies often have fewer public and non-profit entities from which to build the coalitions that cangenerate needed match funding for initiation and maintenance of programs that benefit rural communities.

*2. Population-based formulas*

Programs with allocation formulas based on numbers of clients or anticipated costs may be biased against ruralcommunities with small numbers of participants and the inability to "spread costs" across a larger client base.For example, the Ryan White CARE Act Title II directs States to establish consortia for the delivery of HIV-related support and medical services within areas of the State "most affected by HIV disease." Most ruralcommunities have not had large numbers of individuals with HIV.

*3. Targeting and eligibility*

Programs that provide funds through States may limit rural communities' participation in these programs. Forexample, funds sent to States in block grants may result in great variability in rural service, as some States maytarget rural service areas while others do not.  Tribes' access to block grant dollars is also limited. Unlessstatutory language specifically identifies rural or Tribal communities for service, cost factors and lack ofawareness lead States to direct funds to the areas where there is greater perceived benefit for the expenditure.

*4. The need for outreach*

Authorizing statutes that do not require outreach efforts to providers or families result in lack of awareness ofservices and limited participation. Without rural outreach language, States may not be encouraged to serverural communities and these communities frequently never learn of opportunities. For example, although ACF'sChild Care and Development block grant requires State plans to include a consumer education component forparents of all eligible children and quality initiative set-aside monies are available for rural communities, there isnot a specific rural outreach requirement. This may contribute to the variability across States in the proportionof rural families receiving child care services. Thus, the inclusion of rural outreach language in this fundingmechanism may be useful in focusing State efforts on informing and assisting eligible geographically isolatedfamilies to obtain needed access to child care services.

5*. Data Collection Limitations*

Concern about the undue burden of data collection and paperwork reduction has led to significant limitations onthe allowable collection of data that would assist many programs to better understand and respond to theneeds of rural communities. For example, the lack of available public transportation is uniformly recognized asa serious barrier to accessing services in rural communities. However, there is limited HHS program-specificinformation on the need for or costs of transportation in rural communities. Particularly in social servicesprograms, little attention has been paid to defining the rural differential in these programs.

There are unique statutory barriers that are not applicable across all programs.  For example, confidentialityprotections limit data analysis for smaller geographic areas for CDC's National Center for Health Statistics.While providing important protections for citizens, this hinders some in-depth rural analysis of national surveydata that might better inform policy making. Statutory language that requires HRSA's Quentin Burdickinterdisciplinary training grants to include a research component presents barriers to smaller academicinstitutions that do not sponsor significant research activities.

**Regulatory Barriers**

The Task Force identified a number of regulatory barriers, but few unique to serving rural constituents. Forexample, the requirement for individual plans, periodic reporting and comprehensive final reports can representan overwhelming burden to small rural agencies with limited staff, as they attempt to coordinate multiplefunding sources.  

*1. Defining rural*
The federal government has several ways of defining geographic areas as either rural or urban ranging fromthe Office of Management and Budget's (OMB) "Metropolitan-Non-metropolitan" system to the CensusBureau's definition of urban and urbanized areas, as well as several methodologies used by the Department ofAgriculture. Some HHS programs, however, use no definition at all and allow their grantees to self-declarewhether they serve rural communities. 

The most widely used definition across the federal government and HHS is the OMB methodology. This systemdesignates counties as either metropolitan (i.e., urban) or non-metropolitan (i.e., rural) areas. Under thisdefinition, any county not considered a metropolitan statistical area (MSA) is considered rural. Metropolitancounties must include one city with 50,000 or more inhabitants or an urbanized area (defined by the Bureau ofthe Census) with at least 50,000 inhabitants and a total Metropolitan Statistical Area (MSA) population of atleast 100,000 (75,000 in New England). Under the OMB definition, any adjacent counties in which at least fiftypercent of the population is in the urbanized area surrounding the largest city are also included in themetropolitan area. Additional "outlying counties" are included in the metropolitan area if a substantial proportionof the employed people in the county commute to the central city or area.

Use of the OMB definition can affect application for, and awarding of, grants for rural health and social services.This is largely due to the use of counties in OMB urban/rural designations. There is great variation in the size ofcounties across the country. One major problem arises in the case of larger counties. Under OMB's county-based geographic classification system, many counties with substantial rural areas are designated as urbanbecause they may contain an urban area in one part of the county. For example, San Bernardino County inCalifornia covers more than 20,000 square miles and contains a portion of the greater Los Angeles area in itswestern corner but also contains vast stretches of desert including Death Valley in its eastern portion.Programs and services in San Bernardino County cannot qualify for rural health and social service grants orspecial rural Medicare payment protections, although they may serve communities that are rural by everymeasure but that of the OMB. 

The development of a new demographic classification system could facilitate a more effective HHS response torural communities as well as a more precise assessment of HHS' service to rural communities.

**"The health care system is highly regulated, and rural providers are particularly feeling the effects of regulation as theystruggle with reimbursement and workforce challenges." - Minnesota Rural Health Association**
*2. Collecting data*

As previously indicated, HHS programs do not routinely collect service area and outcome data that describeshow and precisely where they serve rural people and communities. Sparse populations make the cost ofconducting household-based representative surveys expensive and limit HHS' ability to conduct rigorousquantitative research. The diversity of rural areas and rural communities limits the generalizability of researchdata; service area data is not collected by race, ethnicity and disability, obscuring the diversity of ruralcommunities. Narrow reading of privacy statutes limits the ability of researchers to collect data in rural areasbecause of smaller sample sizes. One notable exception is SAMHSA's National Household Survey on DrugAbuse which provides information on the prevalence of substance use in the population and collectsinformation on the socio-demographic characteristics of users, including their place of residence.

*3. Unique situations*

There are a number of unique situations that are not addressed in federal regulations. For example, asubstantial proportion of rural residents access drinking water exclusively through private water wells. However,private well water is not regulated at the federal or State level and can be a significant source of contaminantsand pathogens. Another example is an INS rule that mandates release of parolees prior to completion of TBtreatment. Difficulty tracking these patients affects rural areas and contributes to the development of multi-drugresistant TB.  Program regulations do not address situations where there may not be a road to the client, suchas in Western frontier areas. Confidentiality requirements take on very different meanings in communitieswhere there is limited anonymity. 

**Administrative, Policy and Resource Barriers**

Most of the barriers identified were "resource" barriers, meaning that resources were inadequate to addressrural problems within the scope of HHS' programs. 

*1. Categorical funding*

Multiple agencies and constituents who responded to the Task Force's request for comments expressed thatcategorical and limited funding makes reaching remote populations difficult. Categories of funding begin todefine the need rather than the need defining the response. Rural communities often lack the information,knowledge and capacity to identify the range of funding sources, to redefine their needs to fit the eligibilitycategories and to produce the reports required for funding.  

*2. The regional nature of rurality creates challenges*

In addition, the regional nature of rural America makes it hard to serve rural residents. Frontier areas, populatedlargely by white Americans, differ greatly in their health needs from Southeastern rural communities, populatedlargely by African Americans. These differences are evident when customizing prevention programs, fundingproviders and measuring health status.

In some rural areas, regional identities are based on county and, sometimes, State lines. The closest medicalor social service may be in the next county or the closest, larger city in another State. 

*3. Whom we consult*

Another policy barrier internal to HHS is our interaction with constituent groups. HHS often uses nationalassociations of State and local government representatives as proxies for those governmental entities in HHSregulatory and policy consultation processes. These organizations may not have a rural focus and may excludethe rural perspective unless specifically requested. 

*4. Working with States and communities*

Working with States presents several challenges. The variability in their responsiveness to rural issues andinadequate institutional capacity at State and community levels limits sustained interventions. For example,States may not have well-developed systems for tracking service delivery and needs at sub-State levels.

**"The health care infrastructure in many rural communities is financially fragile and thus especially sensitive to changes inMedicare's policies."  - Clinic Director in Wisconsin**
*5. Infrastructure barriers*

Rural residents need better transportation to health and social services, as well as to obtain and maintainemployment. Communities should ideally have affordable and accessible public transportation, yet inadequateresources as well as poor transportation infrastructure limit access. 

Transportation for medical purposes and to serve individuals with disabilities is especially lacking. Geographicdistances, road conditions and weather often limit service delivery, especially to rural elders. Distance itself is aproblem, as it raises the cost of delivering services.

Workforce shortages (health care providers, personal care) limit the success of HHS' programs, where theworkforce is inadequate in number and training to deliver programs to rural populations. In addition, time offfrom work for training is difficult, since small rural staffs must ensure coverage. Related to workforce shortagesis lack of interpreters and translation services that present barriers to access to quality health care and socialservices by persons with limited English proficiency and persons with disabilities.

Technology, especially telemedicine, seen as a logical solution to distance and workforce problems, presentsproblems to rural communities which often lack the technological infrastructure to support such options. Fundstend to support pieces of it but are not available to support full participation in telemedicine programs. Inaddition, a large proportion of telemedicine funds has gone to academic medical centers, which, for the mostpart, are in urban areas.  

Many local health departments lack high speed continuous Internet access (Only 48.9 percent have access);broadcast communications capacity (44.9 percent have this capacity); and facilities and equipment for distance-based training (e.g., satellite downlink, teleconferencing, web-based training). This access may be especiallylimited in rural health departments.

A final barrier related to infrastructure is the small number of community-based organizations in rural areas.Without existing non-profit organizations in their communities, rural areas are less likely to be eligible to applyfor and receive federal or other health and human services grants.

*6. Costs of delivering care in rural areas*

Higher costs for providing care in rural areas, without related higher payments, are also a problem for ruralcommunities. Rural communities do not have sufficient use of services nor demand for individual services torealize scaled cost savings.  For example, rural providers that have low numbers of low-income individuals andreceive a smaller percentage of State dollars through the ACF Community Services Block Grant find the natureof rural poverty frequently requires greater resources because of higher per client costs. 

Providing services in rural areas often entails moving the client or the service provider over great distances,using a limited provider network and working with a client population often resistant to service. All of theseconditions raise the cost of providing service. 

**"The cost of running a medical practice is no less expensive in a rural area than in an urban area. When I buy astethoscope, do I get a rural discount?" - Physician in Oregon**
Statutory payment caps also disadvantage rural providers. For example, the statutory payment cap forscreening services at Medicare rates, sufficient for many urban screening services, is not sufficient to coverhigher costs of delivering mobile mammography to rural women through the National Breast and CervicalCancer Early Detection Program carried out by CDC.

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

Differing regulations - federal, State and local  - are confusing to rural communities.  Effective health and socialservices program delivery requires local agencies and service providers to weave a service safety net from theoften fragmented array of federal and State funding options.  

The ability to weave an effective net is directly related to the capacity of the community and its organizations toacquire, understand, integrate and respond to an enormous variety of program information and requirements. 

Larger communities may have the resources to employ full-time grant writers and program administrators toaddress these formidable information demands. This situation in essence constitutes a cycle in which thosethat most need help are least likely to qualify. Even when successful in obtaining funding, rural communitiesstruggle with the ability to produce the planning and reporting information required for each individual fundingsource.

**Research and Policy-Making Efforts
A number of HHS agencies have a role in conducting research and supporting a rural perspective in policy anddecision making. Much of this work is conducted to inform the public, Congress, State-level leaders, Triballeaders, local level leaders, as well as HHS leaders and staff. The general public is also informed through theseefforts. The support of rural policy and decision making runs across the Department ranging from targetedresearch studies to evaluation of programs as well as national meetings and conferences.

The Office of Rural Health Policy serves as a focal point for rural health issues within the Department. TheOffice, which was created in 1987, is charged in its authorizing language in the Social Security Act with advisingthe Secretary and the Department on rural health issues. ORHP reviews key Medicare and Medicaidregulations to assess the impact on rural providers and beneficiaries and also funds rural focused healthservices research. ORHP currently administers eight grant programs designed to expand rural health capacityat the State and local level. 

HRSA, AHRQ, NIH, CMS, SAMHSA, ACF and the Office of the Assistant Secretary for Planning and Evaluationall support health and social services research on a variety of administration policies and programs includingMedicare, Medicaid, mental health, substance abuse and TANF. Of these, only HRSA's Office of Rural HealthPolicy and NIH offer rural-specific services research. Other HHS-supported research projects tend to be moreglobal in nature. CDC recently produced a national chart book on rural and urban health indicators thathighlighted key differences in health status between rural and urban populations. 

Several of the HHS operating divisions are working to emphasize flexibility in current programs to better meetrural needs. AoA has emphasized creating flexibility in its funding streams to allow States and local Agencieson Aging to tailor programs to local needs. AoA is also working with States so that a substantial percentage ofthe services in a new Alzheimer's Disease Demonstration grant program are delivered to people living in ruralareas. 

HHS agencies and offices are also reaching out to rural constituency groups on a variety of policy andprogrammatic

issues. CMS is currently sponsoring rural "listening sessions" with providers and association representatives onkey rural Medicare issues. HRSA's Bureau of Primary Health Care annually convenes a joint task force ofmembers of the National Rural Health Association and the National Association of Community Health Centersto discuss issues that cut across both organizations. 

The Office of Intergovernmental Affairs has represented the Department on the National Rural DevelopmentCouncil and participated in activities of the National Rural Development Partnership since 1991. ThePartnership consists of 40 State Rural Development Councils as well as the Washington, DC based NationalCouncil. IGA has worked with the Partnership to add health and social services perspectives to their economicdevelopment strategies.

Developing HHS-Wide Goals and Strategies
To begin its Department-wide planning effort, the Rural Task Force established five goals:

Goal 1: Improving rural communities' access to quality health and human servicesGoal 2: Strengthening rural families.Goal 3: Strengthening rural communities and supporting economic development.Goal 4: Partnering with State, local and Tribal governments to support rural communities.Goal 5: Supporting rural policy and decision-making and ensuring a rural voice in the consultative process.

These goals were intended to broadly capture most of the Department's rural programs and policy-makingefforts. Each agency and staff office was asked to develop a plan addressing these five goals. Five goalworkgroups used these as a basis for developing an HHS-wide plan and making recommendations to theSecretary.

**Public Comment to Inform the Task Force 
Recognizing the value of input from people living in rural communities, the HHS Rural Task Force invited publiccomment on the five goals of the HHS Rural Initiative. Through a Notice in the Federal Register published onAugust 29, 2001, the Task Force encouraged people at the local, State, and Tribal levels to share theirthoughts about how the Department can better serve rural communities.  

More than 450 individuals and organizations shared their insight and experience. Comments ranged frompeople simply thanking Secretary Thompson for his focus on rural services to technical comments about theimpact of particular HHS health care 

financing regulations on small, rural providers. The comments received were organized and analyzed in relationto the five goals of the HHS Rural Initiative. The following are the common themes that supported the work ofthe goal workgroups:

**Goal 1: Improving rural communities' access to quality health and human services.**
- Improve access to transportation services and increase vehicle ownership so rural families can attend socialservices appointments or medical visits, obtain and maintain employment and more readily contribute to thelife of the community.
- Recruit and support more rural providers, particularly those providing mental health, substance abuse ordental services.
- Support better rural options for community-based care for individuals with disabilities and elderly people.
- Increase support for rural child care, telemedicine, Head Start, EMS, HIV/AIDS services and rural healthclinics.  
- Increase reimbursement for rural providers and minimize the impact of geographic payment adjustmentsbetween rural and urban providers.

**Goal 2: Strengthening rural families.**
- Support youth and adolescent opportunities through health and social services career development, byincreasing after-school options and by partnering with rural youth organizations.
- Support adult literacy and social capital through training and educational programs to help people transitionfrom welfare to work.
- Help families make better health, social and life-task decisions through parenting education programs.
- Increase support for rural caregivers and respite services.

**Goal 3: Strengthening rural communities and supporting economic development.**
- Increase technical assistance on HHS grant programs to rural communities.
- Partner with the US Department of Agriculture's   Cooperative Extension Services and Vocational Training Programs offered at rural Community Colleges.  Support telemedicine, teleservices and rural infrastructure needs.  Provide a tax credit or expanded loan forgiveness for rural providers as an incentive for serving ruralAmerica.   **Goal 4: Partnering with State, local and Tribal governments to support rural communities.**  Support State or regional rural summits.
Build on the strength of existing partnerships with Community Action Agencies, State Offices of Rural Health,etc. to better connect HHS programs with the communities they serve.
Foster better relationships between Tribal governments and State agencies who receive HHS funding.
  **Goal 5: Supporting rural policy and decision-making and ensuring a rural voice in the consultativeprocess**.  Use a common definition of "rural" across HHS programs.
Recognize that GPRA measures that value the most people served for the money may disadvantage ruralcommunities because of lower volume of people served.
Involve consumers in the policy-making process to attain a "true" rural voice.
Form a new rural agency within HHS that looks at both social services and health.
Integrate "rural" into Healthy People 2010 goals.
  In addition to these themes, many comments offered agency specific suggestions. These program specificrecommendations are being shared with the proper agency for future consideration. These comments will beused to develop further strategies for improving rural health and human services.  
**Cross-Cutting Recommendations:One Department Serving Rural America
Drawing from these public comments and from the individual goals submitted by each agency and staffdivision, the Task Force developed a series of strategies to improve how HHS serves rural communities. Anumber of proposals  supported the Task Force's concept of  "One Department, Serving Rural America." Thesestrategies cut across all goals and most aspects of the Department and require a fundamental change in ourprocess. These goals were pulled into a series of recommendations for restructuring the way HHS works onrural issues as a Department and with State, local and Tribal governments. 

Effective, coordinated health care and social services are essential in rural communities, where resources and providers are limited. The Task Force's examination of HHS' rural support revealed that improvements could bemade in program coordination and policy.  Our current federal approach to providing rural services - throughdiscrete categorical funding - makes rural service providers "specialize" in an attempt to meet grantrequirements, despite the fact that many of these programs serve the same clients. Our research and policy-making efforts have not been coordinated and in some instances have been duplicative. The newly createdHHS research coordination council presents an opportunity to overcome these challenges and to develop aDepartment-wide rural research agenda.  

We also miss opportunities to inform policy-making by not distinguishing data as rural or urban or by requiring data that describes rural programs and outcomes. HHS could better serve ruralcommunities by making a fundamental change in its approach to programs and policy-making affecting thesecommunities. HHS needs to integrate its own programs and policy making efforts, then help States and ruralcommunities do the same. The Rural Task Force believes that we should characterize this as "OneDepartment, Serving Rural America."
**1. Ways we can improve rural health and social services             coordination within HHS.**- Create a formal structure within HHS with responsibility for coordinating rural policy initiatives among HHSagencies and staff divisions, as well as with external partners.
Based on the work of this Task Force, create a cross-HHS workgroup that follows up on the proposedstrategies. This workgroup would meet quarterly with the Secretary, or the Deputy Secretary, and report onHHS' progress toward achieving the goals proposed by the Task Force.

**"Social service agencies in certain parts of our region continue to be underfunded with high *[staff]* turnover rates." - RuralProvider in Pennsylvania**- Enhance HHS budget documents to include a more thorough consideration of rural issues.
Explore the feasibility of developing a rural impact analysis statement to be included, as appropriate, in allproposed regulations or regulatory changes.

Create opportunities for HHS staff and program managers to learn about other programs that serve ruralcommunities. 

Create a single point of entry or focal point to coordinate assistance for rural communities with limitedinfrastructure as they seek assistance from the Department of Health and Human Services.

Ensure that central and regional HHS office grant officers receive up-to-date information about HHS-fundedprojects at the community level.

Create an "overlay" map of community-based programs that is web-based and available to HHS staff, as wellas State and community-based health and social services providers.  

Integrate the Department's technical assistance for new rural grant seekers who do not currently receivefunding from HHS. Create a Department-wide plan for providing technical assistance across health andhuman services to rural communities, rather than a program by program approach. 

Working with the newly created HHS research coordination council, develop a coordinated research agendato identify rural needs and assess the impact of health and social services on rural economies.  Wheneverpossible, disaggregate rural/urban data in research funded by HHS.

**2.  Ways we can support the integration of primary health care, behavioral health and social services atthe State level.**
- Sponsor Regional HHS-wide conferences to meet with State, local and Tribal rural leaders to communicatedepartment-wide information to participants and to listen to State and local concerns. 
Support State-level rural health and social services workshops, as part of that State's rural health meeting. At this workshop, State-level health, behavioral health and social services staff would examine the ways thatthey could integrate their services with local rural providers.

Support two State-level demonstrations that would include an evaluation component, assisting those Statesto develop a plan to coordinate rural primary and behavioral health service providers to address rural issues.Findings from these demonstrations would be shared with federal and State staff and rural providers. 

**3.  Support the coordination of HHS' health and social services programs at the community level.**
- Support two demonstrations in small rural communities that would assist them in developing community-wideplanning efforts. For example, how can the local hospital, community health center, public health and socialservices departments and Head Start ensure they have adequate numbers of nurses, social workers, frontoffice staff, etc.
Work with the appropriate health and social services national organizations to include workshops on serviceprovision in rural communities in their national or regional membership meetings, emphasizing the need forthe coordination of services in rural communities.

Build on earlier efforts by the Office of Rural Health Policy, the Indian Health Service and the Centers forMedicare & Medicaid Services to improve collaboration between local health providers and the local Tribalhealth systems.

Identify ways to channel input from community leaders into HHS program consultation processes and sharewith communities the ways their input has been used.

Consider using Secretarial authority, under the newly proposed State Program Integration Waivers, or otherappropriate mechanisms to consolidate program funds at the State or local level.

Undertake two cross-cutting policy initiatives as models (one for health services, one for social services) thatseek to improve the way the Department makes policy that relates to rural communities. The health projectcould address health quality in rural areas. The social services project could manage an examination ofwhether the administrative systems (such as data reporting and performance measurement systems) forTANF, Head Start, Social Services Block Grant, Community Services Block Grant or other social servicesprograms support the development of effective rural strategies.

Many of these proposals will be strengthened by partnerships with other federal Departments, the privatesector, foundations, and other organizations.  The Department will need to engage them and seek their supportas it goes forward to implement many of these strategies.

**Other Administration Initiatives
In the course of the preparation of this report, it became clear that the five goals of the Secretary's Initiative onRural Communities reflect the goals of several ongoing Presidential and Secretarial Initiatives, including theNew Freedom Initiative, the President's Blueprint for New Beginnings, the Border Health Initiative, the NativeAmerican Initiative and the Faith-Based Initiative. The President's Blueprint for New Beginnings, which outlinedthe President's first budget, as well as the New Freedom Initiative, set broad policy goals for improving the waythe Government does its business and doing so in a way that improves access to needed services while alsoreaching out to State and local governments in an ongoing partnership. Initiatives focusing on border healthand Native Americans as well as the Faith-Based Initiative echo similar refrains about improving the wayfederal programs serve Americans.  Several consistent themes emerge:  improving access to needed services;reaching out to State and local governments to foster more effective partnerships; and improving theresponsiveness of federal programs.

The Secretary's Rural Initiative relates to the HHS priorities of the President's Blueprint for New Beginnings inseveral areas. Doubling resources for NIH, strengthening the health care safety net, reforming the NationalHealth Service Corps' (NHSC) efforts to recruit and retain health care providers, increasing access to drugtreatment and supporting the Healthy Communities Innovation Initiative all coincide with the Rural Initiative goalone of improving rural communities' access to quality health and social services. Goal two, strengthening ruralfamilies, relates to the President's Blueprint for New Beginnings by promoting safe and stable families, creatingafter-school certificates, promoting responsible fatherhood, supporting maternity group homes, and providingan Immediate Helping Hand for prescription drug benefits.

Two other current HHS initiatives also share some common goals with the Rural Initiative by attempting to moredirectly meet the needs of health care providers and the people they serve. The Secretary's Regulatory ReformInitiative seeks to reduce regulatory burdens in health care and respond faster to the concerns of health careproviders, State and local governments and individual Americans who are affected by HHS rules. This activityhas particular relevance for rural providers who often lack the administrative resources to deal with regulatorychanges. CMS is also reaching out to the provider and beneficiary community through its "Open Door" listeningsessions in a number of key areas, including rural health. The intent of this initiative is to strengthencommunication and information sharing between CMS and beneficiary groups, plans, physicians and otherproviders. 

The Border Health Initiative shares several common goals with the Rural Initiative. These include improvingrural communities' access to quality health and social services, strengthening rural families, strengthening ruralcommunities and supporting economic development and partnering with State, local and Tribal governments tosupport rural communities. Specifically, the commitment to community-based, culturally competent health careis a common theme between these two initiatives.

HHS' emphasis on outreach to American Indians and the Rural Initiative reflect common goals in improving access to quality health and social services, specifically culturally appropriateservices and partnering with State, local and Tribal governments to support rural communities.

The President's Faith-Based Initiative works to promote public/private partnerships that level the playing fieldfor all faith-based and community organizations applying for federal grants.  This Presidential Initiativeoverarches all the Rural Initiative goals toward improving rural communities' access to quality

health and social services, strengthening rural families, strengthening rural communities and supportingeconomic development, and partnering with State, local and Tribal governments to support rural communities with particular emphasis on supporting rural policyand decision-making and ensuring a rural voice in the consultative process. Especially in rural America, faith-based organizations play a critical role in the coordination of and provision of needed health and humanservices.

Finally, the President's Anti-Bioterrorism Initiative and the Secretary's Rural Initiative share the similar goal ofimproving rural communities' access to quality health and social services. The need for strengthening thecapacity for medical response and emergency services as well as creating partnerships and networks amongpublic health, medical and public safety entities to enhance preparedness and response to threats of bio-terrorism is highlighted in both Initiatives.

**Conclusion
Nowhere is the shared future of Americans more immediate and present than in many rural communities wherethe needs of each resident are often apparent. With this context as a setting, these communities are the bestplace in which to make fundamental changes and improvements in the operations and policies of HHS on anational, regional and local level. The ideal of One Department is nowhere more possible than in smallcommunities around the country that need unified, visionary leadership that no longer ideologically andadministratively separates the complementary services of HHS. Our shared future depends in great measureon our ability to secure the social and economic safety and health of all Americans. Now is the time to embracethe future of rural America, essentially all of our future, and our opportunity to lead the way in transforming thefederal government's response to those in need.

**NOTES
1.  This number is based on US Census Bureau data from 1990 with 2000 projections provided by the USDA EconomicResearch Service.
2.  USDA Economic Research Service. "Rural Population and Migration: Rural Population Change". 2000.
3.  Ricketts, TC, Johnson-Webb, K, Randolph, RK.  "Populations and Places in Rural America" in Rural Health in theUnited States. New York: Oxford University Press. 1999.
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5.  Eberhardt MS, Ingram DD, Makuc DM, et al. Urban and Rural Health Chartbook. Health, United States, 2001.Hyattsville, MD: National Center for Health Statistics. 2001.
6.  USDA Economic Research Service. "Rural Population and Migration: Race and Ethnicity in Rural Areas". 2000.
7.  Fluharty, Charles. "Rural America: Challenges and Opportunities". Presentation to the NCSL Annual Meeting Assembly on Federal Issues Committee on Agriculture and International Trade.  San Antonio, Texas, August 12, 2001.
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17.  Centers for Disease Control and Prevention, National Center for Health Statistics. National Health Interview Survey. 1997-1998.
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19.   National Advisory Committee on Rural Health. "Medicare Reform: A Rural Perspective". 2001.
20.  Health Resources and Services Administration, Area File. 1998.
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22.  Medicare Payment Advisory Commission. Report to the Congress: Medicare in Rural America. 2001.
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29.  Centers for Disease Control and Prevention, National Center for Health Statistics.  National Vital Statistics System. 1996-1998.
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31.  National Center for Health Statistics. Public Use Data File Documentation: Link Birth/Infant Death Data Set: 1991 Birth Cohort.  Hyattsville, MD. 1995.
32.  National Center for Health Statistics. Vital statistics of the United States. Volume II-Mortality, Part B. 1992.
33.  National Association of County and Community Health Officials. "Local Public Health Agencies: The Rural Experience." Presentation for the National Rural Health Association Meeting, Dallas, TX, May 24, 2001.
34.  National Advisory Committee on Rural Health. "Rural Public Health: Issues and Considerations". June, 1999.
35.  Centers for Disease Control and Prevention, National Center for Health Statistics.  National Vital Statistics System. 1996-1998.
36.  Blatt J, Furman SM. Residence location of drivers involved in fatal crashes. Accid Anal and Prev. 30(6): 705-11. 1998.
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