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 Department of Health and Human Services Health Resources and Services Administration
 AGENCY: Health Resources and Services Administration, HHS.
 SUMMARY: The Health Resources and Services Administration's (HRSA) Office of Rural Health Policy (ORHP) has sought to identify clear, consistent, and data-driven methods of defining rural areas in the Metropolitan counties of the United States. ORHP has funded development of Rural-Urban Commuting Area (RUCA) codes as the latest version of the Goldsmith Modification. HRSA is seeking comments on ORHP's use of RUCAs to better target Rural Health funding and projects. While other agencies of HHS may choose to adopt ORHP's definition of “rural” there is no requirement that they do so and they may choose other, alternate definitions that best suit their program requirements. Background The Office of Rural Health Policy (ORHP) was authorized by Congress in December 1987 in Public Law 100-203 and located in the Health Resources and Services Administration (HRSA). Congress charged the Office with informing and advising the Department of Health and Human Services on matters affecting rural hospitals and health care and coordinating activities within the Department that relate to rural health care. The fiscal year (FY) 1991 appropriation allocated funds for Health Services Outreach Grants in rural areas. The FY 1991 Senate Appropriations Committee Conference Report stated that these grants were intended for “outreach to populations in rural areas that do not normally seek health or mental health services.” With the creation of the Rural Health Outreach Grant Program, HRSA assumed the responsibility of determining eligibility for the grants. In 1991, there were two principal definitions of “rural” that were in use by the Federal Government. The oldest was the Census Bureau definition, which defined “rural” as all areas that were either not part of an urbanized area or were not part of an incorporated area of at least 2,500 persons. Urbanized areas were defined as densely settled areas with a total population of at least 50,000 people. The building block of urbanized areas is the census block, a sub-unit of census tracts. The other major Federal definition in use was based on the Office of Management and Budget's (OMB) list of counties that are designated as part of a Metropolitan Area. All counties that were not designated as Metropolitan were considered “rural” or, more accurately, non-metropolitan. Metropolitan Areas, in 1990, had to 
                        ( print page 24590)
                        include “a city of 50,000 or more population,” or “a Census Bureau defined urbanized area of at least 50,000 population, provided that the component county/counties of the metropolitan statistical area have a total population of at least 100,000.” At that time, around three quarters of all counties in the United States were not classified as parts of Metropolitan Areas. Both the Census Bureau and OMB definitions were criticized for not actually defining “rural” at all but simply defining rurality by exclusion; all areas that are not “urbanized” are rural in the Census definition, and all counties that are not “Metropolitan” are non-metropolitan or rural under the OMB definition. Under both definitions, rurality is not actually defined; rather, rural is simply what is not included in the defined classifications. Due to ease of use (counties are easily recognizable administrative units, while Census blocks are not), ORHP chose to use the OMB definition as the basis of determining eligibility for its Rural Health Grant Programs. In effect, this meant that the population in all non-metropolitan counties was eligible, but none of the population in Metropolitan counties was eligible. At the same time, ORHP recognized that there were still rural areas within the Metropolitan counties. It was estimated that approximately 14 percent of the Metropolitan population, nearly 25 million people, resided in rural areas as defined by the Census Bureau in 1980. Rather than exclude large numbers of rural citizens from eligibility for the Rural Health Outreach Grants, ORHP sought a rational, data-driven method to designate rural areas inside of Metropolitan counties. Known as the “Goldsmith Modification” for its principal developer, Harold F. Goldsmith, this method is described in detail in the paper “Improving the Operational Definition of “Rural Areas” for Federal Programs” available at   
                        *http://ruralhealth.hrsa.gov/​pub/​Goldsmith.htm.*
                         The original Goldsmith Modification used data from the 1980 decennial census and applied only to Large Metropolitan Counties (LMCs), those of at least 1225 square miles in area. Using census tracts as a sub-county unit, the Goldsmith Modification enabled the identification of rural areas inside Metropolitan counties. The Goldsmith Modification permitted health care providers and other organizations in designated rural census tracts in LMCs to apply for and receive Rural Health grants. It was also used by the Centers for Medicare and Medicaid Services (CMS) to determine eligibility for some of its programs. There were, however, certain limitations to the use of the Goldsmith Modification. Due to the lack of availability of data from the 1990 census, data from the 1980 census was used. In addition, analysis of data was limited to counties that met the somewhat arbitrary criteria of being larger than 1225 square miles in area. ORHP continued to pursue means of identifying rural areas using sub-county units of measurement. Ideally, use of a sub-county unit would allow consideration both of the scale of the population residing in the unit and their proximity to other services. ORHP has funded the development of RUCA codes as an update to the Goldsmith Modification to be used for determining grant eligibility. Developed by Richard Morrill and Gary Hart, of the University of Washington, and John Cromartie, of the U.S. Department of Agriculture's (USDA) Economic Research Service, the RUCAs are described at length in a 1999 paper published in the journal 
                        *Urban Geography.* RUCAs, like the Goldsmith modification, are based on a sub-county unit, the census tract, permitting a finer delineation of what constitutes rural areas inside Metropolitan areas. There are over 60,000 census tracts, none of which overlap county borders. The merits of using census tracts as the unit of measurement were described in a paper in the USDA publication 
                        *Rural Development Perspectives*
                         in 1996. “Census tracts are large enough to have acceptable sampling error rates (containing an average of 4,000 people); are consistently defined across the Nation; are usually subdivided as population grows to maintain geographic comparability over time; and can be aggregated to form county-level statistical areas when needed.” Using data from the Census Bureau, every census tract in the United States is assigned a RUCA code. Currently, there are ten primary RUCA codes with 30 secondary codes (see Table 1). Table 1.—Rural-Urban Commuting Areas (RUCAs), 2000
1 Metropolitan area core: Primary flow within an urbanized area (UA):1.0 No additional code.1.1 Secondary flow 30% to 50% to a larger UA.2 Metropolitan area high commuting: Primary flow 30% or more to a UA:2.0 No additional code.2.1 Secondary flow 30% to 50% to a larger UA.3 Metropolitan area low commuting: Primary flow 5% to 30% to a UA:3.0 No additional code.4 Micropolitan area core: Primary flow within an Urban Cluster of 10,000 to 49,999 (large UC):4.0 No additional code.4.1 Secondary flow 30% to 50% to a UA.4.2 Secondary flow 10% to 30% to a UA.5 Micropolitan high commuting: Primary flow 30% or more to a large UC:5.0 No additional code.5.1 Secondary flow 30% to 50% to a UA.5.2 Secondary flow 10% to 30% to a UA.6 Micropolitan low commuting: Primary flow 10% to 30% to a large UC:6.0 No additional code.6.1 Secondary flow 10% to 30% to a UA.7 Small town core: Primary flow within an Urban Cluster of 2,500 to 9,999 (small UC):7.0 No additional code.7.1 Secondary flow 30% to 50% to a UA.7.2 Secondary flow 30% to 50% to a large UC.7.3 Secondary flow 10% to 30% to a UA.7.4 Secondary flow 10% to 30% to a large UC.8 Small town high commuting: Primary flow 30% or more to a small UC.8.0 No additional code.8.1 Secondary flow 30% to 50% to a UA.8.2 Secondary flow 30% to 50% to a large UC.8.3 Secondary flow 10% to 30% to a UA.8.4 Secondary flow 10% to 30% to a large UC.9 Small town low commuting: Primary flow 10% to 30% to a small UC:9.0 No additional code.9.1 Secondary flow 10% to 30% to a UA.9.2 Secondary flow 10% to 30% to a large UC.10 Rural areas: Primary flow to a tract outside a UA or UC:10.0 No additional code.10.1 Secondary flow 30% to 50% to a UA.10.2 Secondary flow 30% to 50% to a large UC.10.3 Secondary flow 30% to 50% to a small UC.10.4 Secondary flow 10% to 30% to a UA.10.5 Secondary flow 10% to 30% to a large UC.10.6 Secondary flow 10% to 30% to a small UC.
 More complete information on the latest iteration of the RUCA codes is available at the Department of Agriculture's Web site, measuring rurality: Rural-urban commuting area codes 
                    *http://www.ers.usda.gov/​briefing/​Rurality/​RuralUrbanCommutingAreas/​*( print page 24591)
                    and at the WWAMI (Washington, Wyoming, Alaska, Montana, & Idaho) Rural Health Research Center's Web site, 
                    *http://depts.washington.edu/​uwruca/​.* In the past, ORHP has issued a list of eligible, rural ZIP codes in Metropolitan counties based on the RUCAs rather than eligible census tracts due to potential applicants for Rural Health grants being able to easily ascertain whether they lived in an eligible ZIP code area. However, with the advent of the World Wide Web, applicants are now able to easily access information about census tracts, and to identify the tract identifying number of any address—(
                    *http://www.ffiec.gov/​geocode/​default.htm*). Further information on the ZIP code approximation of the census tract-based RUCA codes is available at 
                    *http://depts.washington.edu/​uwruca/​approx.html.* HRSA believes that the use of RUCAs allows more accurate targeting of resources intended for the rural population. Both ORHP and CMS have been using RUCAs for several years to determine programmatic eligibility for rural areas inside of Metropolitan counties. ORHP currently considers all census tracts with RUCA codes 4-10 to be rural. While use of the RUCA codes has allowed identification of rural census tracts in Metropolitan counties, among the more than 60,000 tracts in the U.S. there are some that are extremely large and where use of RUCA codes alone fails to account for distance to services and sparse population. In response to these concerns, ORHP has designated 132 large area census tracts with RUCA codes 2 or 3 as rural. These tracts are at least 400 square miles in area with a population density of no more than 35 people. ORHP will continue to seek refinements in the use of RUCAs. This may include further data on travel times so that areas with heavy commuting to urbanized areas, but which are too distant from the urbanized area for the residents to be able to easily access health care services, can also be designated as rural. HRSA is now seeking public comments on: 1. The use of census tract RUCA codes to determine eligibility rather than RUCA codes which have been cross-walked to ZIP code areas, 2. The possible use of RUCA sub-codes, to more accurately identify rural areas inside Metropolitan counties, and 3. The possible use of travel times along with RUCAs to identify census tracts inside Metropolitan counties as rural rather than using tract size and population density. DATES: The public is encouraged to submit written comments on the report and its recommendations July 2, 2007.
 ADDRESSES: The following mailing address should be used: Office of Rural Health Policy, Health Resources and Services Administration, 5600 Fishers Lane, Parklawn Building, 9A-55, Rockville, MD 20857. HRSA/ORHP's facsimile number is (301) 443-2803. Comments can also be sent via e-mail to 
                        *shirsch@hrsa.hhs.gov.*
                         All public comments received will be available for public inspection at ORHP/HRSA's office between the hours of 8:30 a.m. and 5 p.m.
 FOR FURTHER INFORMATION CONTACT: Questions about this request for public comment can be directed to Steven Hirsch, by e-mail (
                        *shirsch@hrsa.hhs.gov*) or at the address above. Dated: April 25, 2007. Elizabeth M. Duke, Administrator.


[FR Doc. E7-8492 Filed 5-2-07; 8:45 am] BILLING CODE 4165-15-P