Defining what constitutes a “rural area” might seem straightforward, but it’s a surprisingly complex and crucial task, especially when it comes to healthcare. For organizations seeking to improve health outcomes in these communities through rural health grants, a clear and precise definition is not just academic—it’s the key to accessing vital funding and resources. This article delves into why the Federal Office of Rural Health Policy (FORHP) at the Health Resources and Services Administration (HRSA) takes such a detailed approach to defining rurality, and why it matters for the health and well-being of millions.
Understanding Rural Definitions: More Than Just Open Spaces
Why can’t we just rely on a simple understanding of “rural” as sparsely populated countryside? The reality is that different government agencies use varying definitions of rural areas for different purposes. While the United States Census Bureau (Census) and the Office of Management and Budget (OMB) provide their own delineations, FORHP has developed a distinct definition tailored to address the specific challenges of rural health. This nuanced approach recognizes that rurality is multifaceted, encompassing not only population density but also geographic isolation and terrain.
The original definitions from Census and OMB, while valuable for broad demographic and administrative purposes, fall short when specifically targeting healthcare needs in rural communities. These definitions can sometimes misclassify areas, either overlooking genuinely rural populations within metropolitan counties or incorrectly labeling vast, unpopulated areas as non-rural. For FORHP, accuracy is paramount to ensure that grants reach the communities that need them most.
The FORHP Definition: A Tailored Approach to Rural Health
To overcome the limitations of broader definitions, FORHP employs a more granular and comprehensive methodology. Their definition incorporates data from the Census, OMB, and, crucially, the U.S. Department of Agriculture Economic Research Service (ERS). This includes leveraging Rural-Urban Commuting Area (RUCA) codes and the Road Ruggedness Scale (RRS).
FORHP defines rural areas as encompassing:
- Non-metropolitan counties: Counties outside of major urban centers, as defined by OMB.
- Outlying metropolitan counties: Specific metropolitan counties that, despite being classified as metro, lack a significant urban population of 50,000 or more.
- Census tracts within metropolitan counties using RUCA codes: This targets areas within metro counties that exhibit rural characteristics, specifically census tracts with RUCA codes 4-10.
- Large, sparsely populated census tracts: Recognizing that large geographic areas with low population density can be rural even within metro counties, FORHP includes census tracts of at least 400 square miles with a population density of 35 or fewer people per square mile and RUCA codes 2-3.
- Rugged terrain census tracts: Acknowledging the impact of terrain on healthcare access, FORHP includes census tracts with a high Road Ruggedness Scale (RRS) of 5 and RUCA codes 2-3, provided they are at least 20 square miles in area within metropolitan counties.
This multi-layered definition allows FORHP to identify rural areas with greater precision, capturing pockets of rurality that might be missed by simpler classifications. According to 2020 Census data, this definition designates 20.3% of the US population (62.8 million people) and a significant 87.4% of the nation’s land area as rural.
Contrasting Definitions: Census, OMB, and FORHP
Understanding why FORHP’s definition diverges from those of the Census and OMB is crucial to appreciating its importance for rural health initiatives.
How the Census Defines “Urban”
The Census Bureau, instead of defining “rural,” focuses on classifying areas as “urban.” Anything outside of an urban area is considered rural. Urban areas, according to the Census, are defined as having at least:
- 5,000 people, or
- 2,000 housing units.
Following the 2020 Census, the Bureau classified 20% of the population (66.3 million people) and a vast 97% of the land area as rural based on this approach. While this provides a broad overview, it can be less precise for targeting specific rural health needs.
OMB’s Metropolitan and Micropolitan Classifications
OMB categorizes counties as metropolitan (metro), micropolitan (micro), or neither, based on urban core populations. While OMB doesn’t explicitly use the term “rural,” FORHP’s definition considers all non-metro counties as rural.
| Area or County | Rural or Not Rural |
|---|---|
| Metro area (urban core of 50,000 or more people) | Not rural |
| Micro area (urban core of 10,000 – 49,999 people) | Rural |
| Counties outside of Metro or Micro Areas | Rural |
In 2020, non-metro counties, as defined by OMB, encompassed 46.0 million people (approximately 13.7% of the population) and 71.6% of the country’s land area. OMB updates these classifications periodically, with the latest updates reflected in OMB Bulletin 23-01.
Limitations of Census and OMB Definitions for Rural Health
While both Census and OMB definitions are valuable, they present challenges when specifically applied to rural health policy:
- Census Urban Classifications Ignore Boundaries: Census urban area classifications don’t always align with city or county boundaries, making it difficult to use common geographic units to determine rurality.
- OMB Metro Areas Can Include Vast Rural Spaces: OMB’s metro designations can encompass large, sparsely populated areas within metro counties, like the Grand Canyon being located within a metro county. This can lead to misclassification of genuinely rural populations as non-rural under OMB’s system.
The Importance of a Nuanced Rural Definition for Healthcare Access
FORHP’s refined definition, incorporating RUCA and RRS, addresses these limitations by:
- Focusing on Census Tracts: Assessing rurality at the smaller census-tract level allows for a more precise identification of rural pockets, even within larger counties.
- Accounting for Core Rural Characteristics: RUCA codes and RRS factors enable FORHP to consider critical aspects of rurality such as population density, geographic isolation, and terrain ruggedness in greater detail.
By using RUCA codes, FORHP can differentiate between census tracts within metro areas, recognizing that some tracts may retain rural characteristics despite being part of a larger metropolitan county. RUCA codes categorize census tracts based on population density, urbanization, and commuting patterns, providing a more nuanced understanding of rurality than simple metro/non-metro classifications.
Similarly, the Road Ruggedness Scale acknowledges that terrain significantly impacts accessibility to healthcare. Areas with rugged terrain often face challenges related to transportation and service delivery, making them particularly vulnerable in terms of healthcare access.
How to Determine Rural Area Eligibility
For organizations seeking rural health grants, determining if a specific location qualifies as rural under the FORHP definition is straightforward using the Rural Health Grants Eligibility Analyzer. This online tool utilizes FORHP’s definition and allows users to check the rural status of a location or service area.
Definition Evolution and Impact
The definition of “rural” is not static. FORHP continuously monitors research and analysis in rural area definitions and updates its approach as new data and methodologies become available. Recent expansions to the definition include:
- FY22: Inclusion of outlying metro counties without a substantial urban population.
- FY25: Incorporation of census tracts with highly rugged roads within metro counties.
These updates reflect an ongoing effort to refine the definition and ensure it accurately captures the evolving landscape of rural America. Changes to the definition, as well as updates to underlying data from OMB, Census, RUCA, and RRS, can impact the eligibility of areas for rural health grants. Staying informed about these updates is crucial for organizations working in rural health.
Conclusion: Why Rural Definitions are Essential for Equitable Healthcare
Defining rural areas is not merely an exercise in categorization; it’s a fundamental step towards ensuring equitable access to healthcare for all Americans. FORHP’s detailed and evolving definition of rurality is vital because it:
- Directs Resources Effectively: It ensures that limited grant funding reaches the communities with the most pressing rural health needs.
- Promotes Accurate Needs Assessment: A precise definition allows for a more accurate assessment of the unique healthcare challenges faced by rural populations.
- Supports Tailored Interventions: By recognizing the multifaceted nature of rurality, the definition enables the development of more effective and targeted healthcare interventions.
By moving beyond simplistic classifications and embracing a nuanced understanding of rurality, FORHP’s definition plays a critical role in strengthening rural health systems and improving the lives of millions living in rural communities across the United States. For the most current information and to check specific locations, the Rural Health Grants Eligibility Analyzer remains the authoritative resource.
