Defining "Rural" Areas: Impact on Health Care Policy and Research

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Defining "Rural" Areas: Impact on HealthCare Policy and Research

July 1989

NTIS order #PB89-224646



FOREWORD

Thedesigned problems of health careto advance the Nation’s in rural areas have long occupied a special niche in policieshealth. Programs for recruitment, training, and deployment of health care personnel, for constructing health-care facilities, and for financing health care oftenhave included special provisions for rural areas. These programs have often also includedattempts to mitigate the negative impacts on rural areas of policies primarily designed for andresponsive to the needs of urban areas. However, some rural areas continue to have highnumbers of hospital closures, ongoing problems in recruiting and retaining health personnel, anddifficulty in providing medical technologies commonly available in urban areas. Mountingconcerns related to rural residents’ access to health care prompted the Senate Rural HealthCaucus to request that OTA conduct an assessment of these and related issues. This Staff Paperwas prepared in connection with that assessment.

Rural definitions may greatly influence the costs and effects of health policies, because thesize and composition of the U.S. rural population and its health care resources vary markedlydepending on what definitions are used. There is no uniformity in how rural areas are definedfor purposes of Federal program administration or distribution of funds. This paper examinesdichotomous designations used to define rural and urban areas and discusses how they areapplied in certain Federal programs. In addition, several topologies are described that are usefulin showing the diversity that exists within rural areas. These topologies may be helpful inidentifying unique health service needs of rural subpopulations.

A second OTA paper, Rural Emergency Medical Services, will also precede the publicationof OTA’s full assessment on Rural Health Care.



Defining “Rural” Areas: Impact on Health Care Policyand Research

by

Maria Hewitt

Health ProgramOffice of Technology Assessment

Congress of the United StatesWashington, D.C. 20510-8025

July 1989

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

Carol Guntow prepared this paper for desk-top publishing.

The views expressed in this Staff Paper do notnecessarily represent those of the TechnologyAssessment Board, the Technology AssessmentAdvisory Council, or their individual members.

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

Washington, DC 20402



CONTENTS

Chapter Page1.

2.

3.

4.

5.

6.

7.

8.

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

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

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

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

5

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

Relationship Between Urban/Rural andMetropolitan/Nonmetropolitan Designations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

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

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

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

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

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

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

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

Commuting-Employment Patterns . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22Economic and Socio-Demographic Characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

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

Availability of Vital and Health Statisticsfor Nonmetropolitan Areas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .27

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

Medicare Reimbursement Using MSAs To Define Urban and Rural Areas.....................35The Rural Health Clinics Act . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37Providing Services in “Frontier” Areas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38

Conclusions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...

41

AppendixA. Summary of the Standards Followed in Establishing

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

B. The Census Bureau’s Urbanized Area Definition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47C. Census Geography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48

D. Rural Health Care Advisory Panel . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53E. Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54

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

TablesTable1. Urban and Rural Population by Size of Place (1980) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62. Ten States With the Largest Rural Population (1980) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

3. States With More Than One-Half of Their Population Residingin Rural Areas (1980) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

7

i i i



CONTENTS (cent’d)

Tables (cent’d)Table Page4.

5.

6.

7.8.

9.

10.

11.

12.

13.

14.

15.

16.

17.

18.

19.

20.

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

States With More Than One-Half of Their Population Residingin Nonmetropolitan Areas (1986) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

10

Selected Federal Department/Agencies Using MSA Designationsfor the Administration of Programs or the Distribution of Funds . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Population Inside and Outside of MSAs by Urban and Rural Residence (1980)................l5Classification of Nonmetropolitan Counties by Urbanization and Proximityto Metropolitan Areas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

19

Nonmetropolitan County Population Distribution by Degree of Urbanizationand Adjacency to an MSA (1980) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

20

U.S. Population by County’s Largest Settlement and Adjacencyto an MSA (1980) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

20

Bluestone and Clifton County Classifications Based onUrbanity and Population Density . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

21

Population-Proximity: A Measure of a County’s Relative Accessto Adjacent Counties’ Populations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

22

County Typology Based on Employment, Commuting, andPopulation Characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

23

Distribution of U.S. Counties by Typology Based on Employment, Commuting,and Population Characteristics (1986) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

Classification of Nonmetropolitan Counties by Economic andSocio-Demographic Characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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

25

Proportion of the Population 65 and Older byMetropolitan/Nonmetropolitan and Urban/Rural Residence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27Proportion of Nonmetropolitan Population Age 65 and Older byLevel of Urbanization and Adjacency to an MSA (1980) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

27

Nonmetropolitan Infant Mortality Rates by Urban Area and Race,

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

28Characteristics of Different Categories of U.S. Nonmetropolitan Counties . . . . . . . . . . . . . . . . . . . . . . . . . . 30

FiguresFigure Page1. Urbanized Areas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

5

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

3. The Relationship Between Metropolitan Statistical Areas (MSAs),Urbanized Areas, and Urban and Rural Areas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

13

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

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

6. Areas With Cervical Cancer Mortality Rates Significantly HigherThan the U.S. Rate, and in the Highest 10% of all SEA Rates(White Females, 1970-1980) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

7. Death Rates Due to Unintentional Injury by County . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 328. Death Rates Due to Motor Vehicle Crashes by County . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 339. Frontier Counties: Population Density of 6 or Less . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39

iv



1. SUMMARY

It is difficult to quantify rural healthproblems and to make informed policy deci-sions without a clear definition of what andwhere “rural” areas are. Small population,sparse settlement, and remoteness are all fea-tures intuitively associated with “rural. ”These features exist on a continuum, how-ever, while Federal policies usually rely ondichotomous definitions.

Urban and rural areas are often definedusing the designations of either the Office of Management and Budget (OMB) or theBureau of the Census. Rural areas are theremaining areas that are not captured in ei-ther OMB’s “metropolitan statistical area”(MSA) designation or in Census’ urban or ur-banized area definitions. Counties are thebuilding blocks of OMB’s MSAs and are easy

to use, because county-based data are readilyavailable. One or more counties form anMSA on the basis of population size anddensity, plus the degree of area-wide eco-nomic integration as reflected in commutingpatterns. The Census’ urban and urbanizedarea definitions rely on settlement size anddensity without following county boundaries,making them more difficult to use. Bothmethods identify about a quarter of the U.S.population as rural or “nonmetropolitan,” butthese populations are not identical. For ex-ample, about 40 percent of the Census-

defined rural population live within MSAs,and 14 percent of the MSA population live inCensus-defined rural areas. The Census’rural population includes residents of smalltowns and cities but excludes those living intowns larger than 2,500, many of whommight be considered rural. MSAs can includeareas that are sparsely populated and could beconsidered rural, while nonmetropolitan areasshow significant within-area variation.

There is no uniformity in how ruralareas are defined for purposes of Federalprogram administration or distribution of funds. Different designations may be used

by the same agency. For example, Congressdirected the Health Care Financing Adminis-tration to use Census’ nonurbanized areadesignation to certify health facilities underthe Rural Health Clinics Act, but to useOMB’s MSA/nonMSA designations to cate-gorized hospitals as urban or rural for pur-poses of hospital reimbursement under Medi-care. In general, rural hospitals are reim-bursed less than their urban counterparts.While persistent differences between metro-politan and nonmetropolitan hospital costshave been observed, hospital location may bea correlate rather than a determinant of costdifferences. Therefore, hospital-specif icmeasures are being sought that might replacethe present MSA adjustments to the basicprospective payment formula. Topologiesthat categorize counties according to their de-

gree of urbanization or their employment andcommuting patterns could be used to refinethe definition of labor market areas, an im-portant component of the Medicare formula.

There have been calls to develop a stan-dard rural typology that would capture theelements of rural diversity and improve theuse and comparison of nationally collecteddata. These topologies usually are based onthe following features: population size anddensity; urbanization; adjacency and rela-tionship to an MSA; and principal economic

activity. Although a standard typology maybe desirable, it will be difficult to arrive at,because the different topologies have meritfor various purposes. Nevertheless, therecontinues to be a need for a standardizednonmetropolitan topology. It is especiallyimportant to display vital and health statisticsin a standardized way, because markedly dif-ferent conclusions can be reached, dependingo n th e de fi ni ti on o f ru ra l us ed . B et te rmeasures of population concentration or dis-persion within counties would be helpful--

especially for sparsely settled “frontier” areas--to distinguish between urban and ruralareas within the same counties.



2. INTRODUCTION

Although there has been widespread con-cern regarding a “health care crisis” in ruralareas, there is little agreement as to whatrural areas are. How rural areas (or ruralpopulations) are defined is far from academ-ic, since urban/rural designations are basic toparticipation in certain Federal programs andto payment rates from Federal sources. In-deed, the perceived magnitude of rural healthcare problems and the impact of any changein public policy depend on how rural isdefined.

The features most intuitively associatedwith rurality are small populations, sparsesettlement, and remoteness or distance fromlarge urban settlements. Historically, ruralpopulations have been distinguished from ur-

ban ones by their dependence on farming oc-cupations and by differences in family size,lifestyle, and politics ( 13). However, becauseof dramatic improvements in transportationand communication, migration to and fromrural areas, and diversification of the ruraleconomy, these clear distinctions no longerexist. The presence of farms, mining areas,and forests in rural areas contribute to persis-

tent differences, most notably lower popula-tion densities (1 3). By 1980, however, overtwo-thirds of the work forceoutside of metropolitan areasin three industries--service,and retail trade (49).

both inside andwere employedmanufacturing,

The purpose of this staff paper is to:

1.

2.

3.

4.

describe the principal “rural” definitionsapplied by the Federal Government thataffect health programs and policies --i.e., urban and rural areas (and popula-tions) as defined by the Bureau of theCensus and metropolitan statistical areasas defined by the Office of Manage-ment and Budget;

describe the classifications used to dis-tinguish different types of rural areas;discuss how Federal agencies have usedthese definitions to compile vital andhealth statistics and to implement pro-grams; anddiscuss the strengths and weaknesses of rural definitions and classifications cur-rently in use.

3



3. DELINEATING “RURAL” AND “URBAN” AREAS

The concepts of “rural” and “urban” nowexist as part of a continuum. While fewwould argue about the extremes of thatcontinuum- - e.g., an isolated farming com-munity in Texas at one extreme and NewYork City at the other--where to draw theline between urban and rural has becomemore difficult. Many Federal policies, how-ever, rely on dichotomous rural/urban desig-nations. This section describes the two mostimportant dichotomous geographic designa-tions: the Bureau of the Census’ urban andrural areas (and populations), and the Officeof Management and Budge t ’s (O MB)metropolitan statistical areas and residualnonmetropolitan territory. Several geographicclassification schemes are then described thatportray the urban-rural continuum.

U.S. Bureau of the Census

According to the Census Bureau, urbanand rural are “type-of-area concepts ratherthan specific areas outlined on maps” (50).The urban population includes persons livingin urbanized areas (see below) and thoseliving in places with 2,500 residents or moreoutside of urbanized areas. The populationnot classified as urban comprise the rural

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

residents and those living outside of “places”in the open countryside. Census-recognized“places” are either: 1) incorporated places suchas cities, boroughs, towns, and villages; or 2)closely settled population centers that are out-side of urbanized areas, do not have corpo-rate limits, and have a population of at least1,000.1 The rural population is divided fur-

1 The min imum popu la t i on o f t hes e un inc orpora tedareas , cal led census des ignated places , i s lower inAlaska and Hawai i .

ther into farm (see below) and nonfarm pop-ulations.

Urbanized areas consist of a central core(a “central city or cities”) and the contiguous,

closely settled territory outside the city’spolitical boundaries (the “urban fringe”) thatcombined have a total population of at least50,000 (48). The boundary of an urbanizedarea is based primarily on a residential popu-lation density of at least 1,000 persons persquare mile (the area generally also includesless densely settled areas, such as industrialparks) (49). The boundaries of urbanizedareas are not limited to preexisting county orState lines; rather they often follow theboundaries of small Census-defined geog-raphic uni ts such as census t racts andenumeration districts. Many urbanized areascross county and/or State lines (see figure 1).

Figure 1--- Urbanized Areas

Urbanized area

B /

County D

SOURCE : U.S. Depar tment o f Comnerce, Bureau of theCensus , I ICenSUS and Geography-Concepts and

P r o d u c t s , 08 Factf i r ider CFF No. 8 (Wash-ington, D C : U . S . G o v e r n m e n t P r i n t i n g O f -f i c e , Augus t 1985) .

5



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

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

Number Percentof p l aces Populat i on o f U s .

U . S . t o t a l

Urban areasPlaces of 1,000,000 or morePlaces of 500,000-999,999Places of 250,000-499,999Places of 100,000-249,999P lac es o f 50 ,000-99 ,999P lac es o f 25 ,000-49 ,999P lac es o f 10 ,000-24 ,999P lac es o f 5 ,000-9 ,999P lac es o f 2 ,500-4 ,999Places of less than 2,500Other urban area

a

Rural areasP lac es o f 1 ,000-2 ,499Places under 1,000O t h e r r u r a l a r e ab

22,529

8,7656

1634

117290675

1,7652,1812,6651,016

13,7644,4349,330

226,545,805

167,050,99217,530,24810,834,12112,157,57817,015,07419,786,48723,435,65427,644,90315,356,137

9 , 3 6 7 , 8 2 61,260,246

12,662,718

59,494,8137,037,8403,863,470

48,593,503

100.0%

7 3 . 77 . 74 . 85 . 47 . 58 . 7

10.312.26 . 84 . 10 . 65 . 6

2 6 . 33 . 11 . 7

2 1 . 4

~Includes urban res idents not l i v ing in Census-des ignated places .

I n c l u d e s r u r a l r e s i d e n t s n o t l i v i n g i n C e n s u s - d e s i g n a t e d p l a c e s a n d r e s i d e n t s o f t h e r u r a l p o r t i o n o f e x -t e n d e d c i t i e s .

SOURCE: 1980 Census of Population, Volume 1, Charac ter is t i cs of the Populat ion, 1981, table 5, p. 1 - 3 7 .

The 1980 Census identified 373 urbanizedareas in the United States and Puerto Rico(52).2

The Census definition of urban areas haschanged considerably over time. Prior to1900, the lower population limit for the sizeof places considered urban was set at either

4,000 or 8,000. The limit was lowered to2,500 residents in 1900(47). This definitionworked well until suburban development out-side corporate boundaries became extensive.To improve the definition, people living infairly densely populated areas (at least 1,000

z S i n c e 1 9 7 0 , r u r a l a r e a s h a v e b e e n r e c o g n i z e d~ithin c e r t a i n c i t i e s w h o s e c o r p o r a t e l i m i t s i n -c l u d e l a r g e a r e a s l a c k i n g u r b a n d e v e l o p m e n t . Ther u r a l p o r t i o n o f t h e s e Ilextended ci t ies~ i s a t

l e a s t 5 s q u a r e m i l e s i n a r e a a n d h a s a p o p u l a t i o nd e n s i t y o f l e s s t h a n 1 0 0 p e r s o n s p e r s q u a r e m i l e .T o g e t h e r , s u c h a r e a s m u s t c o n s t i t u t e a t l e a s t 2 5p e r c e n t o f t h e l a n d a r e a o f t h e l e g a l c i t y o r i n -c l ude a t l eas t 25 s quare m i l es ( 50) . In 1980 therew e r e 8 7 e x t e n d e d c i t i e s w i t h a total o f 1 6 1 , 1 4 0rura l r es i den t s ( 41) .

persons per square mile) in the immediate vi-cinity of cities of 50,000 or more populationwere counted as urban instead of rural begin-ning in 1950 (21). With the exclusion of these suburban residents, the size of the 1950rural population dropped from 62 million to54 million (47).

The rural population has been divided bythe Census Bureau into the farm and nonfarmpopulations. The farm population includespeople living in rural-areas on properties of 1acre of land or more where $1,000 or more of agricultural products were sold (or wouldhave been sold) during the previous 12months .3 In 1987, the farm population was

3 F r o m 1 9 6 0 t o t h e m i d 1 9 7 0 s , t h e f a r m p o p u l a t i o nc o n s i s t e d o f al l p e r s o n s l i v i n g i n r u r a l t e r r i t o r y

o n p l a c e s o f 1 0 o r m o r e a c r e s , i f a t l e a s t $ 5 0w o r t h o f a g r i c u l t u r a l p r o d u c t s w e r e s o l d frcnn t h eplace d u r i n g t h e p r e c e d i n g 1 2 m o n t h s . P e r s o n sl i v i n g o n p l a c e s o f u n d e r 1 0 a c r e s w e r e a l s o i n -c l u d e d i f a g r i c u l t u r a l s a l e s t o t a l e d $ 2 5 0 o r m o r e( 5 5 ) .



Defining “Rural” Areas: Impact on Health Care Policy and Research 7

Table 2. --Ten States With The Largest RuralPopulation (1980)

Ru ral po pu lat io n PercentS t a t e ( i n 1 ,000s ) o f S t a t e

Pennsylvania aNor th Carol inaTexas

OhioMichiganNew YorkC a l i f o r n i aGeorgiaIndianaI l l i n o i s

3,6433 , 0 5 92,896

2,8792,7112,7002 , 0 6 02,0541,9651,908

3 0 . 75 2 . 02 0 . 4

2 6 . 72 9 . 315.48 . 7

3 7 . 63 5 . 81 6 . 7

SOURCE: U.S. Department of Commerce, Bureau of theC e n s u s , C o u n t y a n d C i t y D a t a B o o k : 1 9 8 3(Washington, DC: U.S. Government Pr int ingO f f i c e , 1 9 8 3 ) .

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

the rural population and 2 percent of the to-tal resident U.S. population. In contrast,farm residents represented 30 percent of thepopulation in 1920(55).

According to the 1980 Census, 73.7 per-cent of the U.S. population was urban, butthe proportion ranged from a low of 33.8percent in Vermont to 100 percent in theDistrict of Columbia (51). Table 1 shows thedistribution of the 1980 urban and rural pop-ulation by size of place. Over 85 percent of the rural population live in places or areas

with fewer than 1,000 residents. Table 2shows the ten States with the largest ruralpopulations. Table 3 shows the seven Stateswith more than one-half of their populationresiding in rural areas.

The Census Bureau’s ‘urbanized” areaconcept does not apply to towns, cities, orpopulation concentrations of less than 50,000.Those living nearby, but outside of the limitsof smaller cities or towns are not counted asbeing part of an “urbanized” area, even

though the “suburban” population may belarge and economically integrated with thetown. For example, the population surround-ing the incorporated village of Hayward, Wis-consin (county seat of Sawyer County), ex-

ceeds the 1,456 population of Hayward. There s ide n t s o f t he su r round ing a re a useHayward’s facilities such as a nursing homeand fire station but are not included in thevillage population. This “undercount” hashampered the village’s ability to obtain grantsto improve area services (13). Numerousareas such as Hayward, that are considered“rural” by virtue of the fact that they are out-side of an urbanized area and have a popula-tion of 2,500 or less, would be considered ur-ban if the population immediately surround-ing the corporate area were included. Manytowns and villages have resolved this problemby annexing surrounding developed territory(12).

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

in Rural Areas (1980)

Rural populat ion PercentState ( i n 1 , 0 0 0 s ) o f S t a t e

Vermont 339 6 6 . 2W e s t V i r g i n i a 1,244 6 3 . 8South Dakota 370 5 3 . 6M i s s i s s i p p i 1,328 5 2 . 7Maine 591 5 2 . 5Nor th Carol ina 3 , 0 5 9 5 2 . 0North Dakota 334 5 1 . 2

SOURCE: U.S. Depar tment of Commerce, Bureau of theCensus, Count Y and C i t y Data Book : 1983,(Washington, DC: U.S. Government Pr int ingO f f i c e , 1 9 8 3 ) .

The Office of Management and Budget:Metropolitan Statistical Areas

A metropolitan statistical! area (MSA)4 isan economically and socially integrated geo-graphic unit centered on a large urban area.In general terms, an MSA includes a large

population center and adjacent communitiesthat have a high degree of economic and so-

4 F r o m 1 9 5 9 t o 1 9 8 3 , HSAS uere cal[ed S t a n d a r dM et r o p o l i t a n S t a t i s t i c a l A r e a s (SMSAS) ( 5 3 F R5 1 1 7 5 ) . T h e t e r m MSA i s u s e d t h r o u g h o u t t h i spaper , even when refer r ing to 1980 Census data.



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

cial integration with that center (54). Thiscontrasts with Census’ urban area, which isdefined solely on the basis of where peoplereside (i. e., population size and density).MSAs are defined by OMB5 and are used byFederal agencies for collecting, tabulating,and publishing statistical data. Some Federalagencies also use MSA designations to imple-

ment programs and allocate resources al-though OMB does not define them with suchapplications in mind. The business com-munity uses MSA data and rankings ex-tensively, for example to make investmentdecisions and to assess the desirability of markets (38).

The official standards that are used todefine MSAs are reviewed prior to eachdecennial Census. 6 According to standardsadopted for the 1980 Census, an MSA must

have:

7

s a c i t y with 50,000 or more residents; ors an urbanized area (as defined by the

Census Bureau) with at least 50,000people that is part of a county orcounties that have at least 100,000people.

In most areas, counties are the buildingblocks of MSAs. In the six New EnglandStates, MSAs are composed of cities andtowns, rather than whole counties.8 M S A s

s T h e m e t r o p o l i t a n a r e a c o n c e p t a p p e a r e d i n U . S .C e n s u s p u b l i c a t i o n s a s e a r l y a s 1 9 1 0 b u t Has n o twidely i n c o r p o r a t e d o r u s e d u n t i l t h e 1 9 5 0 c e n s u sw h e n t h e c o n c e p t w a s g e n e r a l i z e d t o c o u n t y l i n e s(12,47) .

6 The Office of Management and Budget ’s Stat is t i ca lPo l i c y Of f i ce , Of f i c e o f I n f o rmat i on and Regu la to r yA f f a i r s , r e v i e w s a n d r e v i s e s MSAS w i t h a d v i c e f r o mt h e i n t e r a g e n c y F e d e r a l E x e c u t i v e C o m m i t t e e o nM e t r o p o l i t a n S t a t i s t i c a l A r e a s ( 5 6 ) .

7 S e e a p p e n d i x A f o r a s u m m a r y o f t h e 1 9 8 0 MSA

s tandards .

8 New England USA standards are based primarily onp o p u l a t i o n d e n s i t y a n d c o m m u t i n g p a t t e r n s ( 5 6 ) .The s i x New Eng land S ta tes a re Ma ine , New Hamp-s h i r e , V e r m o n t , M a s s a c h u s e t t s , R h o d e I s l a n d , a n dConnec t icut .

often include more than one county; i.e., oneor more central counties containing the area’smain population concentration and outlyingcounties that have close economic and socialrelationships with those central counties. Tobe included in the MSA, the outlying coun-ties must have a specified level of commutingto the central counties and must also meet

certain standards regarding metropolitancharacter, such as population density (see ap-pendix A). Consolidated MSAs(CMSAs) arelarge metropolitan complexes within whichindividual components are defined, desig-nated as primary MSAs (PMSAs) (see appen-dix A).

Problems in MSA classification may oc-cur when county boundaries do not conformclosely to actual urban or suburban develop-ment. An MSA may inappropriately include

nonsuburban areas located in the outlyingsections of some counties. For example, in aspatially large county with a concentratedmetropolitan area, a large, sparsely populatedarea maybe included in the MSA. Thisproblem occurs more frequently in the West,where counties are bigger than those in theEast. On the other hand, an MSA may ex-clude suburban areas just across the countyline. For example, a county with a suburbanpopulation that commutes to a neighboringMSA may be excluded from that MSA be-cause it also includes a large, sparsely popu-

lated section and therefore has a low averagepopulation density. 9 While these problemsoccur, they occur infrequently (56).

About three-quarters (76.6 percent) of the U.S. population lived in the 275 MSAsde s igna t e d a s o f 1983 .10 T h e s e M S A srepresent only 16.2 percent of the total U.S.

9 See a p p e n d i x B f o r a d e s c r i p t i o n o f c r i t e r i a u s e din i nc l ud ing ou t l y i ng c oun t i es i n an USA.

10 B y J u ne 30, 1 9 8 8, intercensal p o p u l a t i o ne s t i m a t e s o r s p e c i a l c e n s u s p o p u l a t i o n c o u n t s h a dbeen used to add seven newly qual i f ied HSAS and tod e s i g n a t e t h r e e n e w c e n t r a l c i t i e s w i t h i n e x i s t i n gMSAS ( 1 2 ) .




.




Table 4---Ten States With The LargestNonmetropolitan Population (1986)

Nonmet ropo l i t an PercentS t a t e p o p u l at i o n ( i n 1 ,000s ) o f St at e

TexasNor th Carol inaOhio

GeorgiaI l l i n o i sKentuckyM i s s i s s i p p iPennsylvania aMichiganIndiana

3 , 2 0 92 , 8 4 72 , 2 7 7

2,1822,0332,0331,8371,8301,8111,760

19.24 5 . 02 1 . 2

3 5 . 71 7 . 65 4 . 57 0 . 015.419.83 2 . 0

SOURCE : U . S . B u r e a u o f t h e C e n s u s , S t a t i s t i c a lAbs t rac t of the Uni ted States : 1988, 108thed . (Was h ing ton , DC: 1987) , t ab l e 33 .

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

counties and county equivalents) are non-11 Table 4 shows the 10 Statesmetropolitan.with the largest nonmetropolitan populations.Table 5 shows the 15 States with more thanone-half of their population residing in non-metropolitan areas.

Before 1970, an MSA’s “recognized largepopulation nucleus” had to include a centralcity of at least 50,000 population or twincities with a total population this large. Nowthere is no minimum population size for anMSA’s central city, and it is easier to include

contiguous populations in the urbanized area(6). With the relaxation of MSA criteria,some of the 58 MSAs designated followingthe 1970 and 1980 censuses are demographi-cally dissimilar from those MSAs meetingearlier standards. For example, of the 33MSAs newly designated after the 1980 censusthat lacked a city of 50,000 or more resi-dents, 25 had rural population percentagesthat were closer to nonmetropolitan norms (62percent) than metropolitan norms (15 percent)(6). Furthermore, many of these do not have

facilities and services traditionally associated

11 T h e r e were 717 met ropol i tan comties ( e x c l u d i n gNe~ England) as of June 30, 1988 (12).

Table 5--- States With More Than One-Half of Their Population Residing in Non-

metropolitan Areas (1986)

Nonmetropol i tan PercentS t a t e p o p u l a t i o n ( i n 1 , 0 0 0 s ) o f S t a t e

IdahoVermont

MontanaSouth DakotaWyomingM i s s i s s i p p iMaineW e s t V i r g i n i aNorth DakotaArkansasIowaAlaskaKentuckyNebraskaNew Mexico

416

619508361

1,837

1,217426

1,4391,629

2,033848776

8 0 . 77 6 . 9

7 5 . 67 1 . 87 1 . 27 0 . 06 3 . 96 3 . 46 2 . 76 0 . 757.15 6 . 05 4 . 553.15 2 . 5

SOURCE: U.S. Bureau of the Census, S t a t i s t i c a l A b -s t r a c t o f t h e U n i t e d S t a t e s : 1 9 8 8 , 1 0 8 t h

ed . (Was h ing ton , DC: 1987) , t ab l e 33 .

with metropolitan areas, such as hospitalswith comprehensive services, a 4-year col-lege, a local bus service, a TV station, or aSunday paper (6).

A few counties that have not qualifiedfor MSA status on the basis of demographiccharacteristics have become designated asMSAs through the Federal legislative process.Specifical ly, s ince 1983, one new MSA

(Decatur, Alabama) has been created (com-prising two counties)12 and the boundaries of two existing MSAs have been enlarged bystatute (62).13 The proponents of the bill tocreate the Decatur, Alabama MSA argued that“MSA status would encourage a measure of economic recovery to this area... without anyadditional financial burden on the FederalGovernment” (45). Hospitals located in thenewly designated MSA of Decatur, Alabamaare expected to receive an additional $3 mil-lion per year in Medicare reimbursements be-

IZ Pub l i c Lau 100-258 .

13 Pub l i c Law 100-202, Sec. 530 andPWlic Law 99-500.



Defining “Rural” Areas: Impact on Health Care Policy and Research Ž 11

cause of this change from nonmetropolitan(rural) to metropolitan status. The increase inMedicare outlays for these two countieswould in aggregate decrease reimbursement toother hospitals because the total amount of funding for the Medicare program was notchanged by this act (44).

The MSA definition is designed strictlyfor statistical applications and not as ageneral-purpose geographic framework. Infact, according to official standards, “no Fed-eral department or agency should adopt thesestatistical definitions for a nonstatistical pro-gram unless the agency head has determinedthat this is an appropriate use of the classifi-cation” (56). The OMB does not take into ac-count or attempt to anticipate any nonstatisti-cal uses that may be made of the MSAdefinitions and will not modify the defini-

tions to meet the requirements of any non-statistical program (62). Nonetheless, Federalagencies often use MSA designations to im-plement their programs. Table 6 contains apartial list of Federal programs that useMSAs for the administration of programs orthe distribution of funds.

Table 6--- Selected Federal Depart-ment/Agencies Using MSA Designations for

the Administration of Programs or the Dis-tribution of Funds

a

Depar tment of Agr icul tureFarmers Home AdministrationRural Hous ing Ass is tance

Depar tment of Educat ionHigher Educat ion Ass is tanceFederal Impac t Payments for Educat ionSumner Food Service Program

Department of Health and Human ServicesFederal Grants for Res idency Train ingAid to Organ Procurement Organizat ionsMedicare Prospective Payment SystemJuveni le Del inquency Treatment GrantsProv is ion of Serv ices to Medicare Benef ic iar ies

by Heal th Maintenance Organizat ions (HMOs)

Department of Housing and Urban DevelopmentEnterpr ise ZonesPublic Housing DevelopmentCommunity D e v e l o p m e n t B l o c k G r a n t P r o g r a mUrban Development Action GrantsAss is ted Hous ing Fai r Market RentsRental Rehabilitation Awards

D e p a r t m e n t o f t h e I n t e r i o rRecreat ion AreasWastewater Treatment Works Grants

Department of LaborJob Train ing Par tnership Ac t

%ost U S A a p p l i c a t i o n s l i s t e d Mere i d e n t i f i e d b ysearching the U.S. Code and the Code of FederalR e g u l a t i o n s (CFR) for the term 1’MSA. IC T h i s l i s ti s no t caqwehensive.

SOURCE: Bea, K., l lMetrwlitan S t a t i s t i c a l A r e a

Standards: A p p l i c a t i o n s i n F e d e r a lP o l i c y ,

w(CRS Dra f t ) , 1989 ; U .S . Depar t -

ment of Commerce, OFSPS, “Report on the

Inpct o f S t a n d a r d M e t r o p o l i t a n S t a t i s t i -cal Areas on Federal Programs,ll 1978.



4. RELATIONSHIP BETWEEN URBAN/RURAL ANDMETROPOLITAN/NONMETROPOLITAN DESIGNATIONS

Conceptually, the urban/rural and metro/ nonmetropolitan designations are quite dif-ferent. Urban/rural are geographic designa-tions based on population size and residentialpopulation densities, while the MSA concept

embodies both a physical element (a city andits built-up suburbs) and a functional dimen-sion (a more-or-less unified local labormarket) (21 ). The Census-defined urbanpopulation and the MSA population intersectbut are by no means identical; they are evenless congruent geographically. Common toboth are residents of most urbanized areas,the densely set t led area that forms thenucleus of the MSA (see figure 3). 1 T h eCensus’ urban population includes the ur-banized area population and those livingoutside urbanized areas in places with 2,500or more residents. The MSA population gen-erally includes all those living in the countyor counties that contain the urbanized areaand the residents of additional counties thatare economically integrated with that metro-politan core. Forty percent of the 1980 ruralpopulation lived in MSAs, and 14 percent of the MSA population lived in rural areas (seetable 7). About one-fourth of farm residentslive in MSAs (55).

“Rural area,” “nonurbanized area, ” and

“nonmetropolitan area” have all been used todisplay vital and health statistics or to imple-ment Federal policies in health and otherareas. These “rural” definitions can be ana-lyzed in terms of how well they include “ruralareas” and how well they exclude “urbanareas.” The Census-defined “rural area” is themost specific measure, since it excludes ur-banized areas and places with 2,500 residentsor more. Thus, few would argue that an areadesignated as rural according to the Censusdefinition is really urban. However, somemight argue that the Census definition would

1 There are a few urbanized areas outside of MSAs.

z A sma[ 1 n u m b e r o f r u r a l r e s i d e n t s o f e x t e n d e dc i t i es are exc [ uded f rom the urban and urbanizedarea populat ion.

incorrectly classify as urban small townswhich are located far from a large populationcenter. In contrast, the “nonurbanized area”definition includes as rural all territory out-side of its densely populated area, regardless

of population size. Thus, while all “ruralareas” would be included, some cities andtowns of as large as 40,000 residents wouldalso be included, as well as some outer sub-urbs of large urban areas.

Figure 3---The Relationship BetweenMetropolitan Statistical Areas (MSAs),

Urbanized Areas, and Urban and Rural Areas

q

q

Urban places

•

Rural areas

Count ies 1 through 4 comprise the MSA.

Urbanized areas form the nuc leus of the MSA and cans p a n tuo or more count ies (e. g. , count ies 1 through4 ) . T he re ar e a fe w u r ba ni ze d a re as i n non-MSAcount ies (e. g. , county 7) .

U r b a n a r e a s i n c l u d e u r b a n i z e d a r e a s a n d pl a c e s( e . g . , c i t i e s a n d t o w n s ) with 2,500 o r more r es i -d e nt s . S uc h p la ce s a re ca ll ed u r ba n places.

Rural p laces are located outs ide of urbanized areasand have fewer than 2,500 res idents .

R u r a l a r e a s a r e t h e r e s i d e n t i a l t e r r i t o r y ( s h a d e dg r a y ) l e f t a f t e r u r b a n i z e d a r e a s a n d u r b a n p l a c e sar e exc l uded . T h e USA has rural areas wi th in i t .

SOURCE : Off ice of Technology Assessment , 1989.

13




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

SOURCE : American Map Corporation, Bus iness Cont ro l At las 1988 (Maspeth, New York : Amer ican Map Corpora-

tion, 1988). -



Defining ‘Rural” Areas: Impact on Health Care Policy and Research Ž 15

The nonMSA designation falls in betweenthe other two designations. If nonMSAs areused to define rural areas, some large townsand cities located outside of MSAS

3 would beincluded as rural while small towns and spar-sely populated areas within MSAs would beexcluded from the rural category. This ex-

clusion is less a concern in the EasternUnited States, where counties are relativelysmall, 4 and such towns would generally beexpected to be relatively close to an ur-banized area. However, in some of the largecounties in the West, some areas within anMSA are far from an urbanized area (e.g.,San Bernardino County--figure 4).

3 There are at least 100 places with p o p u l a t i o n s o f

25 ,000 o r more wtside of MSAS.

d A t y p i c a l c o u n t y i n t h e E a s t h a s a l a n d a r e a o f4 0 0 t o 6 0 0 s q u a r e m i l e s . U e s t o f t h e M i s s i s s i p p iR i v e r t h e r e a r e g r e a t v a r i a t i o n s , b u t t h e a v e r a g ec o u n t y l a n d a r e a i s j u s t o v e r 1 4 0 0 s q u a r e m i l e sexc luding Alaska (29) .

Table 7 .--Population Inside and Outside of MSAs by Urban and Rural Residence (1980)

Percent ofPopulat ion MSA/nonMSA

U . S. t o t a l 226,545,805

Inside MSAs 149,430,623 100.0

Urban 145,442,528 8 5 . 8Urban i zed areas 137,481,718 81.1Ce n t r al c i t i es 66,222,207 39.1Urban f r i nge 71,259,511 42.1

Rural 23,988,095 14.2

Outside MSAs 57,115,182 100.0Urban 21,608,464 3 7 . 8Rural 35,506,718 6 2 . 2

SOURCE: U.S. Department of Commerce, Bureau of theCensus , 1980 Census of Populat ion, Volume1 . C h a r a c t e r i s t i c s o f t h e P o p u l a t i o n ,1981, table 6, pp. 1-39.



5. UNDERSTANDING DIVERSITY WITHIN RURAL AREAS:URBAN/RURAL TOPOLOGIES

Dichotomous measures of urbani ty/ rurality not only obscure important dif-ferences between urban and rural areas butalso wide variations within rural areas. Con-sequently, there have been recommendations

to implement a standard rural typology thatwould capture the elements of rural diversityand improve use and comparison of data (14).In the absence of such standardized data, it isdifficult to quantify rural health problemsand to make informed policy decisions.

In this section, several county-basedrural /urban topologies or c lassif icat ionschemes are described that incorporate one ormore of the following measures:

s

s

s

population size and density;

proximity to and relationship with urbanareas;degree of urbanization; andprincipal economic activity.

Only county-based topologies are consid-ered here, because the county is generally thesmallest geographic unit for which data areavailable nationally. Counties also haveseveral other characteristics that make themuseful units of analysis: county boundaries aregenerally stable; counties can be aggregatedup to the State level; and counties are impor-

tant administrative units for health and otherprograms. For small-area analyses and forresearch purposes, ZIPCodes may be usefulunits of analysis. However, ZIPCodes bound-aries are not stable and sometimes crosscounty lines.

Topologies Used To DescribeNonmetropolitan Areas

Several topologies have been developedto classify nonmetropolitan counties. Ninecounty-based topologies are described below.1

These topologies are generally used for re-

search purposes and have not yet been usedby Federal agencies to implement healthpolic ies or to present vi ta l and heal ths t a t i s t i c s . Be fo re d i sc us s ing spe c i f i ctopologies, four geographic/demographic

measures common to most of the topologiesare briefly described: 1 ) population size, 2)p o p u l a t i o n d e n s i t y , 3 ) a d j a c e n c y t ometropolitan area, and 4) urbanization.

Population Size. --Population size canrefer to the total population of the county orto the largest se t t lement in the county.Presentation of an area’s population by settle-ment size helps to illustrate how the popula-tion is distributed. In 1980, 43 percent of theU.S. population lived in places of less than10,000 population or the open countryside

(see table 1). The Census Bureau’s urbandefinition depends in part on population size(i.e., those living in places of 2,500 or moreoutside of urbanized areas).

Population Density. --Population densityis calculated by dividing the resident popula-tion of a geographic unit by its land areameasured in square miles or square kilo-meters. In 1980, half of the U.S. population(excluding Alaska and Hawaii) l ived incounties with less than 383 persons per squaremile (21 ). Population density ranges from64,395 persons per square mile in New YorkCounty, New York (Manhattan) to 0.1 persquare mile in Dillingham Census Division,2

Alaska. Figure 5 shows how the U.S. popula-tion is distributed. Urbanized areas aredefined primarily by population density (i.e.,territory with at least 1,000 residents persquare mile). One drawback of populationdensity is that it doesn’t describe how thepopulation is distributed within an area. Forexample, a spatially large county that includesboth small, densely settled urban areas and

large, sparsely populated areas would have apopulation density that masks such extremes.

1 Not a l 1 rura l topologies that have been proposedare descr ibed i n this sect i on. Excluded from dis-cussi on are severa 1 economic indices developed i nthe 1960s that assoc iated economic underdevelopnent

ui th rural i ty.

z T h e r e a r e n o c o u n t i e s i n A l a s k a . T h e c o u n t yequi vat ents are the organized boroughs and O1census

areas]’ (U . S . Dept . o f Commerc e , 1980 Cens us o fP o p u l a t i o n , Volune 1, 1981).

17



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



Defining “Rural” Areas: Impact on Health Care Policy and Research s 19

Adjacency to Metropolitan Area. --Acounty’s adjacency to a metropolitan area canbe measured geographically (e.g., sharing aboundary) or functionally (e.g., proportion of residents commuting to an MSA for work).Many residents of these adjacent counties,however, live some distance from an urbancenter, particularly in large counties in the

West. Furthermore, natural geographic bar-riers or an absence of roads may impede ac-cess to metropolitan areas.

Urbanization --- Some topologies use vari-ous measures of the level of urbanization todifferent ia te nonmetropoli tan counties .Sometimes, urbanization is measured by theabsolute or relative size of the Census-d e f i n e d u r b a n p o p u l a t i o n . F o r n o n -metropolitan counties this generally means thepopulation living in places with 2,500 or

more residents or proportion of the county’spopulation that is urban. In other topologies,an urbanized county is defined by the size of the county’s total population (e.g., countieswith 25,000 or more residents).

Urbanization/Adjacency toMetropolitan areas

Analysts at the U.S. Department of Agri-cul ture (USDA ) have c lass i f ied non-metropolitan counties on two dimensions: 1 )the aggregate size of their urban population

and 2) proximity/adjacency to metropolitancounties (see table 8) (22).3 The urban popu-lation follows the Census Bureau’s definition.Urbanized counties are distinguished fromless urbanized counties by the size of the ur-ban population (i.e., urbanized counties haveat least 20,000 urban residents and less ur-banized counties have 2,500 to 19,999 urbanresidents). A nonmetropolitan county’s ad-

jacency to an MSA is defined both by sharedboundaries (i.e., touching an MSA at more

3 T h i s c l a s s i f i c a t i o n a l s o i n c l u d e s t h r e e t y p e s o fm e t r o p o 1 i t an count i es based on HSA tot a 1popu 1 at i on- - sma 11 (under 250,000 popu 1 at ion), me-dium (250,000 to 999,999), and large ( 1 mi 1 I ion ormore).

Table 8--- Classification of NonmetropolitanCounties by Urbanization and Proximity

to Metropolitan Areas(2,490 counties as of 1970)’

Urbanized adjacent (173 counties)s Counties with an urban population of at least

2 0 , 0 0 0 w h i c h a r e a d j a c e n t t o a m e t r o p o l i t a ncounty .

Urbanized nonadjacent ( 1 5 4 c o u n t i e s )s C o u n t i e s w i t h a n u r b a n p o p u l a t i o n

2 0 , 0 0 0 w h i c h a r e n o t a d j a c e n t t o acounty .

Leas urbanized adjacent (565 counties)s C o u n t i e s w i t h a n u r b a n p o p u l a t i o n

o f a t l e a s tm e t r o p o l i t a n

o f 2 . 5 0 0 t o1 9 , 9 9 9 w h i c h a r e a d j a c e n t t o a m e t r o p o l i t a ncount y.

Less urbanized nonadjacent (734 counties)C o u n t i e s w i t h a n u r b a n p o p u l a t i o n o f 2 , 5 0 0 t o1 9 , 9 9 9 w h i c h a r e n o t a d j a c e n t t o a m e t r o p o l i t a ncounty .

Rural adjacent (241 count ies )Count ies wi th no places of 2,500 or more popula-t ion which are adjacent to a met ropol i tan county .

Rural nonadjacent ( 6 2 3 c o u n t i e s )s C o u n t i e s w i t h n o p l a c e s o f 2 , 5 0 0 o r m o r e p o p u -

l a t i o n w h i c h a r e n o t a d j a c e n t t o a m e t r o p o l i t a ncount y.

aC l a s s i f i c a t i o n o f n o n m e t r o p o l i t a n a r e a s u s i n g 1 9 8 0

Census data is for thcoming f rom the Depar tment ofAgriculture (McGranahan, personal communication ,1989) .

SOURCE : McGranahan et al . , 1986, “Soc ia l and Eco-nomic Charac ter is t i cs of the Populat ion inMetro and Nonmetro Count ies, 1970-1980.

11

than a single point) and by commuting pat-terns (i.e., at least 1 percent of the county’sl a b o r f o r c e c o m m u t e s t o t h e c e n t r a lcounty(ies) of the MSA) .4 Nearly 40 percentof the nonmetropolitan counties are adjacentto MSAs, and just over one-half of the non-metropolitan population resides in these ad-

jacent counties (see table 9).

d T h e c l a s s i f i c a t i o n s c h e m e Has i n t r o d u c e d i n 1 9 7 5by Hines , Brown , and Zimner o f U S D A . C a l v i n B e a l ea n d D a v i d Broun, a l s o a t U S D A , l a t e r m o d i f i e d t h ec l a s s i f i c a t i o n t o i n c l u d e t h e 1 p e r c e n t comnu t ing

r e q u i r e m e n t f o r a d j a c e n t c o u n t i e s ( 1 3 ) . A 2 p e r -c e n t consnuting leve[ i s u s e d i n a m o r e r e c e n t v e r -s i o n o f t h e typology (5).




This typology still masks differencesamong nonMSA counties. For example, botha county with one town of 20,000 and acounty with eight towns of 2,500 would beconsidered urbanized under this typology.The county with several small towns is un-likely to have the level of services of acounty with its population concentrated into

larger towns.

Adjacency to Metropolitan Areas/LargestSettlement Size

Another county typology groups non-metropolitan counties by adjacency to MSAsand by size of the largest settlement (21)(table 10). Size of largest settlement is a use-ful parameter to include when analyzinghealth services since large settlements aremore likely to have hospitals and specialized

health care providers. However, the presenceTable 9-- Nonmetropolitan County

Population Distribution by Degree of Urbanization and Adjacency to an MSA

(1980)

P o p u l a t i o n a Percentb

( 1,000s) of nonMSA

U . S . t o t a l

MSA counties

NonMSA countiesUrbanized

Adjacent to MSANot adjacent to MSA

Less urbanizedAdjacent to MSANot adjacent to MSA

T o t a l l y r u r a lAdjacent to MSANot adjacent to MSA

226,546

163,526

63,020 100.0%

14,802 23.59 , 5 9 4 15.2

15,350 2 4 . 415,529 2 4 . 6

2 , 7 3 7 4 . 35,008 7 . 9

aTotal MSA/nonMSA populat ions d i f fer f rom those in

t a b l e 7 b e c a u s e t h i s typlogy r e l i e s o n 1 9 7 0 MSA

d e s i g n a t i o n s .

b Percent does not sun to 100 due to rounding.

S O U R C E: D . A . , McGranahan, et al. , “ Social a n dE c o n o m i c C h a r a c t e r i s t i c s o f t h e P o p u l a -t i o n i n M e t r o a n d N o n m e t r o C o u n t i e s ,1970-1980.11

of a large town or city does not guaranteeeasy access to facilities for all residents of aspatially large county.

Population Density: Incorporation of theFrontier Concept

The National Rural Health Association

(NRHA) has proposed a classification systemthat includes four types of rural areas (27)

adjacent rural areas--counties contiguousto or within MSAs which are verysimilar to their urban neighbors;urbanized rural areas--counties with25,000 or more residents but distantfrom an MSA;frontier areas--counties with populationdensities of less than 6 persons persquare mile, which are the most remoteareas;

Table IO--- U.S. Population by County’sLargest Settlement and Adjacency

to an MSA (1980)

P o p u l a t i o n P e r c e n t( 1 , 0 0 0 s ) o f U s .

U . S . t o t a l 226,505

NonMSA counties 60,512Counties not adjacent to an USA

L a r g e s t s e t t l e m e n tUnder 2,500

2,500 t o 9 ,99910,000 to 24,99925,000 or more

Count ies adjacent toL a r g e s t s e t t l e m e n t

Under 2,5002,500 t o 9 ,99910,000 to 24,99925,000 or more

MSA countiesL a r g e s t s e t t l e m e n t

Under 100,000100,000 to 249,999250,000 to 499,999500,000 to 999,9991,000,000 to 2,999

3,000,000 or more

an MSA

,999

4 , 5 4 3

10,2557,1204,124

3 , 1 5 713,23612,4675 , 6 1 0

165,994

3,61118,46124,88328,64050,524

39,875

100.0

2 6 . 7

2 . 0

4 . 53 . 11 . 8

1 . 45 . 85 . 52 . 5

7 3 . 3

1 . 68 . 2

1 1 . 01 2 . 62 2 . 3

1 7 . 6

SOURCE: A d a p t e d f r o m L . , L o n g , a n d D . , D e A r e ,l lRepopu(ating t h e c o u n t r y s i d e : A 1 9 8 0

C e n s u s T r e n d ,M

S c i e n c e , v o l . 2 1 7 , S e p t .17, 1982, pp. 111-116.



Defining “Rural” Areas: Impact on Health Care Policy and Research • 21

• countryside rural areas--the remainderof the country not covered by otherrural designations.

This typology includes some importantconcepts not covered by other topologies,such as the concept of the “frontier” area.This typo logy also differs from othertopologies because it includes some countieswithin MSAs (i.e., in the adjacent rural areacategory ). Since the categories are notmutually exclusive, however, some countieswill fall into more than one group. For ex-ample, under this typology 3 of 14 countiesin Arizona would be both “urbanized ruralareas” and “frontier areas” because thecounties’ populations exceed 25,000 residentsand the population density is less than 6 per-sons per square mile. 5 County population sizeis a poor indicator in the West because many

counties there are much larger than else-where.

Urbanization/Population Density

Two other rural topologies incorporatepopulation density and urbanization. Thef i r s t i s a c l a s s i f i c a t i on de ve lope d byBluestone 6 and the second is a modificationby Clifton of that classification (see table11).7 Urbanization is defined in terms of theproportion of the county that is urban (i.e.,lives in towns of 2,500 or more). An ad-vantage of using the percent of a county’spopulation that is urban is that it is not in-fluenced much by the size of the county, orby a county’s including a large stretch of un-populated territory. Density is heavily af-fected by these conditions. Combining mea-

5 The three Ar izona count ies are Apache, Coconino,and Mohave.

6 Herman Bluestone, II FOCUS for Area Deve 10pment

Ana [ ys is: Urban Or ientat ion of Counties, E c o n o m i c

D e v e l o p m e n t Di v i si o n, E c on o m i c R es e ar c h S e rv i c e,USDA as ci ted in Sinclair and Nanderscheid.

7 I v e r y C l i f t o n , A g r i c u l t u r a l E c o n o m i s t , E c o n o m i cResearch Service, USDA, unpubl i shed manuscr ipt asci ted by Sinclair and Manderscheid.

Tab le 11 - - Bluestone and Clifton County

Classifications Based on Urbanization andPopulation Density

P o p u l a t i o nper square

Percent urban m i l e

B l u e s t o n e c l a s s i f i c a t i o nM e t r o p o l i t a n

Urban

Semi - isolated urban

D e n s e l y s e t t l e d r u r a l

S p a r s e l y s e t t l e d r u r a lwith someurban popu la t i on

S p a r s e l y s e t t l e d r u r a lwi th no urbanpopu la t i on

C l i f t o n ' s c l a s s i f i c a t i o n

Urban

Semi - urban

D e n s e l y s e t t l e d r u r a l

Rural

GT 85 percent

GT 50 percent

LT 85 percent

GT 50 percent

LT 50 percent

LT SO percent

O percent

GE 50 percent

GE 50 percent

LT 50 percent

LT 100

GT 100

GT 500

100-500

LT 100

50-100

LT 50

LT 50

GE 200

30-200

GT 30

LT 30

ABBREVIATIONS: GT=greater than; GE=greater than orequal to; LT=less than.

S O U R C E: B . , S i n c l a i r , a n d L . , M a n d e r s c h e i d , “ AC o m p a r a t i v e E v a l u a t i o n o f I n d e x e s o fR u r a l i t y - - T h e i r P o l i c y I m p l i c a t i o n s a n dD i s t r i b u t i o n a l I m p a c t s ,

t’ c o n t r a c t r e p o r t ,

Depar tment of Agr icul tura l Economics .

sures of urbanization and density providessome indication of the degree of populationconcentration or dispersion. However, aswith the USDA typology, a county with onetown of 20,000 and a county with eight townsof 2,500 may not be distinguished under thisscheme.

Distance From an MSA or Population Center

Two rural indexes8 are based on distancefrom an MSA or population center. Hathawayet al., developed a size-distance index that

8 These rural indexes are d i f ferent frun t o p o l o g i e si n t h a t t h e y a r e c o n t i n u o u s ( e . g . , a s c a l e fr~ 1to 100) rather than categor ical measures .




includes two measures: miles from an MSAand the population of that MSA (39). Smithand Parvin considered three county charac-teristics in their rural index: population-proximity; population density; and employ-ment in agriculture, forestry, or fisheries(40,43). A county’s population-proximity in-dicates the relative access to adjacent

counties’ populations.

Population-proximity is measured as thecounty population plus the size-distance ratioof surrounding counties. 9 To illustrate, thepopulation-proximity for County A of size20,000 surrounded by four counties Bthrough E is as follows:

Table 12--- Population-Proximity: A Measureof a County’s Relative Access to Adjacent

Counties’ Populations

Di st an ce b etween Ra ti o o fCo un ty A an d t he p op ul at io nindicated county t o d i s t a n c e

count y p o p u l at i o n ( m i l e s )a

( p o p . / m i l e )

A 20,000B 15,000 30 5 0 :c 60,000 1,500D 250,000 100 2,500E 100,000 10 10,000

Sun of rat ios . . . . . . . . . . . . . . . . . . . . . . . . . . 14,500Add population of County A.. . . . . . . . . . . . 20,000Populat ion-prox imi ty for County A. . . . . . 34,500

aDis tance is the number of mi les between the countys e a t o f C o u n t y A a n d t h e c o u n t y s e a t o f t h e i n d i -cated county .

SOURCE : Adapted from Select Committee on Aging, 1983" S t a t u s o f t h e R u r a l E l d e r l y . "

The combination of distance to adjacentpopulation centers and size of that populationin a typology is attractive because distance is

9 T h e p o p u l a t i o n - p r o x i m i t y i s “ the sun of the tota lp o p u l a t i o n i n t h e r e f e r e n c e comty and the sun oft he r a t i os o f t he ntmber o f p e r s o n s i n a l l c o u n t i e swi th in 125 mi les of the reference county d iv ided byt h e d i s t a n c e i n m i l e s bet~een t h e c o u n t y s e a t i nt h e r e f e r e n c e c o u n t y a n d t h e c o u n t y s e a t i n e a c hc ounty w i t h i n t he s pec i f i ed d i s t anc e (43).U

a good access indicator and population sizeindicates service availability. The topologiesincorporating these measures may be most in-formative for geographically small counties.For large counties, however, the distancefrom one county seat to the next is unlikelyto be applicable to those living at a distancefrom the county seat.

Commuting-Employment Patterns

A relatively new county classificationsystem incorporates measures of populationsize, urbanization, commuting patterns of workers, and the relationships between work-place and place of residence (28). The classi-fication criteria are shown in table 13 and thedistribution of U.S. counties according to thistypology is shown in table 14. The inclusionof employment and commuting measures may

allow this typology to identify groups of counties that are economically related such asservice and labor market areas.

Economic and Socio-DemographicCharacteristics

Nonmetropolitan counties have also beenclassified according to their major economicbases, land uses, or population characteristics(table 15) (7).10 Fifteen percent of non-metropolitan counties (370 of 2,443 countiesin the 48 conterminous States) remain un-

classified using this approach. Among thecounties that are classified, 70 percent fallinto only one of the seven categories; theremaining 30 percent fall into two or morecategories (37).

Some of the data used to develop thisclassification are now a decade old (e.g., farmemployment), and it is likely that with con-tinued diversification of the rural economy

10 These represent the nonmet ropol i tan count ies asdef ined in 1974.






Table 14--- Distribution of U.S. Counties byTypology Based on Employment, Commuting,

and Population Characteristics (1986)

Number of Percentcount i es o f U s .

Nonmetropol i tan county t rees 2393 2 3 . 2

Centers 543 11.1S a t e l l i t e s 212 2 . 4

commuting count ies wi th center 239 2 . 7Smal l centers 565 3 . 7Rural commuting count ies 333 1 . 7Rural coun t i es 501 1 . 6

Met ropol i tan county type 745 7 6 . 8

Metro centers 295 4 4 . 7M e t r o s a t e l l i t e s 91 10.0Met ro commut ing sate l l i tes 193 15.0Metro suburban 133 6 . 6Met ro dormi t o ry 33 less than 1

S O U R C E : J . , P i c k a r d , "An Economic Development

C o u n t y C l a s s i f i c a t i o n f o r t h e U n i t e dStates and i ts Appalachian County Types , "A p p a l a c h i a n R e g i o n a l C o m m i s s i o n , W a s h -ington, DC June 1988.

since the late 1970s, even fewer counties 11

would be classified into one of these groups.On the other hand, many rural economiesremain small and dependent on a single in-dustry or occupation despite the economicdiversification(7).

Conclusion

In summary, several topologies for non-metropolitan counties have been developedincorporating measures of population size anddensity, urbanization, adjacency and rela-tionship to MSA, and principal economic ac-tivity (see table 16). While it is desirable tohave a standardized typology to portray thediversity of rural areas, the potential uses of

1 1 I f t h e c l a s s i f i c a t i o n s c h e m e uere u p d a t e d , t h ep r o p o r t i o n o f n o n m e t r o p o l i t a n c o u n t i e s e i t h e r n o tc l a s s i f i e d o r f a l l i n g i n t o m o r e t h a n o n e g r o u pw o u l d l i k e l y b e g r e a t e r t h a n t h e p r e s e n t 4 3 p e r -c en t .

topologies are varied and require inclusion of different measures. For example, to studythe geographic variation of access to healthcare, a typology that includes population size,density, and distance to large settlements is of interest. To study health personnel labormarket areas, however, a typology based oneconomic areas, market areas, or worker

commuting patterns is preferable. On theother hand, rural economists or sociologistsma y be more i n t e re s t e d i n i de n t i fy ingcounties with economies dependent on farm-ing, mining, or forestry.

While no one typology meets all potentialneeds, there are several desirable features of any typology. For example, for many pur-poses it is helpful to have topologies withmutually exclusive (i.e., nonoverlapping) cat-egories. The National Rural Health Associa-

tion’s typology includes frontier (less than 6persons per square mile) and urbanized ruralcounties (population of 25,000 or more andnot adjacent to an MSA). Yet it is possiblefor counties to meet both criteria.

The concept of urbanization is incor-porated into several of the topologies. Insome cases, urbanization is determined by theabsolute or relative size of a county’s urbanpopulation and in others, by the size of acounty’s largest settlement. When the size of the urban population is used, a county with

one large city with the balance of the countysparsely populated, would be indistinguishablefrom a county with several smaller towns. Aslevel of resources are likely to be city-sizedependent, topologies using this measure of urbanization may not discriminate well forsome applications. On the other hand, whilelargest settlement size might be indicative of level of services available in the county, it isnot informative of how remote those servicesmight be for all county residents. In geog-raphically small counties, large settlements arelikely to be accessible to all county residents.In the West, however, counties can be aslarge as some Eastern States, and somemeasure of proximity would be useful to in-dicate physical access. Measures of how




Table 15. --Classification of Nonmetropolitan Counties by Economic andSocio-Demographic Characteristics

a

Farming-dependent counties702 count ies concent rated largely in the Pla ins por t ion of the Nor th Cent ra l region.Farming cont r ibuted a weighted annual average of 20 percent or more of tota l labor and propr ietor incomeover the f ive years f rom 1975 to 1979.

M an u f ac t u r in g -d e pe n de n t c o u n t i e s678 count ies concent rated in the Southeas t .Manufac tur ing cont r ibuted 30 percent or more of tota l labor and propr ietor income in 1979.

MNining-dependent c o u n t i e s200 count ies concent rated in the West and in Appalachia.Mining cont r ibuted 20 percent or more to tota l labor and propr ietor income in 1979.

Specialized government counties31 5 c ount i es s c a t t e red t h roughout t he c oun t r y .Government ac t iv i t ies cont r ibuted 25 percent or more to tota l labor and propr ietor income in 1979.

Persistent poverty counties2 4 2 c o u n t i e s c o n c e n t r a t e d i n t h e S o u t h , e s p e c i a l l y a l o n g t h e M i s s i s s i p p i D e l t a a n d i n p a r t s o f A p -pa lac h ia .Per capi ta fami ly income in the county was in the lowes t quint i le in each of the years 1950, 1959, 1969,and 1979.

Federal Lands counties247 counties concentrated in the West.Federal land was 33 percent or more of the land area in a county in 1977.

Destination retirement counties515 count ies concent rated in several nor thern Lake States as wel l as in the South and Southwest .For the 1970 to 1980 per iod, net immigrat ion rates of people aged 60 and over were 15 percent or more ofthe expec ted 1980 populat ion aged 60 and over . R e t i r e m e n t c o u n t i e s a r e d i s p r o p o r t i o n a t e l y a f f e c t e d b yent i t lement programs benef i t ing the aged.

aT h e nutr&er of nonmetropolitan c o u n t i e s d o e s n o t a d d to the tota l n-r ( 2 ,443) , bec aus e t he c a tegor i es

are not mutual ly exc lus ive and 370 count ies do not f i t any of the categor ies .

SOURCE: B e n d e r , L.D., G r e e n , B . L . , Hady, T.F . , e t a l . , Economic Research Serv ice, U.S. Depar tment of Ag-r icul ture, The Diverse Soc ia l and Economic St ruc ture of Nomnetrocmlitan A m e r i c a , R u r a l D e v e l o p -ment Research Report No. 49 (Washington, DC: U . S . Goverrmnent P r i n t i n g O f f i c e , Septenber 1 9 8 5 ) .

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

Measures

Populat ionTypology s i z e Den s i t y Ur b an i zat i o n Adjacency D i s t a n c e Economy

USDA-l a . . . .

s. . . .

Long and DeAreb

s. . . .

s. . . .

NRHAC

s s. .

. . . .

B l u e s t o n ed . .

s. .

s. . . .

C l i f t o ne . . . .

s. . . .

P a r v i n a n d S m i t hfs

. . . . . .

Hathaway g

s. .

. . . .

s. .

P i c k a r dh

s. .

s. . . .

s

USDA-2i . . . . . . . .

s

~cGranahan, D.A. et al., U S D A , 1 9 8 6 .Long, L. and DeAre, D., 1982.

~~~~~~~\~ural Health A s s o c i a t i o n , a s cited in pat~~ L., ,989, H . a s c i t e d i n S i n c l a i r , B . , a n d Mandersch&id, L . V . ,

.

1974.~C[ifton, I . a s c i t e d i n S i n c l a i r , B . , a n d Manderscheid, L.V . , 1974.Parvin, D.H. and Smi th, B.J. as cited in U.S C o n g r e s s , H w s e o f R e p r e s e n t a t i v e s , T a s k on the Rural Eldelry

of the Select Comnittee on Ag ing , 1983 .‘Hathaway, D.E. a s Cited i n Sinc[air, B . , a n d Manderscheid, L . V . , 1974.‘Pickard, J . , Appa lac h ia 21(3):19-24, Sumner, 1988.IBender, L.D. et a l . , USDA, 1985.

SOURCE: Off ice of Technology Assessment , 1989.




evenly the population is distributed mightalso be useful for large counties.12 Several of the topologies incorporate an adjacent-to-MSA measure, which is an indicator of accessto level of services. The proportion of acounty’s population that is urban is a usefulmeasure in large Western counties becauseunlike population density, it is a measure thatis not influenced much by size of county orby population distribution.

Nonmetropolitan county data can also bedisaggregate regionally by State or groups of States (e.g., the four Census regions or nineCensus divisions), or by economic areas (e.g.,Bureau of Economic Analysis Areas orBEAs). The Bureau of the Census defines“county groups” that are usually contiguouscounties that combined have a population of 100,000 or more. 1 3 T h e s e c o u n t i e s a r e

generally grouped according to meaningfulState regions such as planning districts (50).

A new category of nonmetropolitan areacalled “micropolitan area” has recently beendescribed (42a). While not a typology, then e w c a t e g o r y d o e s d i s t i n g u i s h n o n -metropolitan areas that exert similar socialand economic influences on their regions asmetropolitan areas do on a larger scale. Mostmicropolitan areas are single counties but afew span two counties or are independentcities. Micropolitan counties are relativelylarge (40,000 or more residents) and include acentral “core city” with at least 15,000 resi-dents. 14,15 Many micropolitan areas are COl-

.

lege towns, sites of military bases, and retire-ment areas. More than 15 million people orabout one-quarter of nonmetropolitan resi-dents live in the 219 identified micropolitan 16

areas.

12 T h e H o o v e r i n d e x i s a m e a s u r e o f p o p u l a t i o nc o n ce n t ra t i on o r d i s p er s i o n. Th e i n de x r an g es fr omz e r o , which i n d i c a t e s a p e r f e c t l y u n i f o r m distr ib-ut ion in which each subarea has the same proport iono f t o t a l p o p u l a t i o n a s i t d o e s o f l a n d a r e a , t o1 0 0 , w h i c h r e p r e s e n t s t h e c o n c e n t r a t i o n o f a l l t h ep o p u l a t i o n i n t o a s i n g l e s u b a r e a ( 2 1 ) . T o e s t i m a t ec ounty popu la t i on d i s pers i on , s ubc ounty geograph i ca re as w ou l d b e u s ed . O th e r m et h o d s t o me as u r ep o p u l a t i o n c o n c e n t r a t i o n o r d i s p e r s i o n i n c l u d e t h en e a r e s t - n e i g h b o r s t a t i s t i c o r t h e q u a d r a n t t e c h n i -que , bu t bo th r equ i r e a geograph i c i n f o rmat i on s y s -t e m i n c o r p o r a t i n g l o n g i t u d e a n d l a t i t u d e m e a s u r e s(9, 17,24) .

]3 Thes e c ounty g roups a re on l y de f i ned i n pub l i cuse data f i les .

1 4 I f a n o n m e t r o p o l i tan c i t y o f 1 5 , 0 0 0 o r m o r er e s i d e n t s has at l eas t 40 percent of i t s populat ioni n e a c h o f two c o u n t i e s , t h e micropol itan a r e a i n -c l udes bo th c oun t i es .

15 I n f o u r S t a t e s ( M a r y l a n d , M i s s o u r i , N e v a d a , a n dV i r g i n i a ) s o m e c i t i e s ( c a l l e d i n d e p e n d e n t c i t i e s )have the sane s tatus as count ies and are cons ideredmicropolitan i f t h e y h a v e 1 5 , 0 0 0 o r m o r e r e s i d e n t sa n d a r e l a r g e r t h a n 1 5 s q u a r e m i l e s . I f t h e c i t yi s areally s m a l l e r , i t i s j o i n e d uith t h e a d j a c e n tcounty to form the area.

1 6 A l i s t o f micropolitan a r e a s i s a v a i l a b l e f r o mNiagara Concepts , P.O. Box 296, Tonauanda, New York14151” 0296.



6. THE AVAILABILITY OF VITAL AND HEALTH STATISTICSFOR NONMETROPOLITAN AREAS

Given the diversity of nonmetropolitanareas, it is important to present vital andhealth and statistics by State, region, or bynonmetropolitan typology. Data from thedecennial Census and national vital statistics(e.g., natality and mortality data) are pub-lished for nonmetropolitan areas by State anddegree of urbanization, but few other sourcesof health information are published alongthese dimensions. For example, the NationalCenter for Health Statistics does not publishdetailed nonmetropolitan data (e.g., cross-tabulated by Federal region) in their reportson National Health Interview and NationalMedical Care Utilization and ExpenditureSurveys. Sometimes, limitations of the wayin which the data are collected (e. g., the

sample size or frame) limit the extent towhich nonmetropolitan data can be displayed.In general, however, survey data files areavailable for public use and can be analyzedby area.

The choice of definition of “rural” usedto present demographic and health data canmake a substantive difference. For example,whether a disproportionate number of ruralresidents are elderly depends on how rural isdefined. Table 17 shows the proportion of

Table 17--- Proportion of the Population 65

and Older by Metropolitan/Non metropolitanand Urban/Rural Residence

Percent ageArea U .S . p o p ul a ti o n 65 an d o ver

M e t r o p o l i t a n 169,430,577Nonmetropol i tan 57,115,228

Urban 167,054,638Rural 59,491,167

M e t r o p o l i t a nUrban 145,451,315

C e n t r a l c i t i e s 67,854,918

N o t c e n t r a l c i t i e s 7 7 , 5 9 6 , 3 9 7Rural 23,979,262

Nonmetropol i tanUrban 21,603,323Rural 35,511,905

1 0 . 713.0

11.410.9

10.911.8

10.29 . 0

14.312.2

SOURCE : U.S. Department of Commerce, Bureau of theCens us , 1980 Cens us : Genera l Soc ia l andEconomic Charac ter is t i cs .

the population aged 65 and older according tometro/nonmetropolitan and urban/ruraldesignations. The elderly appear to make upa larger proportion of the total population innonmetropolitan than metropolitan areas (13.0v. 10.7 percent). Using the urban/rural cate-gories, however, the opposite is true--there isa greater proportion of elderly residents inurban than rural areas (11.4 v. 10.9). Theexplanation of this discrepancy appears to bethat there are proportionately more persons65 and older living in urban nonmetropolitanareas (14.3 percent) and fewer in ruralmetropolitan areas (9.0 percent). Moreover,when nonmetropolitan county MSA-adjacencyand size of the urbanized population are con-sidered, the aged appear to be over-

represented in the less urbanized and non-adjacent counties (see table 18).

Table 18-- - Proportion of NonmetropolitanPopulation Age 65 and Older by Level

of Urbanization and Adjacencyto an MSA

a(1980)

b

PercentU.S. Po pu lat io n age 65

( 1,000s) and older

U . S . t o t a lMet ropol i tan count ies

Nonmetropol i tan count iesUrbanized

Adjacent to met ro a r e a

Not adjacent

Less urbanizedAdjacent to int ro areaNot adjacent

T o t a l l y r u r a lAdjacent to met ro areaNot adjacent

226,546163,526

63,020

14,8029,594

15,35015,529

2 , 7 3 75,008

11.21 0 . 7

1 2 . 8

1 1 . 911.0

13.313.5

1 3 . 71 4 . 6

~rbanized c o u n t i e s a r e t h o s e w i t h a n u r b a n p o p u -l a t i o n o f a t l e a s t 2 0 , 0 0 0 ; l e s s u r b a n i z e d c o u n t i e sa r e t h o s e w i t h a n u r b a n p o p u l a t i o n o f b e t w e e n2 , 5 0 0 t o 1 9 , 9 9 9 ; a n d t o t a l l y r u r a l c o u n t i e s a r et h o s e with no populat ions of 2,500 or more.

b1980 C e n s u s i n f o r m a t i o n i s d i s p l a y e d u s i n g t h e1 9 7 0 c l a s s i f i c a t i o n o f c o u n t i e s .

S O U R C E: D . A . , McGranahan, et al. , “ Social a n dE c o n o m i c C h a r a c t e r i s t i c s o f t h e P o p u l a -t i o n i n Hetro a n d N o n m e t r o C o u n t i e s ,1970-80 , 11 USDA, ERS, Rura l Dev e lopmentResearch repor t 58, appendix , table 2.

27




Infant mortality is also better understoodby looking beyond metropolitan/nonmetro-politan comparisons. Department of Healthand Human Services (DHHS) publishes dataon infant mortality for urban and “not urban”p l a c e s w i t h i n m e t r o p o l i t a n a n d n o n -metropolitan counties (nonmetropolitan urbanplaces are defined as those with populations

of 10,000 or more). 1 Table 19 shows thatwithin U.S. nonmetropolitan areas ( 1985-1986), white infant mortality rates were lower in nonurban places than in urban places (9.3versus 9.9). Black infant mortality, in con-trast, is higher in non urban places (17.8versus 16.5). In some nonmetropolitan areas(e.g., Alabama), infant mortality is higher inthe more rural areas for both whites andblacks (see table 19).

In summary, quite different conclusionsabout the rural population may be reached bychanging the definition of rural areas. Fur-thermore, important within-area variationsare obscured when national data are not pub-lished for sub nonmetropolitan areas.

The problem of limited rural data is nota new one for policy makers. In 1981, theNational Academy of Sciences addressed theissue in a report, Rural America in Passage:Statistics for Policy. A panel on Statistics forRural Development Policy comprised of agri-cultural economists, statisticians, geographers,

sociologists, and demographers made a num-ber of recommendations to improve the per-ceived poor availability and quality of ruralstatistical databases. The panel recommendedthat the Federal Government “take a more ac-tive role in the coordination of statistical ac-tivities and in developing and promulgatingcommon definitions and other statistical stan-dards that are appropriate for implementationat the Federal, State, and local levels.” Thepanel concluded that a single definition of “rural” is neither feasible nor desirable but

1 DHHS d e f i n e s u r b a n p l a c e s i n U S A c o u n t i e s a st h o s e with p o p u l a t i o n s o f 1 0 , 0 0 0 o r m o r e b u t l e s st h an 5 0, 00 0. T h is u r b an d e f i n i t i o n d i f f er s f r o mt h e B u r e a u o f t h e C e n s u s d e f i n i t i o n s o f u r b a n o rurbanized areas .

Table 19.--Nonmetropolitan Infant Mortality

Rates by Urban Area and Race, U.S. Totaland Alabama (1986)

I n f a n t m o r t a l i t y r a t e ( n o . d e a t h s )(deaths under age 1 p e r 1 , 0 0 0 b i r t h s )

Un i t edSta tes Alabama

Nonmetropol i tanUrban places

a

WhiteBlackOther

Balance of areaWhiteBlackOther

1 0 . 4 ( 1 7 , 9 2 6 )1 0 . 8 ( 4 , 0 7 5 )9 . 9 ( 3 , 0 1 9 )

16.5 (9 58 )7.1 ( 9 8 )

1 0 . 3 ( 1 3 , 8 5 1 )9 . 3 ( 1 0 , 6 4 4 )

1 7 . 8 ( 2 , 6 3 2 )1 0 . 7 ( 5 7 5 )

1 2 . 7 ( 5 5 3 )1 0 . 9 ( 1 1 5 )7 . 4 ( 4 7 )

1 6 . 3 ( 6 7 )7 . 6 ( 1 )

1 3 . 3 ( 4 3 8 )1 0 . 5 ( 2 2 8 )1 9 . 2 ( 2 1 0 )

. . ( o )

aUrban places i n nonMSA c o u n t i e s a r e t h o s e w i t hpopulat ions of 10,000 or more.

SOURCE : Depar tment of Heal th and Human Serv ices ,P u b l i c H e a l t h S e r v i c e , V i t a l S t a t i s t i c s o f

t he U. S.: 1 98 6, 1 98 5, V o l . 1, N at a l i t y ,Pub. No. 88-1123, 88-1113 (Washington, DC:U . S . G o v e r n m e n t P r i n t i n g O f f i c e , 1 9 8 8 ,1987) ; 1986 , 1985, Vo l . 2 , Mor ta l i t y , Pub .No . 88-1114, 88-1102 (Washington, DC: U.S.Govermnent Pr in t i ng Of f i c e , 1988 , 1987) .

recommended that data be organized in abuilding-block approach so that differentdefinitions and topologies could be con-structed. The panel recognized the need fora common aggregation scheme for counties.It recommended the development of a stan-da rd c l a s s i f i c a t i on o f nonme t ropo l i t a ncounties related to the level of urbanization.The panel recommended that if possible, thecounty classification should be supplementedby a distinction between urban and ruralareas within counties (13).

The lack of consistent county codingposes difficulties for those interested in de-ve lop ing c oun ty -ba se d de f in i t i ons a ndtopologies. Unique county identifiers calledcounty FIPS (Federal Information ProcessingStandards) codes are provided by the National

Institute of Measurement and Technology

z T h e N a t i o n a l I n s t i t u t e o f M e a s u r e m e n t a n d T e c h -n o l o g y w a s f o r m e r l y t h e B u r e a u o f N a t i o n a l S t a n -dards .




but are not universally used (8). The panelrecommended that Federal and State data berecorded with such county codes to permittabulations for individual counties and groupsof counties. Adherence to a county codingsystem would facilitate aggregation of in-formation regardless of how rural is defined.Since the report was issued in 1981, few of its recommendations have been implemented(8).

The relative merits of the county-basedtopologies for health service planning and re-search can be evaluated using the AreaResource File (ARF), a county-level database maintained by the Health Resources andServices Administration (61). The file con-tains data necessary for the Bureau of HealthProfessions to carry out its mandated programof research and analysis of the geographic

distribution and supply of health personnel.Population, economic, and mortality data, andmeasures of health personnel, health educa-tion, and hospital resources, are included inthe file (61).

The ARF has been used to show how thea va i l a b i l i t y o f phys i c i a n a nd hosp i t a lresources varies by type of nonmetropolitanarea (table 20) ( 18). For example, whenphysician availability is examined by type-of-county, wide variations in physician-to-population ratios are evident. The average

physician-to-populat ion ra t io is 64 per100,000 in nonmetropolitan counties 3 but itranges from 131 per 100,000 in high-densitycounties to a low of 45 per 100,000 in persis-tent poverty counties (see table 20). Some-what surprisingly, there appear to be relative-ly more physicians in nonadjacent than ad-

jacent nonmetropolitan counties (67 comparedto 59 per 100,000). A possible explanation isthat physicians serving many of the residentsof the adjacent nonmetropolitan counties are

3 T h i s a n a l y s i s was ( im i t e d t o nonmetropolitan

count i es of 1 ess than 50,000 populat ion i n 1985.O n l y p h y s i c i a n s e n g a g e d i n p a t i e n t c a r e a r e in -

C 1 Uded.

preferentially locating in the outlying sub-urban areas of MSAs.

Maps effectively illustrate geographicvariation in health status and access to healthcare resources. U.S. cancer atlases have beenpublished at the county level providing avisualization of geographic patterns of cancer

mortality not apparent from tabular data( 6 0 ) .4 Rural women in the lower socio-economic classes have high rates of cervicalcancer and for white women, maps showconcentrations of cervical cancer throughoutthe South, especially in Appalachia (see fig-ure 6).

Maps of the United States by countyshow higher death rates due to unintentionalinjury (e.g., housefires and drownings) andmotor vehicle crashes in rural areas, particu-larly in Western, sparsely populated counties

(see figures 7-8). The large volume of travelon major routes traversing rural areas doesnot account for the high rural death rates.Instead, road characteristics, travel speeds,s e a t - b e l t u s e , t y p e s o f v e h i c l e s , a n davailability of emergency care are factors thatmay contribute to the excess of motor vehiclecrash deaths in rural areas (3).

Maps of nonmetropolitan county varia-tion in health indicators (e. g. , infantmortality) and the distribution of health careresources (e.g., physicians, hospitals) will soonbe published in the Rural Health Atlas.5 Atypology of rural medical care is being devel-oped for the Atlas, which incorporatesmeasures of access to primary care physiciansand health facilities. Such a typology willhelp ident ify isola ted communit ies withlimited access to health care (35).

d The U.S. C a n c e r A t l a s m a p s c a n c e r m o r t a l i t y b ycounty groupings cal led State Economic Areas (SEA) .5 0 6 S E A S w e r e d e l i n e a t e d b y t h e B u r e a u o f t h eCens us i n 1960. S E A S a r e g e o g r a p h i c u n i t s ~ith

sirni lar d e m o g r a p h i c , c l i m a t i c , physiographic, a n dc u l t u r a l f e a t u r e s ( 6 0 ) .

J T h e a t l a s i s s c h e d u l e d t o b e p u b l i s h e d b y r e -s e a r c h e r s a t t h e U n i v e r s i t y o f N o r t h C a r o l i n a b yOctober , 1989 (35) .




Table 20.--Characteristics of Different Categories of U.S. Nonmetropolitan Counties(2,092 nonmetropolitan counties of less than 50,000 population in 1985)

8

1985 1986 1986 1980 1979Category M.D.+ h o s p i t al h o s p i t al Age X i n

(numbet of count ies ) DO/100,000 b ed s /1 ,000 days per 1,000 over 65 p o v er t y

U.S . t o ta l ( 2092)Urbanized (83)

Less urban (1239)

Rura l ( 770)

MSA adjacent (751)

MSA nonadjacent (1341)

1980 populat ion dens i ty

3 o r l es s ( 194)

>3 and < 6 (181)

>6 and < 9 (123)

>9 and < 50 (1235)

>50 and < 100 (320)

more than 100 (39)

Eas t (59)

S o u t h A t l a n t i c ( 3 2 4 )

South (624)

Cent ra l ( 799)

West (286)

A g r i c u l t u r a l o n l y ( 4 6 4 )

A g r i c u l t u r a l t o t a l ( 6 8 0 )

Manufac tur ing only (290)

M a n u f a c t u r i n g t o t a l ( 5 0 0 )

Mining only (97)M i n i n g t o t a l ( 1 8 3 )

Federal Lands only (35)

F e d e r a l l a n d s t o t a l ( 2 1 0 )

Government only (75)

Government total (246)

Poverty only (41)

Pov er t y t o ta l ( 238)

Ret i rement only (140)

Ret i r ement t o ta l ( 420)

6 4 . 2113.7

7 1 . 9

4 6 . 5

5 8 . 6

6 7 . 3

4 8 . 9

5 9 . 2

6 3 . 4

6 0 . 5

8 0 . 5

130.5

115.7

6 0 . 7

5 4 . 4

6 4 . 9

7 5 . 4

5 2 . 2

49.1

6 8 . 3

6 2 . 4

6 1 . 257.1

106.8

7 5 . 8

76.5

6 6 . 6

4 5 . 3

4 3 . 0

79.1

6 7 . 5

5 . 06 . 4

5 . 5

4 . 1

4 . 3

5 . 4

4 . 9

7 . 2

6 . 1

4 . 6

4 . 9

7 . 7

5 . 5

4 . 2

4 . 3

5 . 9

5.1

5 . 7

5.1

4 . 5

4 . 3

5 . 14 . 3

3 . 8

3 . 9

9 . 9

7 . 0

3 . 4

3 . 3

4 . 5

4 . 0

9621421

1081

721

858

1021

1382

1035

858

1053

1959

1443

1193

942

1o11

944

847

824

774689

698

643

2382

1603

535

575

841

743

14.212.5

1 3 . 9

15.1

1 3 . 9

1 4 . 8

13.1

1 4 . 7

1 5 . 9

1 4 . 8

12.5

11.4

13.5

1 2 . 7

1 4 . 8

1 6 . 0

11.5

1 6 . 6

1 5 . 9

1 3 . 2

1 3 . 4

12.21 1 . 8

1 0 . 0

1 1 . 4

13.4

13.2

13.5

1 3 . 6

1 6 . 9

1 5 . 6

1 7 . 615.2

1 6 . 7

19.3

16.4

18.2

1 7 . 9

16.5

16.1

18.5

1 5 . 7

1 2 . 0

1 2 . 8

2 0 . 7

2 2 . 0

14.3

14.3

17.1

1 8 . 8

15.2

1 6 . 8

16.016.5

12.0

1 4 . 8

18.0

19.4

2 9 . 9

2 8 . 3

1 6 . 0

1 7 . 6

a2 8 2 nomtetropolitan count ies uith 50,000 or more populat ion were exc luded f rom analyses .

SOURCE: K i n d i g , D . A . , e t a l . ,l lN~t ropo( i tan County Typology a n d H e a l t h Resources;ti

unpub l i s hed manu-s c r i p t , Dec . 15 , 1988 .




Figure 6--- Areas With Cervical Cancer Mortality Rates Significantly HigherThan the U.S. Rate, and in the Highest 1O

O /o of all SEA Rates

(White Females, 1970-1980)

SOURCE: U.S. Department of Health and Human Services, P u b l i c H e a l t h S e r v i c e , N a t i o n a l I n s t i t u t e s o f H e a l t h ,At las of U.S. Cancer Mor ta l i t y Among Whites: 1950-1980, DHHS Pub. No. (NIH) 87-2900 (Bethesda, MD:1987).




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

0.00 —

I I 38.16 —

72.07 —

90.44 — 429.00

SOURCE : Baker, S. P., Uhitfield, R. A., and O]Nei 11, B . , qwty Mapping of Injured Mortal i ty , ” The J ourna lo f Trauna 28(6):741-745, Jme 1 9 8 8 .




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

57.28– 1465.20

SOURCE : Baker, S. P., Uhitfield, R.A. , and O’Neill, B . , llGeOgr@ic variations i n M o r t a l i t y F r o m Motor

Veh i c l e Cras hes , U New England Journal of Medic ine 316(22):1384-1387, May 28, 1987.



7. USING OMB AND CENSUS DESIGNATIONSTO IMPLEMENT HEALTH PROGRAMS

There is no uniformity in how ruralareas are defined for purposes of Federalprogram administration and distribution of f un ds . E ve n w it hi n ag en ci es d if fe re ntdefinitions maybe used. This may occur

when agenc ies implement programs orpolicies for which rural areas have beendefined legisla t ively. For example, theMSA/nonMSA designations are used to cate-gorize hospitals as urban or rural areas forpurposes of hospital reimbursement underMedicare. On the other hand, in the case of clinics certified under the Rural HealthClinics Act, “rural” is defined as CensusBureau-designated nonurbanized areas.Certified clinics receive cost-based reim-bursement from Medicare and Medicaid.

These two examples of how the MSA andCensus designations are used are described inmore detail in the following section. Finally,the definition of “frontier” areas is describedas it is used by the Department of Health andHuman Services (DHHS).

Medicare Reimbursement: Using MSAs ToDefine Urban and Rural Areas

Several geographic designations affecthospital reimbursement under Medicare’sprospective payment system (PPS). Different

reimbursement rates are calculated for hospi-tals located in rural, large urban (populationof more than a million), l and other urbanareas. Under PPS, Congress directed theHea l th Care F inanc ing Adminis t ra t ion(HCFA) to define “rural” and “urban” hospi-tals as those located in nonmetropolitan andmetropolitan areas, respectively.2 On aver-age, urban hospital per-case payments are 40percent higher than those of rural hospitals

because of differences in urban and ruralstandardized amounts, average wage andcase-mix indexes, and other factors.

Rural hospitals designated as “sole com-

munity hospitals” are not subject to the samereimbursement methods as other rural hospi-tals. 3 These hospitals are “by reason of fac-tors such as isolated location, weather condi-tions, travel conditions, or absence of otherhospitals, the sole source of inpatient hospitalservices reasonably available in a geographicarea to Medicare beneficiaries.” An excep-tion is also made for large nonmetropolitanhospitals that serve as “rural referral centers”for Medicare patients. These hospitals arereimbursed at the same rate as urban hospitals

(58).

The rural/urban reimbursement differen-tial has not been well-accepted by some hos-pitals. In some cases, the concerns of non-metropolitan hospitals have prompted legis-lators to change the designation of the countyin which the hospital is located from non-metropolitan to metropolitan. The HCFAmetropolitan/nonmetropolitan hospital reim-bursement standards were modified by theOmnibus Reconciliation Act of 1987.4 Somehospitals located in nonMSAs were reassigned

to the urban (MSA) category. Accordingly, ahospital located in a nonmetropolitan countyadjacent to one or more metropolitan area istreated as being in the metropolitan area towhich the greatest number of workers in thecounty commute, if:

s the nonMSA county would otherwise beconsidered part of an MSA area but forthe fact that the nonMSA county doesnot meet the standard relating to the

1 I n Neu E n g l a n d C o u n t y Metropol i t a n A r e a s(MECMAs), a l a r g e u r b a n a r e a i n c l u d e s a p o p u l a t i o nof more than 970,000.

L Certain nornnetropol itan New England count ies weredeemed to be par ts of metropol i tan areas for pur -poses of PPS.

3 T h e p r o s p e c t i v e p a y m e n t r a t e s f o r s o l e cmnun i ty

h o s p i t a l s -al 7 5 p e r c e n t o f t h e h o s p i t a l - s p e c i f i cb a s e p a y m e n t r a t e p l u s 2 5 p e r c e n t o f t h e a p -propr iate regional prospec t ive payment rate (58) .

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

35






er5 (33). Analyses of 1982 data show averagehospital wages in State’s “urbanized ruralcounties” to be 8.5 percent higher than wagesin “other rural counties” ($7.54 v. $6.95) (32).DHHS asserts that wage differentials are al-ready taken into account to some degreethrough other PPS adjustments (i.e., the in-

direct medical education and disproportionateshare adjustments) and the special treatmentfor rural referral centers (53 FR 38498).

ProPAC has also recommended (31,32,33)that defini t ions of urban hospi ta l labormarket areas be modified to include a dis-tinction between an MSA’s central urban andoutlying areas. They suggest that urbanizedareas within an MSA, as defined by theBureau of the Census, could be distinguishedfrom nonurbanized areas. DHHS has rejectedthis proposal, in part because of the difficulty

of assigning a hospital to an urbanized area,the boundaries of which are defined belowthe MSA level. Determining whether or nota hospital is inside or outside of an urbanizedarea involves pinpointing the hospital locationin terms of the smallest units of Census geog-raphy (the block or block group). In a studyconducted for ProPAC ( 1), a process is de-scribed whereby the location of a hospital canbe specified in terms of Census geographyand then mapped to urbanized area bound-aries. According to DHHS, however, defin-ing labor markets below the county levelwould be confusing and difficult to ad-minister.

The Rural Health Clinics Act

Ambulatory services can be reimbursedon an at-cost basis by Medicare and Medicaidif facilities and providers meet certificationrequirements of the Rural Health Clinics Act(Public Law 95-210). To be certified, apractice must be located in a rural area thatis designated either as a health manpower

shortage area (HMSA) or a medically un-deserved area (MUA). The practice mustuse a mid-level practitioner (physician as-sistant or nurse practitioner) at least 60 per-cent of the time that the practice is open.There has been renewed interest in this Actfollowing an increase in the ceiling of rea-

sonable costs reimbursed by Medicare andMedicaid programs. The payment cap is in-dexed to the Medicare Economic Index (36). 6

Rural areas, for purposes of the RuralHealth Clinics Act, are ‘areas not delineatedas urbanized areas in the last census con-ducted by the Census Bureau.” Nonurbanizedareas encompass a larger area than either thenon MSA or Census-defined rural areas.Therefore, Rural Health Clinics can be lo-cated within an MSA (see figure 3) or in anonMSA town with a population of 2,500 or

more (such a town is urban according to theCensus Bureau).

In summary, for purposes of hospitalreimbursement under Medicare, the MSAdesignation is used (with certain specific ex-ceptions) to distinguish urban from rural hos-pitals. Persistent MSA/nonMSA hospital costdifferences have been noted since the PPSrates were first established, but it is likelythat MSA location is an indirect measure of hospital cost. Hospital-specific measures arebeing sought to replace the MSA adjustmentin the PPS formula.

Geographic designations are also used todefine urban and rural labor market areas.Dissatisfaction with having only one rurallabor market area per State (i.e., one labormarket for all non MSA counties) has ledProPAC to recommend two labor marketareas for nonMSA counties. They have sug-gested recognizing as urbanized, nonMSAcounties with a city or town with a popula-tion of 25,000 or greater (33). The average

5 T h i s d e f i n i t i o n o f a n u r b a n i z e d r u r a l c o u n t ys h o u l d n o t b e c o n f u s e d u i t h t h e B u r e a u o f t h eCensus def in i t ion of an urban or urbanized area.

6 T h e s e c h a n g e s t o t h e R u r a l H e a l t h C l i n i c s A c tuere contained i n the Budget Reconc i 1 i at i on Act of1987.






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

( A—- + — ,~

.

SOURCE : U.S. Department of Health and Human Services, Publ ic Heal th Serv ice, Heal th Resources and Serv icesAdminis t rat ion, Bureau of Heal th Profess ions , Of f i ce of Data and Management , Area Resource Fi le,June 16, 1986.



40 • Defining ‘Rural” Areas: Impact on Health Care Policy and Research

Some State Health Departments have hadtrouble identifying service areas meetingthese criteria (26). Whole counties can beidentified as frontier areas on the basis of population density, but available sub-countygeographic units are sometimes inadequate foridentifying health service areas. Populationdata from the 1980 Census are available forsub-county areas such as Census CountyDivisions (CCDs), and Enumeration Districts(EDs) (see appendix D) but these areas can belarge and may not represent a rational healthservice area.10 Z I p C o d e s1 1 m a y b e a g-

gregated to form a rational service area, butthis poses some technical difficulties (19).Following the 1990 Census, Block NumberingAreas will be available for all nonurbanizedareas (see appendix D.--1980 Census geog-raphy).12

10 Some States have def ined pr imary care serv iceareas (e. g. , Neu Y o r k ) .

11 popu la t i on da ta f r om the Census are avai lable byZ I PCode. S o m e i n v e s t i g a t o r s h a v e u s e d ZIPCode-l e v e l c e n s u s d a t a t o d e s c r i b e t h r e e t y p e s o f r u r a larea based upon dens i ty wi th in z ip code: semi - rural( d e n s i t y o f 1 6 t o 3 0 p e r s q u a r e m i l e ) ; r u r a l

( d e n s i t y 6 t o 15 p e r s q u a r e m i l e ; a n d f r o n t i e r(dens i ty less than 6 per square mi le) (10).

12 In 1980, Block Nunber ing Areas were only avai l -a b l e f o r nonurbanized p l a c e s ~ith ov er 10 ,000 pop-u l a t i o n .

It is useful to distinguish frontier areacounties with evenly distributed small settle-ments from counties with one or two largepopulation settlements and large areas withlittle or no settlement. For example, thehealth service needs of two frontier countiesin New Mexico with s imilar populat iondensities differ because of the way the popu-lations are distributed. One county has a to-tal population of approximately 8,000, of whom about 6,000 live in one town. In con-trast, the other county has a total populationof 2,500 living in six widely dispersed towns.If suitable sub-county areas were available,the Hoover Index, which measures populationconcentration or dispersion, could be used todistinguish between these counties. An auto-mated geographic information system calledTIGER (Topologically Integrated GeographicEncoding and Referencing System) has been

developed

13 that will enhance the ability ‘ 0

conduct spatial analyses of population datafrom the 1990 decennial census (23).

13 T I G E R h a s b e e n d e v e l o p e d j o i n t l y b y t h e U . S .G e o l o g i c a l S u r v e y a n d t h e U . S . B u r e a u o f t h ecensus.



8. CONCLUSIONS

The concepts of “rural” and “urban” existas part of a continuum, but Federal policiesgenerally rely on dichotomous urban/ruraldifferences based on designations of the Of-fice of Management and Budget (OMB) orthe Bureau of the Census. OMB’s MSA

designation includes a large population centerand adjacent counties that have a high degreeof economic and social integration with thatcenter. Census’ urban areas include denselysettled “urbanized areas” plus places withpopulations of 2,500 or more outside of ur-banized areas. “Rural” areas are designatedby exclusion: i.e., those areas not classified aseither MSA or urban. About one-quarter of the U.S. population resides in nonMSAs andCensus’ rural areas. The identified popula-tions are different but overlapping. Fortypercent of the 1980 Census’ rural populationlived in MSAs, and 14 percent of the MSApopulation lived in rural areas.

“Nonmetropolitan area,” “rural area,” and“nonurbanized area” have all been used todisplay vital and health statistics or to imple-ment Federal policies. These “rural” defini-tions can be analyzed in terms of how wellthey include “rural areas” and how well theyexclude “urban areas.” For example, we in-tuitively associate farming with “rural” butabout one-fourth of farm residents live in

MSAs (55). Some might argue that isolatedtowns with just over 2,500 residents are in-appropriately excluded from the Census’ ruraldefinition. Others may argue that when non-MSAs are defined as rural, over 100 townswith populations of 25,000 or more are in-appropria te ly included. Moreover, whenMSAs are used to define “urban” in spatiallylarge counties, small towns that are far froman urbanized area are inappropriately calledurban.

Dichotomous measures of urbani ty/ rurality obscure important differences be-tween urban and rural areas and wide varia-tions within a rural area. Consequently, there

have been recommendations to implement astandard rural typology that would capturethe elements of rural diversity and improveuse and comparison of data. Nine county-based rural/urban topologies or classificationschemes that incorporate one or more of the

following measures are reviewed in thispaper: population size and density; proximityto and relationship with urban areas; degreeof urbanization; and principal economy.While a standard typology may seem desir-able, it will be difficult to arrive at, becausethe different topologies are designed andhave merit for various purposes, some of which conflict.

For purposes of health services planningand research, a typology based on largestsettlement size is useful, because the level of available health resources is likely to be re-lated to the size of a city. In spatially smallcounties, large settlements are likely to bequite accessible to all county residents. Inthe West, however, counties can be severaltimes as large as in the East, and somemeasure of proximity would be useful. Ameasure of population concentration and dis-persion, or distance to a large settlement,could serve as an indicator of access to thoseservices. Of the topologies reviewed in thispaper, the one likely to best measure both

level of and access to services is a typologythat incorporates a county’s largest settlementand the county’s adjacency to an MSA.Other topologies that categorize counties ac-cording to employment and commuting pat-terns could be used to refine the definition of labor market areas, an important componentof the Medicare prospective payment system(PPS) formula.

Rural areas are not defined uniformlyfor purposes of Federal program administra-t ion or dis tr ibut ion of funds. Differentdesignations may, in fact, be used by thesame agency. For example, Congress hasdirected the Health Care Financing Adminis-

41




tration to use OMB’s MSA designations tocategorize hospitals as urban or rural for pur-poses of hospital reimbursement under Medi-care, but to use Census’ nonurbanized areadesignation to certify health facilities underthe Rural Health Clinics Act.

The re la t ive meri ts of county-based

topologies for particular applications can beevaluated by using the Area Resource File(ARF), a county-level data base maintainedby the Health Resources and Services Admin-istration. In addition, visual aids such asmaps can effectively serve as an analyticdevice to illustrate geographic variation inheal th s ta tus and access to heal th careresources and could further the developmentand evaluation of topologies. In the spatially

large Western counties, sub-county geo-graphic units need to be employed to helpidentify health service areas with specialcharacteristics such as those that are ‘frontier”(i.e., have 6 or fewer persons per squaremile).

The choice of definition for “rural” that

is used to present demographic and healthdata can make a substantive difference. Forexample, whether a disproportionate numberof rural residents are elderly depends on howrural is defined. Furthermore, wide varia-tions in health status indicators within non-metropolitan areas will not be apparent unlessnonmetropolitan data are disaggregate byregion, urbanization, proximity to urbanareas, or other relevant factors.



APPENDIX A: SUMMARY OF THE STANDARDS FOLLOWED INESTABLISHING METROPOLITAN STATISTICAL AREAS

This statement summarizes in nontechni-cal language the official standards for desig-nating and defining metropolitan statisticalareas. It omits certain exceptions and unusualsituations that are covered in the standards

themselves or in the detailed statement of theprocedures followed in applying the stan-dards.

Population Size Requirements forQualification (Section 1)

To qualify for recognition as a metro-politan statistical area, an area must eitherhave a city with a population of at least50,000 within its corporate limits, or it musthave a U.S. Bureau of the Census urbanized

area of at least 50,000 population, and a totalmetropolitan statistical area population of atleast 100,000. A few metropolitan statisticalareas that do not meet these requirements arestill recognized because they qualified in thepast under standards that were then in effect.

The Census Bureau defines urbanizedareas according to specific criteria, designedto include the densely settled area aroundeach large city. An urbanized area must havea population of at least 50,000. The ur-banized area criteria define a boundary based

primarily on a population density of at least1,000 persons per square mile, but also in-clude some less densely settled areas withincorporate limits, and such areas as industrialparks, railroad yards, golf courses, and soforth, if they are adjacent to dense urban de-velopment. The density level of 1,000 per-sons per square mile corresponds approxi-mately to the continuously built-up areaaround the city, for example, as it would ap-pear in an aerial photograph.

Typically, the entire urbanized area isincluded within one metropolitan statisticalarea; however, the metropolitan statisticalarea is usually much larger in areal extentthan the urbanized area, and includes terri-

tory where the population density is less than1,000 persons per square mile.

Central County(ies) (Section 2)

Every metropolitan statistical area hasone or more central counties. These are thecounties in which at least half the populationlives in the Census Bureau urbanized area.There are also a few counties classed as cen-tral even though less than half their popula-tion lives in the urbanized area because theycontain a central city (defined in Section 4),or a significant portion (with at least 2,500population) of a central city.

Outlying Counties (Section 3)

In addition to the central county(ies), ametropolitan statistical area may include oneor more outlying counties. Qualificationsan outlying county requires a significant levelof commuting from the outlying county tothe central county(ies), and a specified degreeof “metropolitan character.” The specific re-quirements for including an outlying countydepend on the level of commuting of its resi-dent workers to the central county(ies), asfollows:

1.

2.

3.

4.

Counties with a commuting rate of 50percent or more must have a populationdensity of at least 25 persons per squaremile.Counties with a commuting rate of 40to 50 percent can qualify if they have adensity of at least 35 persons per squaremile.Counties with a commuting rate of 25to 40 percent typically qualify throughhaving either a density of at least 50persons per square mile, or at least 35

percent of their population classified asurban by the Bureau of Census.Counties with a commuting rate of 15to 25 percent must have a density of atleast 50 persons per square mile, and in

43



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

addition must meet two of the follow-ing four requirements:

s

s

s

s

the population density must be atleast 60 persons per square mile;at least 35 percent of the populationmust be classified as urban;population growth between 1970 and

1980 must be at least 20 percent; anda significant portion of the popula-tion (either 10 percent or at least5,000 persons) must live within theurbanized area.

There are also a few outlying countiesthat qualify for inclusion in a metropolitanstatistical area because of heavy commuting

from the central county (ies) to the outlyingcounty, or because of substantial total com-muting to and from the central counties.

Central Cities (Section 4)

Every metropolitan statistical area has atleast one central city, which is usually itslargest city. Smaller cities are also identifiedas central cities if they have at least 25,000population and meet certain commuting re-quirements.

In certain smaller metropolitan statisticalareas there are places between 15,000 and25,000 population that also qualify as central

cities, because they are at least one-third thesize of the metropolitan statistical area’slargest city and meet commuting require-ments.

Most places that qualify as central citiesare legally incorporated cities. It is also pos-sible for a town in the New England States,New York, or Wisconsin, or a township inMichigan, New Jersey, or Pennsylvania toqual ify as a centra l c i ty. The town ortownship must, however, be recognized bythe Bureau of the Census as a “census desig-nated place” on the basis of being entirely ur-ban in character, and must also meet certainpopulation size and commuting requirements.

Consolidating or Combining AdjacentMetropolitan Statistical Areas(Sections 5 and 6)

These two sections specify certain condi-tions under which adjacent metropolitanstatistical areas defined by the preceding sec-tions are joined to form a single area. Sec-tion 5 consolidates adjacent metropolitanstatistical areas if their commuting inter-change is at least 15 percent of the numberof workers living in the smaller of the twoareas. To be consolidated under Section 5,each of the metropolitan statistical areas mustalso be at least 60 percent urban, and the to-tal population of the consolidated metropol-itan statistical area must be at least a million.

Section 6 provides for combining as asingle metropolitan statistical area those ad-

jacent metropolitan statistical areas whoselargest cities are within 25 miles of eachother, unless there is strong evidence, sup-ported by local opinion, that they do not con-stitute a single area for general social andeconomic purposes.

Levels (Section 7)

This section classifies the prospectivemetropolitan statistical areas defined by thepreceding sections into four categories basedon total population size: Level A with a mil-lion or more; Level B with 250,000 to a mil-lion; Level C with 100,000 to 250,000; andLevel D with less than 100,000.

Under this section, the metropolitanstatistical areas in Levels B, C, and D (thosewith a population of less than 1 million)receive final designation as metropolitanstatistical areas.

Area Titles (Section 8)

This section assigns titles to the metro-pol i tan s ta t is t ical areas defined by thepreceding sections.




Primary and Consolidated MetropolitanStatistical Areas (Sections 9 through 11)

Within the metropolitan statistical areasclassified as Level A, some areas may qualifyfor separate recognition as primary metro-

politan statistical areas. A primary metro-politan statistical area is a large urbanizedcounty, or cluster of counties, that demon-strates very strong internal economic and so-cial links, in addition to close ties to theother portions of the Level A metro-politanstatistical area.

Section 9 through 11 provide a frame-work for identifying primary metropolitanstatistical areas within metropolitan statisticalareas of at least 1 million population. Ametropolitan statistical area in which primarymetropolitan statistical areas have been iden-

tified is designated a consolidated metro-politan statistical area.

Metropolitan Statistical Areasin New England (Sections 12 through 14)

These sections provide the basic stan-dards for defining metropolitan statisticalareas in New England.

Qualification for recognition as a metro-politan statistical area in New England is onmuch the same basis as in the other States. Afew modifications in the standards are neces-sary because cities and towns are used for thedefinitions. In New England each CensusBureau urbanized area of at least 50,000normally has a separate metropolitan statisti-cal area, provided there is a total metro-politan statistical area population of at least75,000 or a central city of at least 50,000.The total metropolitan statistical area popula-tion requirement is lower than the 100,000required in the other States because the NewEngland cities and towns used in defining

metropolitan statistical areas are much smallerin areal extent than the counties used for thedefinitions in the other States. This makes itpossible to define New England metropolitanstatistical areas quite precisely on the basis of

population density and commuting.

For users who prefer definitions in termsof counties, a set of New England CountyMetropolitan Areas is also officially defined.

However, the official metropolitan statistical

area designations in New England apply tothe city-and-town definitions.

In order to determine the cities andtowns which could qualify for inclusion in aNew England metropolitan statistical area,section 12 defines a central core for eachNew England urbanized area, consisting es-sentially of cities and towns in which at leasthalf the population lives in the urbanizedarea or in a contiguous urbanized area.

Once the central core has been defined,Section 13 reviews the adjacent cities and

towns for possible inclusion in the metro-politan statistical area. An adjacent city ortown with a population density of at least 100persons per square mile is included if at least15 percent of its resident workers commute tothe central core. Towns with a density be-tween 60 and 100 persons per square milealso qualify if they have at least 30 percentcommuting to the central core. However, thecommuting to the central core from the cityor town must be greater than to any othercentral core, and also greater than to anynonmetropolitan city or town.

If a city or town has qualifying commut-ing in two different directions (e.g., to a cen-tral core and to a nonmetropolitan city) andthe commuting percentages are within fivepoints of each other, local opinion is solicitedthrough the appropriate congressional delega-tion before assigning the city or town to ametropolitan statistical area. Some New Eng-land communities also qualify for inclusion in

a metropolitan statistical area on the basis of reverse commuting or total commuting.

Once the qualifying outlying towns andcities have been determined, Section 14qualifies the resulting area as a metropolitanstatistical area provided it has a city of at




least 50,000 or a total population of at least metropolitan statistical areas. It follows the7 5, 00 0. T hi s s ec ti on a ls o s pe ci fi es t ha t s a m e g en e r al a p p r oa c h a s i s u se d f o rseveral of the standards used in the other identifying such areas outside New EnglandStates are also applied to the New England (Section 9). Finally, Section 16 provides thatStates: level and titles for New England primary and

1.

2.

3.

consolidated metropolitan statistical areas areThe central cities of each area are determined by much the same standards asdetermined by Section 4. for the remaining States.

Two adjacent New England metropol-i tan s ta t is t ical areas may be con-solidated under Section 5.New England areas are categorized intolevels according to Section 7A. Thosein Levels B, C, and D are given finaldesignation as metropolitan statisticalareas, and are assigned titles accordingto Section 8.

Primary and Consolidated Metropolitan

Statistical Areas in New England

(Sections 15 and 16)

Section 15 is used to review each LevelA metropolitan statistical area in New Eng-land for the possible identification of primary

Note: OMB is reviewing the MSA standardsand will publish them with some revi-sions before Apr. 1, 1990 (12).

SOURCE: Excerpt from “The Metropolitan

Statistical Area Classification:1980 Official Standards and Re-lated Documents, ” The FederalCommittee on Standard Metro-politan Statistical Areas.



APPENDIX B: THE CENSUS BUREAU’SURBANIZED AREA DEFINITION

The major objective of the CensusBureau in delineating urbanized areas is toprovide abetter separation of urban and ruralpopulation and housing in the vicinity of large cities. An urbanized area consists of a

central city or cities and surrounding closelysettled territory or “urban fringe.”

There are 366 urbanized areas delineatedin the United States for the 1980 census.There are seven urbanized areas delineated inPuerto Rico.

The fo l lowing c r i te r ia a re used indetermining the eligibility and definition of the 1980 urbanized areas.1

An urbanized area comprises an in-corporated place2 and adjacent densely settledsurrounding area that together have a mini-mum population of 50,000. 3 The denselysettled surrounding area consist of:

1. Contiguous incorporated places orcensus-designated places having:

s a population of 2,500 or more; ors a population of fewer than 2,500 but

having either a population density of 1,000 persons per square mile, closely

settled area containing a minimum of 50 percent of the population, or acluster of at least 100 housing units.

2. Contiguous unincorporated area whichis connected by road and has a popula-

] All r e f e r e n c e s t o p o p u l a t i o n c o u n t s a n d d e n s i t i e srelate to data f rom the 1980 census .

z I n H aw a i i , i n c or p o r at e d p la ce s do n o t e xi s t i nt h e s e n s e o f f u n c t i o n i n g l o c a l g o v e r n m e n t a l u n i t s .I n s t e a d , c e n s u s - d e s i g n a t e d p l a c e s a r e u s e d i n

d e f i n i n g a c e n t r a l c i t y a n d f o r a p p l y i n g u r b a n i z e da r e a c r i t e r i a .

3 Th e rural p o r t i o n s o f e x t e n d e d c i t i e s , a s d e f i n e di n t h e C e n s u s B u r e a u t s e x t e n d e d c i t y c r i t e r i a , a r eexc luded f rom the urbanized area. I n a d d i t i o n , f o ran urbanized area to be recognized, i t mus t includea p o p u l a t i o n o f a t l e a s t 2 5 , 0 0 0 t h a t d o e s n o tres ide on a mi l i tary base.

3.

4.

tion density of at least 1,000 personsper square mile.4

Other contiguous unincorporated areawith a density of less than 1,000 per-

sons per square mile, provided that it:s

s

s

eliminates an enclave of less than 5square miles which is surrounded bybuilt-up area;closes an indentation in the boundaryof the densely settled area that is nomore than 1 mile across the open endand encompasses no more than 5square miles; andlinks an outlying area of qualifyingdensity, provided that the outlyingarea is:

--connected by road to, and is notmore than 1½ miles from, the mainbody of the urbanized area; and

--separated from the main body of the urbanized area by water orother undevelopable area, is con-nected by road to the main bodyof the urbanized area, and is notmore than 5 miles from the mainbody of the urbanized area.

Large concentrations of nonresidential

urban area (e.g., industrial parks, officeareas, and major airports), which haveat least one-quarter of their boundarycontiguous to an urbanized area.

d Any area of extensive nonresidential urban landme, (e.g., ra i l road yards, a i rports , factor ies,parks, golf c o u rs es , a n d c em et e ri e s) i s e x c lu d ed i nc omput i ng t he popu la t i on dens i t y .

Note: The Census Bureau is reviewing theurbanized area rules and will publishthem with some revisions by 1990.

SOURCE: Excerpt from 1980 Census of Population Vol. 1, Characteristicsof the Population, Appendix A.Area Classifications.

47



APPENDIX C: CENSUS GEOGRAPHY

CENSUS GEOGRAPHY-CONCEPTS

INTRODUCTION

It is important for anyone using cen-

sus data to be aware of the geographic

concepts involved in taking the census

and allocating the statistics to States,

counties, cities, and smaller areas downto the size of a city block. Preparing for

and taking a census also results in a

number of geographic tools or products

that are helpful to the data user as well

as to the Census Bureau, in activities

such as computerized location coding,mapping, and graphic display. They also

allow users to interrelate local and cen-

sus statistics for a variety of planning

and administrative purposes. This Fact-

finder explains the Census Bureau’s

geographic concepts and products.

Except where noted, the definitions

and references below are those used for

the 1980 Census of Population and

Housing. Figure 10 on page 6 sum-

marizes the geographic areas for which

data are available from other Bureau

censuses and surveys.

Data summarizes are presented in

printed reportsm , microfichem, and

computer tapes @ and flexible dis-kettes K , based on tabulations for the

geographic and statistical levels

d i s c u s s e d b e l o w . M a p s El are a l s o

available. The symbols q and +, keyed

to the legend on page 3, indicate how to

obtain the items described in this

brochure.

REPORTING AREAS

There are a number of basic relation-

ships, illustrated below, among the

geographic areas the Census Bureauuses as “building blocks” in its reports.

Some of the areas are governmental

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

other areas are defined specifically for

statistical purposes. (The statistical

areas are italicized in the diagrams; all

others are governmental.)

United States-The 60 States and theDistrict of Columbia. (Data also arecollected separately for Puerto Rico

and the outlying areas under U.S.sovereignty or jurisdiction.)

Regions/divisions-There are four

Census regions defined for the United

States, each composed of two or more

geographic divisions. The nine divi-

48

Figure 1. CENSUS REGIONS AND GEOGRAPHIC DIVISIONSOF THE UNITED STATES

q The Midwest Region was designated as the

North Central Region until June 1984.

sions are groupings of States. (See

fig. 1.)

•

q

q

Governmental units of the Nation—

States (50) and the District of

ColumbiaCounties and their equiva lents (3,139,plus 78 in Puerto Rico)Minor civil divisions (MCD’s) of coun-

ties, such as t o w n s and t o w n s h i p s

( a p p r o x i m a t e l y 25,000)Incorporated places (about 19,100),e.g., cities and villagescensus county divisions (CCD’s)-In20 States where MCD’s are not ade-quate for reporting subcounty censusstatistics, Bureau and local officials

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

purpose.•Census designated places (CDP’s)–Formerly referred to as “unincor-

porated places,” CDP’s (about 3,500)are closely settled population centers

without legally established limits,

delineated with State and local

assistance for statistical purposes,and generally have a population of at

least 1,000.

Figure 2. NATIONAL GEOGRAPHICRELATIONSHIPS

Nation

IRegions

Divisions

places’ des i g na t e d

p l a c e s ”

Counties

Minor civil census

divisions

/

county

divisions

districts

or block

groups

a Note that places (incorporated and censusdesignated] are not shown within the countyand county subdivision hierarchy, sinceplaces may cross the boundaries of these

areas. A few census reports and tape seriesdo show places within MCD or CCD withincounty, but in these cases data pertain onlyto that part of a place which is within a

Particular higher-level area. Enumerationdistrict and block-group summaries do racog-

nize place boundaries, making ED’s andBG’s important as the Iotwrst common de

nominator for the higher-lwel entities.




q

q

q

q

q

q

q

Census tracts –These statistical sub-

divisions of counties (approximately43,350, including 463 in Puerto Rico),

average 4,000 inhabitants. They are

delineated (subject to Census Bureau

standards) by local committees for

metropolitan areas and roughly 200other counties.

Blocks–Generally bounded by

streets and other physical features,blocks (approximately 2.5 million) areidentified (numbered) in and adjacentto urbanized areas, most incor-porated places of 10,000 or more

population, and other areas that con-

tracted with the Census Bureau tocollect data at the block level. (Fig.

8 illustrates the extent of block-statistics coverage in part of a State.)Five States are completely block-numbered.Block-numbering areas (BNA’s)–

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

defined for the purpose of grouping

and numbering blocks where censustracts have not been established.

Block groups (BG’s)–Subdivisions

of census tracts or BNA’s, BG’s

(about 200,000) comprise all blockswith the same first digit in a tract or

BNA. Averaging 900 population,

BG’s appear in areas with numberedblocks in lieu of ED’s (see below) fortabulation purposes.

Enumeration districts (ED’s)–AnED is a Bureau administrative area

assigned to one census enumerator.ED’s (about 100,000 nationwide)

were used for census tabulation pur-

poses where census blocks were notnumbered. ED size varies con-siderably, but averages 500

inhabitants.

Metropolitan Areas

Standard metropolitan statisticalareas (SMSA‘s)-An SMSA (definedby the Office of Management andBudget) comprised one or more coun-

ties around a central city or urbaniz-ed area with 50,000 or more in-

habitants. Contiguous counties were

included if they had close social and

economic links with the area’spopulation nucleus. There were 323SMSA’s, including 4 in Puerto Rico.

Standard consolidated statistical

areas (SCSA‘s)--SCSA’s (17, in-cluding 1 in Puerto Rico) were com-posed of two or more adjacentSMSA’s having a combined popula-tion of 1 million or more, and with

close social and economic links.

After the relationships between central

urban core(s) and adjacent counties were

Figure 3. GEOGRAPHICRELATIONSHIPS IN AN MSA

MSA

IMetropolitan

groups districts

IBlocks

a In New England, MSA’S are defined in

terms of towns and cities, rather than munties(as in the rest of the country),

b Cen5us tr~ts subdiv ide moat MSAcounties as wel I as about 20I3 other cou ntiea,

As tracts may cross MCD and place bound-

aries, MCD’S and places ar e not shown in

this hierarchy,

analyzed on the basis of the 1980population census and a revised set of

criteria, these areas were redefined andthe word “standard” was dropped from

the titles. Thus, on June 30, 1983,SMSA’s and SCSA’s were redesignated

as

. Metropolitan statistical areas

(MSA'S)

qConsolidated MSA's (CMSA's)and

q Primary MSA (PMSA's)

As the 1982 Economic Censuses

covered calendar year 1982, prior to theJune 1983 date for adopting thechanges, the 1982 SMSA and SCSA

designations and nomenclature were re-tained for those censuses. Some data

from the 1980 Census of Population andHousing were retabulated by MSA andissued in special reports, and the new

definitions were used in preparing

population and migration estimates and

in presenting current statistics from1983 onward.

q

q

q

Urbanized areas (UA's)–A UA (themare 373, including 7 in Puerto Rico)consists of a central city and

surrounding densely settled territory

with a combined population of 50,000

or more inhabitants. (See fig. 5)Metropolitan/nonmetropolitan–

“Metropolitan” includes all popula-tion within MSA’s; “nonmetropoli-

tan” comprises everyone elsewhere.Urban/rural-The urban populationconsists of all persons living in ur-

banized areas and in places of 2,500

or more inhabitants outside these

areas. All other population isclassified as rural. The urban and

rural classification cuts across the

Figure 4. URBAN/RURALGEOGRAPHIC RELATIONSHIPS

/ ALL AREAS

Urban

/ \ Urbanized O t h e r R u r a l Rural

Central Urban Rural Other

cities fringe places’ rural

nonfarm

a Inc lude s bo th gov e r nme nta l a nd s ta -

tistical units.

other hierarchies; there can be bothurban and rural territory withinmetropolitan as well as nonmetro-politan areas.

There are other geographic units forwhich data may be obtained from the1980 Census of Population and Hous-

ing. Some appear in regular publications

and data files: American Indian reser-vations (278, both State and Federal, in-

cluding 3 administered by or for morethan one tribe), Alaska Native villages

(209), congressional districts (435), andelection precincts in some States. Data

are prepared for neighborhoods inalmost 1,300 areas and by ZIP Code

areas nationwide. Data for other areas

are generated in special tabulationsprepared at cost, for example, schooldistricts.

Two types of areas are definedspecifically for the economic censuses:

q central business districts (CBD’s)CBD’s are areas of high land value,

traffic flow, and concentration of retail businesses, offices, theaters,hotels, and service establishments. In

the 1982 Census of Retail Trade, 456CBD’s were defined in (1) any SMSA

central city and (2) any other citywith a population of 50,000 or more

and a sufficient concentration of

economic activity. CBD’s also areshown in place -of-work data from the

1980 Census of Population andHousing.

qMajor retail centers (MRC’s)-MRC’Oare concentrations of retail storeslocated in SMSA’s, but outside theCBD’s. For 1982, 1,545 MRC’s weredefined areas with at least 25 retail

establishments and one or more largegeneral merchandise or department

stores.






The Bureau collects and publishes datafor two kinds of sub-state areas:

Governmental, such as--incorporated places (e.g., cities, villages)and minor civil divisions (MCDs) of counties (e.g., townships),congressional districts and electionprecincts, andAmerican Indian reservations and AlaskaNative villages.

Statistical, including--standard metropolitan statistical areas(SMSAs) and standard consolidatedstatistical area (SCSAs) were used in the1980 decennial and 1982 economiccensuses. In 1983, SMSAs and SCSAswere replaced by metropolitan statisticalareas (MSAs), primary MSAs (PMSAs),

and consolidated MSAs (CMSAs);census county divisions (CCDs) in Stateswhere MCD boundaries are not satisfac-tory for statistical purposes;census-designated places (formerly called“unincorporated places”);urbanized areas;census tracts (subdivisions of counties,primarily in metropolitan areas) andblock numbering areas (BNAs), averag-ing about 4,000 people each;census blocks- -generally equivalent tocity blocks in cities, but are very large

in rural areas;enumeration districts (EDs)--census ad-ministrative areas, averaging around 700inhabitants, used where block statisticsare not available;block groups (BGs)--counterparts to EDsaveraging 900 population, in areas withcensus blocks;neighborhoods --subareas locally definedby participants in the Bureau’s Neigh-borhood Statistics Program; andZIPCodes--Postal Service administrative

areas independent of either governmen-tal or other statistical units.

In the 1982 Census of Retail Trade, theBureau published data for central businessdistricts (CBDs) and major retail centers

(MRCs) outside CBDs; in the Census of Gov-ernments, for school districts and other spe-cial districts; and in foreign trade and inter-national research, for countries and worldareas.

Generally, survey data are published onlyfor the larger areas, such as the United

States, its regions, and some States, whilecensus data are made available for smallerareas as well.

Population and Housing

The decennial census of population andhousing is the most important source of datafor small communities, not only on a widevariety of subjects but in finer geographicdetail than from any other statistical base. Itprovides a uniform set of data for inter-community comparisons as well.

Table A-1 shows the items collected inthe census. The basic data, called “completecount” or “100 -percent,” come from the ques-tions asked for every person and housingunit. Other items are obtained only at asample of households and housing units inorder to keep response burden to a minimum.

The 100-percent data provide the basicpopulation and housing counts and certaincharacteristics -- e.g., age, sex, and race forpeople; and value or rent, and vacant or oc-cupied status for housing units--for all tabu-lation areas, even down to census blocks.Since they are estimates rather than completecounts, the sample statistics for small com-munities must be used with caution.

In general, the higher the geographic orstatistical level of tabulation, the greateramount of detail there is available in thecensus reports. With respect to small com-munities, more data usually are contained inthe printed reports at the county level than

for the county subdivisions and places. (Thisdifference seldom occurs on summary tapefiles or selected microfiche). Only limitedcounty- and subcounty-level data are avail-able on flexible disket tes and throughCENDATA.




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

100-percent population itemsH o u s e h o l d r e l a t i o n s h i pSexRace

AgeM a r i t a l s t a t u sSpanish/Hispanic or ig in or descent

a

Sample population itemsSchool enrol lmentEducat ion at ta inmentState or fore ign count ry of b i r thCi t i zenship and year of immigrat ionCur rent language and Engl ish prof ic iencyAncestry b

Place of residence 5 years agoAct iv i ty 5 years agoVeteran s tatus and per iod of serv iceP r e s e n c e o f d i s a b i l i t y o r h a n d i c a p

a

Chi ldren ever bornM a r i t a l h i s t o r yEmployment status last weekHours worked last weekPlace of workTravel t ime to work

b

Means of t ranspor tat ion to worka

Persons in carpool b

Year last workedI n d u s t r yOccupat ionClass of workerAmount of income by source in 1979

a

Work in 1979 and weeks looking for work in 1979a

100-percent housing itemsNumber of housing units at addressC o m p l e t e p l u m b i n g f a c i l i t i e sNumber of rooms in uni t

Tenure (whether the uni t i s owned or rented)C o n d o m i n i u m i d e n t i f i c a t i o nValue of home ( f o r owner-occupied uni ts and condominiums)R e n t ( f o r r e n t e r - o c c u p i e d u n i t s )V a c a n t f o r r e n t , f o r s a l e , e t c . , a n d p e r i o d o f v a c a n c y

Sample housing itemsNumber of uni ts in s t ruc tureStor ies in bui ld ing and presence of e levatorY e a r u n i t b u i l tYear moved into th is housea

Source of waterSewage disposalHeating equipmentFuels used for home heat ing, water -heat ing, and cook ingC o s t s o f u t i l i t i e s a n d f u e l s

a

Complete k i tchen faci l i t ies

Numbet of bedrooms and bathroomsTelephoneA i r c o n d i t i o n i n gNumber of automobilesNumber of l ight t rucks and vans

b

Homeowner shelter costs for mortgage,real estate taxes, and hazard insurance b

~Changed r e l a t i v e t o 1970.Neu

i tem for 1980.

Derived items (illustrative examples)

Fami l i es Household sizeFami l y t ype and s i ze Persons per room (“ overcrowding" )Family income I n s t i t u t i o n s a n d o t h e r g r o u p q u a r t e r sP o v e r t y s t a t u s Farm residencePopulat ion dens i ty

Note : Th i s i n f o rmat i on per t a i ns t o t he 1980 c ens us and does no t r e f l ec t c hanges i n da ta p res en ta t i on anda v a i l a b i l i t y f o l l o w i n g t h e 1 9 9 0 c e n s u s .

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

CFF No. 22 (Rev.) January 1986.



APPENDIX D: RURAL HEALTH CARE ADVISORY PANEL

James Bernstein, Panel Chair Director, Office of Health Resources DevelopmentNorth Carolina Department of Human Resources

Robert BerglandExecutive Vice President and General ManagerNational Rural ElectricCooperative Association

Washington, D.C.James ColemanExecutive DirectorWest Alabama Health Services, Inc.

Sam CordesProfessor& HeadDepartment of Agricultural EconomicsUniversity of Wyoming

Elizabeth DichterSenior Vice President for Corporate StrategiesLutheran Health Systems

Denver, ColoradoMary EllisDirectorIowa Department of Public Health

Kevin FickenscherAssistant Dean and Executive DirectorMichigan State UniversityCenter for Medical StudiesKalamazoo, Michigan

Roland GardnerPresident

Beaufort-Jasper (South Carolina)Comprehensive Health Center

Robert GrahamExecutive Vice PresidentAmerican Academy of Family PhysiciansKansas City, Missouri

Alice HershExecutive DirectorFoundation for Health Services ResearchWashington, D.C.

David Kindig

DirectorPrograms in Health ManagementUniversity of Wisconsin - Madison

Advisory Panel members provide valuableHowever, the presence of an individual on theagrees with or endorses the conclusions of this

T. Carter Melton, Jr.PresidentRockingham Memorial HospitalHarrisonburg, Virginia

Jeffrey MerrillVice PresidentRobert Wood Johnson FoundationPrinceton, New Jersey

Myrna PickardDeanSchool of NursingUniversity of Texas - Arlington

Carolyn RobertsPresidentCopley Health Systems, Inc.

Morrisville, VermontRoger RosenblattProfessor& Vice ChairmanDepartment of Family MedicineUniversity of Washington

Peter SybinskyDeputy Director for Planning,Legislation, and Operations

Hawaii Department of Health

Fred TinningPresident

Kirksville College of Osteopathic MedicineKirksville, Missouri

Robert VraciuVice PresidentMarketing& PlanningHealthTrust, Inc.Nashville, Tennessee

Robert WalkerChairmanDepartment of Family andCommunity Health

Marshall University School of MedicineHuntington, West Virginia

guidance during the preparation of OTA reports.Advisory Panel does not mean that individualparticular paper.

53



APPENDIX E: ACKNOWLEDGMENTS

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

Paul AndersonBureau of Emergency Medical ServicesBoise, Idaho

Susan BakerThe Johns Hopkins UniversitySchool of Hygiene and Public HealthBaltimore, Maryland

Keith BeaCongressional Research ServiceWashington, DC

Calvin BealeEconomic Research ServiceU.S. Department of AgricultureWashington, DC

Viola BehnNew York Department of HealthAlbany, New York

Richard BohrerDivision of Primary Care ServicesHealth Resources and Services AdministrationRockville, Maryland

James T. Bonnen

Department of Agricultural EconomicsMichigan State UniversityEast Lansing, Michigan

Don DahmannPopulation DivisionU.S. Bureau of the CensusWashington, DC

Robert DawsonNational Rural Health NetworkNational Rural Electric Cooperative AssociationWashington, DC

Diana DeArePopulation DivisionU.S. Bureau of the Census

Washington, DC

Denise DentonRural Health Office

University of ArizonaTucson, Arizona

Terry DimonMemorial Hospital of Laramie CountyCheyenne, Wyoming

Gar ElisonCommunity Health Services

Utah Department of HealthSalt Lake City, Utah

Bob EriksonDepartment of GeographyUniversity of Maryland, Baltimore CountyBaltimore, Maryland

Richard L. Forstall

Population DivisionU.S. Bureau of the CensusWashington, DC

George GarnettNational Association of EMS PhysiciansSoldotna, Alaska

Wilbert Gesler

Department of GeographyUniversity of North CarolinaChapel Hill, North Carolina

Maria GonzalesOffice of Management and BudgetWashington, DC

54




Mary GoodwinDepartment of AgricultureAustin, Texas

Rena Gordon

Phoenix Rural Health OfficePhoenix, Arizona

John JohnsonPorter Memorial HospitalValparaiso, Indiana

Harvey LichtNew Mexico Health andEnvironment Department

Santa Fe, New Mexico

David McGranahan

Economic Research ServiceU.S. Department of AgricultureWashington, DC

Carol MillerMountain ManagementOjo Sarco, New Mexico

Steven PhillipsNational Governor’s AssociationWashington, DC

Jerome PickardAppalachian Regional CommissionWashington, DC

Stuart A. ReynoldsNorthern Montana Surgical AssociatesHavre, Montana

Steven RosenbergSalinas, California

Howard V. StamblerBureau of Health Professions

Health Resources and Services AdministrationRockville, Maryland

Jack L. StoutThe 4th Party Inc.Miami, Florida

Elsie M. SullivanDivision of Primary Care ServicesHealth Resources and Services AdministrationRockville, Maryland

Tom Swan

Rural E.M.S. Development ServiceCrested Butte, Colorado

Robert T. Van HookNational Rural Health AssociationKansas City, Missouri

John WardwellWashington State UniversityPullman, Washington

Barbara WynnBureau of Eligibility, Reimbursement,and Coverage

Health Care Financing AdministrationBaltimore, Maryland

Thomas C. RickettsHealth Services Research CenterUniversity of North CarolinaChapel Hill, North Carolina



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0