Date:
Duration: approximately
minutes
Featured Speakers
|
Sarah Heppner, MS, Associate Director, Federal Office of Rural Health Policy |
|
Greta Stuhlsatz, PhD, Statistician, Federal Office of Rural Health Policy |
In 2025, many agencies across the federal government
released new data allowing users to understand how rural
populations and areas are changing. This webinar will
provide a brief history of rural population over time and
review how the term “rural” is defined. Presenters from
the Federal Office of Rural Health Policy (FORHP) will
focus on how FORHP compiles information from the Census
Bureau, the Office of Management and Budget (OMB), and
the United States Department of Agriculture (USDA)
Economic Research Services (ERS) to identify rural areas
in the United States for rural health grant program
eligibility. Changes to rural areas, as identified by
FORHP with their most recent September 2025 data release,
will be highlighted.
From This Webinar
Transcript
Kristine Sande: Hello, everyone. I’m
Kristine Sande, and I’m the program director of the Rural
Health Information Hub. I’d like to welcome you to
today’s webinar. And today, we’re going to be discussing
federal rural definitions.
And now it is my pleasure to introduce our speakers for
today’s webinar. Sarah Heppner serves as the associate
director of the Federal Office of Rural Health Policy in
the Health Resources and Services Administration of the
U.S. Department of Health and Human Services. In this
role, Sarah provides programmatic, policy, and
operational support for the office. Sarah has been with
FORHP since 2012, serving as the research coordinator,
the deputy director of the Office for the Advancement of
Telehealth, and the director of Policy Research Division
prior to her current role. She has an undergraduate
degree in chemistry from Wells College and a master’s in
clinical and translational research with a concentration
in research management from the University of Vermont.
Greta Stuhlsatz is a statistician with the Federal Office
of Rural Health Policy. She supports data activities for
the office, including analysis, evaluation, and
visualizations. She has worked for the federal government
since 2021 and previously worked for a research and
capacity building center in Kansas.
And with that, I’ll turn it over to Sarah.
Sarah Heppner: Thank you so much to
everyone who’s either joining us live today or who may be
watching the recording later on. I really appreciate you
taking time out of your busy schedules to be able to
learn a little bit more about how FORHP defines rural and
the role that plays in some of the work that we do in the
office.
All right. So, what I’m going to do before I turn things
over to Greta, who is one of the brains behind all of the
data and analysis that happens, is just talk a little bit
about the Federal Office of Rural Health Policy, why we
exist, and why having a rural definition is very
important to us in the work that we do.
So, for those of us who may not be familiar, we are the
Federal Office of Rural Health Policy. Our acronym is
FORHP. That’s the fun, quirky way that we shorthand our
name. And our goal is to collaborate with rural
communities and partners to support community programs
and provide technical assistance to improve health in
rural America.
So, what does that actually mean? There’s really three
main buckets that our work falls into. And the first is
to be the voice for rural across HHS. When our office was
established back in 1987, that was one of the things that
they wrote into our authorizing legislation, is that they
wanted us to advise the Secretary primarily on the
effects of Medicare and Medicaid policy on rural
communities and folks who provide care in rural
communities. So, we use that to be able to just make sure
that we are amplifying the voices of rural Americans and
to make sure that we are raising our hand when we think
something is going to impact rural communities in a
different way than it will their urban or suburban
counterparts.
The next piece and why we are sort of located in HRSA, in
the Health Resources and Services Administration, rather
than being part of, say, the secretary’s office or being
part of our colleagues at CMS, is that we are a
grantmaking office. And so we are located in HRSA, which
is a grantmaking agency. And that’s the red column that
you can see on the slide here, where our goal is to use
the money that Congress has appropriated to us and the
programs that we create and that are authorized under our
various authorities to increase access to healthcare for
people in rural communities. And that happens at the
state level, that happens at the community level, and
that happens in the grants and cooperative agreements
that we’re able to fund to provide technical assistance,
research, resource development, things like our
colleagues and friends at RHIhub, to make sure that we
are giving folks access to the information they need to
do important work in rural communities.
And then the last piece is this cross-agency
collaboration, technical assistance that we do, where we
work across HRSA, we work across HHS, and we work across
other parts of the federal government to make sure that
we can help folks reach their goals and make sure that
rural can be included as a consideration whenever
possible. We joke around that we will be friends with
anybody, we will collaborate with anybody if it helps to
further the ability to increase access in rural
communities.
So, one of the things that’s really important about our
ability to do this work and that Greta’s going to be
diving more into in a few minutes is, so how do we define
rural? And what’s important about having a national
definition for rural? What are the things we need to take
into consideration to make sure that we are targeting
grant dollars to communities that are rural and to make
sure that we are accurately defining and representing
within the data we have accessible to us what rural
communities look like compared to their counterparts in
urban and suburban areas?
So, with that, I’m going to turn things over to Greta for
the actual reason you all are here, which is to learn
more about this topic.
Greta Stuhlsatz: Thank you, Sarah, for
that great introduction. I had also some notes for this
slide if I had to do it, and I’m glad I didn’t because
you did a much better job than I would have for
explaining our office.
So, I just want to highlight one more time what Sarah
said about this map here. This is kind of a spoiler alert
of what we’re going to be going into today. This shows
all the areas in the U.S. that are considered rural, and
it’s all this blue area is rural and this white area is
not rural.
So, again, my name is Greta Stuhlsatz. I’m a statistician
with the Federal Office of Rural Health Policy. And I’m
really excited to chat with you today about rural
definitions.
So, here’s a little overview as a roadmap of what we’re
going to talk about today. I’ll start off with a little
information about why rural definitions matter. And then
we’ll look at some graphs showing rural changes over
time. Then we’ll get into the meaty part of the
presentation, which talks about who defines rural, and
I’ll focus on the Census Bureau, the Office of Management
and Budget, the Federal Office of Rural Health Policy,
that’s us, and the United States Department of
Agriculture Economic Research Services. We’ll dive a
little deeper to highlight and explain our rural
designation process. And then we’ll go over some useful
tools. I do have some final slides that are some other
definitions of rural from other federal agencies that we
aren’t going to dig into. We might have time to go over
them at the end, but the slides will be there for you to
peruse if we don’t get to them. There’s some maps and
some explanations of how they are defined.
So, let’s start with a little level-setting of why
defining rural even matters. Congress directs funding
specifically to rural communities and for rural issues.
With this funding, programs focus on rural populations
that they have to define in some way. They have to rely
on some kind of criteria to determine who is eligible to
receive these federal resources. Sometimes the term rural
is defined in statute, while there are other situations
where agencies have a little more flexibility to set
their own definitions. And when we talk about rural, it’s
very important to know who we’re talking about and how
many people live in rural areas.
So, the charts on these next two slides show different
cuts of the population by urban and rural. For now, we’re
just going to look at the population as determined by the
Census Bureau. We’re going to keep it simple for now
before we dig in. The first chart shows the share of the
U.S. population that is urban compared to rural from 1790
to 2020. The red line indicates the rural share of the
population and the blue line is urban. You can see that
in 1790, when the first census was taken, the share of
the population that was rural was much greater. Urban
areas held only about 5% of the population and rural
areas held about 95%. And up until around 1920, there
were more people in rural areas than in urban areas. You
can see the lines crossing in 1920. And then after that
year, there was a greater proportion of the population
living in urban areas. In 2020, about 20% of the
population in the United States is rural and 80% of the
population is urban.
Now, as many of you are likely aware, the rural
population is not declining. This chart shows the
population by the numbers rather than percentages of the
whole U.S. population. Urban is, again, shown in blue and
rural is shown in red. Both populations have generally
continued to increase with each decennial census. You can
see in this chart that prior to 1880, there were fewer
than 50 million people in the U.S. But as that’s grown,
the population in both rural and urban areas have grown.
With the 2020 census, the urban population was a little
over 265 million, and the rural population was about 66.3
million. So, no matter how you look at these numbers,
there is a substantial number of people in rural areas
who can benefit from federal resources.
So, the numbers we just looked at show the rural and
urban population according to the Census Bureau. They
maintain the official population count of the United
States. But I want to talk a little bit more about who
else defines rural. As I said, we’re going to focus today
on the Census Bureau, the Office of Management and
Budget, the U.S. Department of Agriculture’s Economic
Research Services, but there’s many, many others. The
rural delineations used by these entities feed into the
definitions that we use. So they’re most helpful in
understanding the Federal Office of Rural Health Policy’s
definition, but this list is not exhaustive. In fact,
there’s so many definitions of rural in the federal
government that the Washington Post ran an article a few
years ago about how many definitions there are, and the
article listed about 12 to 17 definitions. But depending
on what exactly you’re looking at for defining rural,
there can be even more definitions because statute may be
even more specific. And I’ll talk a little bit about why,
while this may be an annoying feature, it’s a necessary
part of how we provide services.
So, let’s look first at the Census Bureau definition that
was used for the charts you saw. They use census blocks,
which are the smallest geographic census unit, and these
are subunits of census tracts, which are even smaller
than counties. Census blocks are grouped into urban areas
that are considered densely developed territory, and they
encompass residential, commercial, and other
non-residential urban land uses. For the census, rural,
then, is the absence of an urban area, so all population,
housing, and territory not included within an urban area.
And the urban areas are updated with every decennial
census, so about every 10 years. A census urban area
comprises a densely settled core of census blocks that
encompass at least 2,000 housing units or a population of
at least 5,000. On the next couple slides, we’ll look at
some maps to see what this looks like on a national
scale.
Here’s the map of the 2020 Census Bureau areas, urban
areas. The purple splotches and dots, those are my words,
not the census’s, represent urban areas. Some are large,
like the shapes in Minneapolis, Seattle, or around New
York City, while others are very small, like the dots
speckled around Montana and Wyoming.
The next slide shows a zoomed-in version of the Census
Bureau’s wall map showing the Washington, Arlington,
DC-Virginia-and-Maryland urban area. As you can see, the
urban areas can cross state boundaries. In this map, you
can also see some differences in how the urban areas are
represented. These small dots are urban areas with a
population less than 10,000, and the large, what I’m
calling splotches, because of their irregular geographic
shape, are urban areas that represent a population of
10,000 or more.
So, the next agency I’m going to talk about for their
definition is the Office of Management and Budget. They
take a similar approach as the census, but they add a
little bit more detail and they take it up to the county
level. So they consider commuting patterns, economic
movement, and proximity to metropolitan counties. They
define Core Based Statistical Areas, or CBSAs, which are
county or counties associated with at least one core of
at least 10,000 people, and then the adjacent counties
that have a high degree of integration with that core.
And I’ll show you a map in a second, in case you want a
little more of a visual.
There’s two types of cores. There’s either metropolitan,
which has a core of 50,000 or more people, or it could be
a micropolitan core, which has a core of between 10,000
but less than 50,000. So the metropolitan cores are large
population centers, and then the micropolitan cores are
still large population centers, but definitely smaller
than the metropolitan ones.
Counties are then determined to be either central or
outlying based on settlement patterns, where people live,
and their integration to other areas based on the
commuting patterns to where they work. Greater population
percentages and a greater integration into the urban core
will make the county qualify as a central county.
So, this is an example in Kentucky. For those of you that
like the visual, this is a Core Based Statistical Area.
And these are the Core Based Statistical Areas that are
relevant to Kentucky. So, if we look at the one at the
top here, this is the Cincinnati-Wilmington-Maysville
CBSA, and this is a good example because it shows that
some of the Core Based Statistical Areas can cross state
lines. This one includes at least one county in Indiana,
Kentucky, and Ohio. The dark green indicates counties
that are metropolitan. And the light green indicates
counties that are micropolitan.
So, in this example, the Cincinnati-Wilmington-Maysville
example on the top, all of the counties are metropolitan
except Mason down here in the bottom right, that light
green one.
So, the following map shows what we looked at in
Kentucky, but on a national scale. And then this one only
highlights in purple the metropolitan counties. Many
reports and documents will talk about metropolitan and
non-metropolitan counties. And typically, this means
they’re using the OMB delineations and separating out the
metropolitan counties that have that large population
core from the non-metropolitan counties. And in this
case, non-metropolitan counties include the micropolitan
counties and what we would call non-core counties that
aren’t included in OMB’s lists to show metropolitan and
micropolitan. So, in this map, all the purple areas are
metropolitan, and then these beige or gray are
non-metropolitan. So they could either be micropolitan or
non-core.
I talked about two pretty good definitions. And so, you
may be thinking, “With the definitions that already
exist, why does the Federal Office of Rural Health Policy
need to create another one?” And there are a few reasons.
One is that many of these definitions focus on urban
areas and then consider rural areas as other or what’s
not looked into. So the Federal Office of Rural Health
Policy tries to focus on identifying areas that are
rural. Our focus is on rural, not necessarily focusing on
urban and then everything else being considered rural.
Rural also means different things to different programs
or for different research topics, and we need different
ways to talk about rural.
So, why don’t we use OMB’s county designations? One of
the reasons we don’t use county designations is that
counties are very large, especially counties west of the
Mississippi. If we depend on county classifications, we
may miss smaller areas within larger counties that don’t
have access to as many resources. The example here shows
San Bernardino County, which is a large county in
Southern California. According to OMB, this is a
metropolitan county, and that’s likely because the
southwest corner of the county dips into Los Angeles and
Long Beach, which is an urban area. However, this county
is over 2,000 square miles. The folks in the gray area on
the map might not have access to the same resources as
those closer to Los Angeles would. So the gray area in
this map is considered rural by the Federal Office of
Rural Health Policy. And again, we’ll get into that more
as I go through these slides.
So, the counties are too big. Why don’t we focus on
something smaller? I’ve talked about the census urban
areas, and they’re a smaller level of geography, based on
census blocks. So why don’t we use that? Well, urban
areas cross state and county lines, making it
administratively difficult to use in identifying rural
areas in a way that will be useful for program
implementation. So what we try to do is we bring all of
the information from many useful resources together in a
way that allows us to identify rural areas to enhance
access to critical initiatives and programs.
I want to take a moment to talk about something called
the Goldsmith Modification. In 1992, the Goldsmith
Modification was outlined in legislation as a way to
identify rural areas within metropolitan counties. Today,
the Federal Office of Rural Health Policy works with the
USDA Economic Research Services to develop tools to help
identify census tracts that are rural within metropolitan
counties. The way we identify these areas is considered
the current implementation of the Goldsmith Modification.
So, you can see again in this map, all these purple areas
with the lighter blue lines, those are boundaries for
census tracts, and those are considered rural with the
current implementation of the Goldsmith Modification in
this larger metropolitan county.
So, I mentioned the Economic Research Services with the
USDA. They developed the Rural-Urban Commuting Area codes
in partnership with FORHP. These are classified by census
tract, mirroring the theoretical concept used by OMB. OMB
is the Office of Management and Budget. They consider
population density, urbanization, and daily commuting.
There are 10 primary and 21 secondary codes that are
designed to be used in different ways depending on
research and program needs. They’re designed using census
tract data, but there’s also ZIP code approximation files
for users. The Federal Office of Rural Health Policy uses
the census tract information.
So, this map shows the RUCA codes. The black to gray
scale shows metropolitan census tracts with different
levels of integration into a core area. So, if you look
at those first three, the black is a metropolitan core.
The lighter, darker gray is metropolitan with a high
commuting and connection into a core. And then there’s
metropolitan low commuting, is that next level. The green
color gradient shows small town areas. And the purple
shows the micropolitan areas. And then the beige is all
rural. So we’ll dig in a little deeper in a moment about
which RUCA codes FORHP uses. But then I have one more
USDA ERS tool that the Federal Office of Rural Health
Policy uses before we dig into FORHP’s definition.
So, the USDA ERS has a couple of new products that are
the Area and Road Ruggedness Scale. When the Federal
Office of Rural Health Policy published a Federal
Register notice about updating our definition in 2020,
many of the comments suggested that FORHP identify
difficult and mountainous terrain because travel on roads
through such terrain is more difficult and
time-consuming. At the time, there wasn’t a dataset that
would allow us to identify this on a national scale at
the census tract level. Now, these datasets exist and
everyone has access to them.
The USDA ERS developed two scales that identify
ruggedness as defined by changes in elevation. The full
report is available on their website if you want to take
a look at it in more detail. And FORHP uses the Road
Ruggedness Scale because roads, rather than overall
topography, have a more defensible connection to access
to healthcare.
So, this map shows the census tracts across the U.S. and
their corresponding Road Ruggedness score. The darker the
area is, the more rugged it is. So you can see some of
the mountain ranges in the U.S. reflected in the census
tract scores. You can see the Appalachian Mountain range
over Kentucky and West Virginia and some of the Rocky
Mountain range in northern Idaho and many mountain ranges
along the West Coast.
So, now that you have some of that background and
scaffolding information, I can get into the definition
that I am most excited to share with you, the Federal
Office of Rural Health Policy’s definition. And I’m going
to step us through the definition, but I want to point
out that we have these five components of our definition.
We look first at the county and then, within the county,
at census tracts. And an area only needs to meet one of
these components in order to be considered rural by the
Federal Office of Rural Health Policy’s definition.
So, we’re going to look first at non-metropolitan
counties. We’ll look first at the counties. And I’m going
to show you this map again that shows these metropolitan
counties and non-metropolitan counties. So, the first
step in our definition is to pull in all the
non-metropolitan counties in the U.S. based on OMB’s
delineations. So, all these gray areas that are
non-metropolitan are considered by FORHP to be rural and
just our first step of the definition.
And then we also have outlying metropolitan counties with
no population from an urban area of over 50,000 or more
people. So, that lets us identify metropolitan counties
that don’t have dense population centers.
So, then we take a look at the census tracts with RUCA
scores of 4 through 10 in metropolitan counties. This is
the RUCA code map. So this is any of the RUCA codes that
go from 4 through 10. So that’s all the purple, all the
green, and all of the beige. And then, when we look at
that, we’re also looking at census tracts of at least 400
square miles in areas with population density of 35 or
less per square mile with RUCA codes of 2 through 3. So
this allows us to pull in some of the gray-gradient
census tracts for large census tracts that have small
population, low population density.
And then, finally, we use census tracts with RRS 5 and
RUCA codes 2 through 3, again, that’s that gray that you
saw in the previous map, that are at least 200 square
miles in area in metropolitan counties. And these are the
most rugged census tracts that are considered highly
rural. So all of these dark red, as long as they do not
also have a RUCA code of 1.
So, here’s the map of the rural counties and census
tracts that are considered rural under FORHP’s
definition. You already saw this map at the beginning of
the presentation, and now you can kind of understand a
little bit more about what components go into our
definition and how we pull in areas to identify rural
populations in the United States. About 20% of the
population is considered rural by FORHP’s definition. But
as you can see by this map, the vast majority of land
area in the U.S. is considered rural.
So, with all the definitions available, it may be
dizzying to figure out how they all fit together and why
it matters. So I want to point out some of the overlap.
And looking at the three definitions that FORHP uses most
frequently, we have these very rough and unscientific
Venn diagrams. They are not to scale. It’s just to kind
of show the overlap. But we can use them to see that all
people and areas that are non-metro according to the
Office of Management and Budget are also rural according
to the Federal Office of Rural Health Policy. But when we
look at the census definition, some people in areas that
are considered rural according to the census are not
rural according to the Federal Office of Rural Health
Policy and vice versa. So, there are also some areas that
are not considered rural by the census, but they are
rural according to the Federal Office of Rural Health
Policy.
And it’s important to note the different purposes for all
of these definitions. Both OMB and census focus on
statistical uses and built area, whereas the Federal
Office of Rural Health Policy has a particular focus on
people in rural areas and access to medical care. So, for
example, with the 2020 census, they changed the way that
they consider urban areas to also include housing units.
And so there may be places like beach towns that have a
whole bunch of housing units but might not have
consistent populations there. So, we try to focus on
people rather than buildings.
So, here’s a quick summary of the most recent change that
we implemented in September of 2025 compared to our
November 2024 update. So, in September of 2025, there
were no methodology changes. And in November of 2024, our
update prior to the most recent one, we added the RRS
codes, the Road Ruggedness Scale, and we also addressed
the Census Bureau’s removal of size differentiation in
urban areas. And I didn’t get into that on this
presentation, but the census used to differentiate their
urban areas on population size. And now, instead of
having two separate designations, they’re just urban
areas. And so we wanted to maintain a difference between
the large urban areas and the small urban areas. And so
we changed our definition a little bit to say that “All
outlying metro counties without an Urbanized Area to be
rural,” we changed that to “Outlying metropolitan
counties with no population from an urban area of 50,000
or more people,” to pull in and maintain the population
size differentiation.
So, for data updates, in November of 2024, we didn’t have
a lot of the 2020 census and USDA ERS information. And so
we were still using 2010 census tracts and census tract
data, USDA ERS RUCA codes and the RRS codes. So, in 2024,
we had the 2023 OMB county designation updates. So we
updated the metropolitan and non-metropolitan
information. In September of 2025, we were able to
incorporate the 2020 census tracts, with the exception of
Connecticut because Connecticut changed to planning
regions. And so we incorporated that as well. And then
2025 USDA RUCA codes and 2025 USDA RRS codes. And those
use the 2020 census tract data.
We also have information about the available files that
you can find on our website. We have ZIP code
approximations that are useful if ZIP codes are the only
information you have and you want to use the Federal
Office of Rural Health Policy designations. However, our
definition is based on counties and census tracts. So
wherever possible, we encourage people to use the county
and census tract files.
And then I just have a little information about the total
land area, population, and population number from 2024 to
2025 with our most recent update. And we see a small
increase in rural land area and a small decrease in rural
population percentage in the whole U.S. And then the
population number has increased from 62.8 million people
with our 2024 update to 64.5 million people with our 2025
update.
And then, here is a map to visually see where some of the
changes occurred. So, with our September 2025 update, you
can see that most of the land area, this light green,
remained rural. So there were no changes. It was rural
and it is still rural. But there are some of these darker
areas, this dark orange, for example, and this dark
green, that changed status from 2024 to 2025. So, the
orange changed status from rural in 2024 to not rural in
2025. And the green changed status from not rural in 2024
to rural in 2025.
So, looking ahead, I want to talk a little bit about
what’s next and what does it all mean. For upcoming
applications for the Federal Office of Rural Health
Policy, applicants have a period of one year to lean on
their previous rural status if they lost eligibility. So,
if anybody is in this part of the U.S. where they were
rural and are now finding they are not rural, they still
have a year that they can still receive Federal Office of
Rural Health Policy funding.
Do we plan on updating our rural methods like we did to
incorporate the Road Ruggedness Scale in 2024? We don’t
anticipate that happening, but we are constantly
monitoring for new data that will allow us to accurately
pull together information to identify rural areas. It
won’t occur… We haven’t noticed anything that will make
that occur anytime soon.
You may also want to know what happens when the
underlying data updates and if we anticipate any of that
to happen in the near future. So, as you’ve learned, we
use four main sources of data. We use the census, USDA
ERS RUCA codes and RRS codes, and the Office of
Management and Budget. Three of those update on this
cadence of the census every 10 years. And we have the
2020 update from those datasets. So, the RUCA codes, the
RRS codes, and the census, we won’t be updating any of
our data with those until after the next decennial
census, which is in 2030.
The Office of Management and Budget updates their data
more frequently, but we don’t anticipate any update until
later in 2026. Or if they update, it won’t be until later
in 2026, and they may decide that it’s not a big enough
change to necessitate having more data, publishing
different data. So, in OMB updates, we will be updating
our data files, but we don’t anticipate that happening
anytime soon. And then the timing of any of this
happening will align with the FY 2027 Federal Office of
Rural Health Policy NOFO releases.
And I’m just looking at the time. And so I am going to go
through some useful tools for you, but I don’t think we
will have time for some of the other rural definitions
that I have. So I will encourage you all to, when you get
the slides, look over those to see if you have any
questions and feel free to reach out to us or the agency
that develops them if you would like to learn more about
those.
So, I’m going to go into some useful tools for you and
your partners. And I’m going to start with the Rural
Health Grants Eligibility Analyzer. This is a tool that’s
developed within HRSA that allows a user to type in an
address or to look by state and county to see if their
county or their address is in an area that is considered
rural. So, in this example here, it’s been searched by
county and it shows Baldwin County, Alabama. So someone
can select Alabama, select Baldwin County, and then click
search. And this is considered the source of truth for
whether or not an area is considered rural. And often
applications for our funding opportunities will ask for
some sort of proof from this tool that shows that your
service area or facility is in a rural health area. And
in this map, this shows the outline of the county and
then the areas in the county that are considered. So in
this one, it says that “Some parts of Baldwin County,
Alabama, are eligible for Rural Health Grants.”
I’d encourage you, if you’re just looking at this and you
see that… If you type in your facility address and you
see that your address is not rural, but you know that you
serve rural populations, I encourage you to look at
specific NOFO opportunities to see what the eligibility
requirements are. Because even if the facility is not in
a rural health area, if your service area or if many of
your patients are rural or live in rural areas, there’s
still opportunities for funding.
The other one is the Rural Health Information Hub’s Am I
Rural? Tool. And this works best with a full address. The
tool will provide data for a centroid with any other
geography. So you want to make sure to type in a full
address here in order to get the most accurate results.
And this is a tool that’s been developed by RHIhub that
allows you to type in an address and it’ll spit out a
report of all the different rural definitions that you
could ever imagine. Probably not. There may be some more.
But it provides many rural definitions.
So you can see in the example here, we used the HRSA
headquarters address, which is not rural by any
definition, but it shows the Core Based Statistical Areas
and whether or not it is metropolitan or micropolitan or
non-core. It shows what the CBSA name is and then its ID.
So you can use this information to either justify, for
other grant opportunities, to justify if your area is
rural according to a different definition, and then also
just kind of learn more about the federal definitions of
rural and the state of your address or facility or
service area.
And then, we also have the Federal Office of Rural Health
Policy Data Files. And these are available. They’re
linked in the PowerPoint. And we have a county and census
tract list in our Excel files. And it’ll show you, when
you pull them up, a list of 2020 census tracts, and it’ll
say whether or not it is FORHP Rural… There’s a column
that says FORHP Rural and yes or no if it is rural.
And then there’s also a list of 2023 counties, and you
can see in that list, you can look up the county, and
then you can also see, in the column labeled County
Eligibility, if it is not fully FORHP Rural or if it is
fully FORHP Rural.
And I want to point out one more thing about using RHIhub
in connection to the data files. Both RHIhub’s Am I
Rural? Tool and our Rural Health Grants Eligibility
Analyzer in the report will tell you what the census
tract is. So, a lot of people don’t know what their
census tract is off the top of their head. It’s not
something that comes up in casual conversation, like
perhaps your county. And so you can find your census
tract to look it up in our data files using any one of
the previous tools.
And then we also have a ZIP Code Approximation Excel
File. And I want to encourage again, wherever possible,
that you use the County and Census Tract Excel File. But
if you only have ZIP code, then this is an approximation
of whether or not that ZIP code would be considered rural
or not, or a location in that ZIP code.
And then there’s also the HRSA mapping tool, and this
allows you to select and plot health centers, shortage
areas, rural health areas, HRSA grants, all sorts of
things. And then you can also upload your data if it has
latitude and longitude data points. So you can upload
your data set to see how they fall on, for example, this
rural health layer. And to do that, you go into the map
and you click on “Facilities, Providers,
Sites/Areas”, and then click on
“Rural Health Areas”, and it will put
an overlay on the map that is green that shows you what
the rural health areas look like.
And then I’m going to stop here and ask for questions.
Sorry to make you dizzy. I just wanted to put our final
slide up here about connecting with HRSA. So you can
learn more about our agency at hrsa.gov, and then you can
sign up for the HRSA e-newsletter that will have all
sorts of information about upcoming opportunities. And
then HRSA is on all of the social media platforms. So, I
will end there and see if there are any questions.
Kristine Sande: So, the first one is
about a frontier definition. It says, “Is frontier no
longer a classification for very rural areas?”
Greta Stuhlsatz: That’s a great
question. And that’s one of the definitions that we
didn’t get a chance to dig into today. So if you explore
the slides once they become available to you, you can see
that the USDA Economic Research Services has a frontier
and rural data file that you can see the frontier
definition, and you can use their data to identify that.
We don’t use it in our definition with the Federal Office
of Rural Health Policy, but it does still exist and you
can still use it. And I believe they’re updating their
data files sometime in the near future. But right now,
they have, if I remember correctly, and let me check my
notes, 2010. Right now, it’s updated to 2010, and they’re
based on ZIP code information. So, sometimes that’s
useful for research that only has ZIP codes or, like you
mentioned, is interested in the very remote or
geographically isolated communities.
Kristine Sande: Great. Thank you. So, a
couple of questions about the map showing the changes
from the ’24 to ’25. The first question is, “The map was
created in August of 2025. So did it use the September
2025 updated rural definition?”
Greta Stuhlsatz: Yes. Yeah. Thank you
for pointing that out. The map has the Updated 8/8/25
because it was made before we published the final data
files. But it is still the September 2025 data files. And
we call it the September 2025 data files because that’s
when it was updated and available publicly. That’s when
we published it. But we have some internal tools that we
developed prior to publishing. And so, I don’t think that
will be corrected for these slides, but in future
presentations, we’ll make sure that those are aligned.
Kristine Sande: All right. And then, “Is
there a state-level breakdown available for the changes
that are shown on that change map?”
Greta Stuhlsatz: Yeah. We don’t have
state-level breakdowns available, but if you reach out to
us, we can help walk through what those changes look
like. And we can help support understanding those
differences and what might have lost rural status and
what might have gained rural status. Also, with each of
the funding opportunities that the Federal Office of
Rural Health Policy is going to publish for this fiscal
year, it includes a list of counties that have
experienced a change between the 2024 and 2025 update.
And then we also have a data file that shows if a census
tract within that county lost rural status. So, when a
NOFO is published with the Federal Office of Rural Health
Policy, if you’re interested in that specific
opportunity, the information will be available to you.
But if you’re more interested generally in what this
looks like at your state, feel free to reach out. We’re
happy to work with you on that.
Kristine Sande: All right. And then a
question about whether the two rural determination sites
are updated with the new definitions or the new data.
Greta Stuhlsatz: Yeah. I think what
you’re referring to, and correct me if I’m wrong, the two
rural determination sites, that would be the Federal
Office of Rural Health Policy’s Rural Health Grants
Eligibility Analyzer that I talked about in the tool
category, and then the Rural Health Information Hub’s
tool for Am I Rural? And yes, both of those are updated
with the September 2025 data. The Rural Health Grants
Eligibility Analyzer is an internal tool to HRSA. And so
we update those as we publish the data. And then we also
work really closely with RHIhub so that whenever we
publish a data source or a data update, RHIhub has that
information too so that we all simultaneously update so
that there isn’t a lag in the information that you all
are seeing when you’re using our tools.
Kristine Sande: Another question about,
“How do these definitions or changes interact with HPSA
scores? Do they? And if so, how?”
Greta Stuhlsatz: So, the HPSA scores are
Health Professional Shortage Areas, and those are not a
component of the Federal Office of Rural Health Policy’s
rural definition. So we don’t incorporate any HPSA score
information. And then the Health Professional Shortage
Areas are based on a formula that also does not consider
the Federal Office of Rural Health Policy’s rural
definition. And I’m not sure how much of the HPSA
criteria leans on some similar source material. Like we
use, the Office of Management and Budget, we use the
census information. I believe HPSAs do as well. So some
of that source information could be similar, but we don’t
do any sort of overlapping as far as our methods goes
with HPSAs.
Kristine Sande: All right. “Does the
definition of rural used in the Rural Health
Transformation Program align with the HRSA definition?”
Greta Stuhlsatz: Yeah. So, I don’t know,
Sarah, if you want to go into more detail on the Rural
Health Transformation part. But I’ll start. And then if
you have more things to add, feel free.
Sarah Heppner: Sure.
Greta Stuhlsatz: So, the Rural Health
Transformation Program mentions the Goldsmith
Modification as a way to identify rural areas within
metropolitan counties. And so that’s one of the reasons
that we highlight the Goldsmith Modification in this
presentation, because it is partnered with the Rural
Health Transformation Program’s definition of rural.
Sarah, if you want to add to that.
Sarah Heppner: Yeah. So, I would say, I
would maybe even take a step back, Greta, and just… For
folks who are listening, the Rural Health Transformation
Program is run by our colleagues at CMS. And so I want to
be really careful that we don’t sort of step into their
lane. Of course, we’re collaborating and working together
through all of this, but I think if folks have a specific
question about a state’s plan versus what was in the NOFO
versus the various definitions of rural, if you feel free
to reach out to us, we can make sure that you get
connected with the right person that can answer your
questions specific to the state you’re thinking about and
things like that.
Kristine Sande: All right. Next question
is, “Does the FORHP definition take into account any
seasonal population fluctuations?”
Greta Stuhlsatz: We do not. Seasonal
population fluctuations is not something that we
consider. And that’s a good example of the data not being
easily accessible. And so, if you know of a dataset that
shows that, we’re happy to dig into it and see what it
looks like, but we don’t currently.
Kristine Sande: All right. So, next
question is, “Is there a gold-standard definition of
rural? It seems like OMB might be, but not sure.” Second
question, “What is the basis for mid-decennial population
estimation that OMB might use?”
Greta Stuhlsatz: Okay. So, the first
question is if there’s a gold standard for rural. And I
love that question. And when I first started working in
rural health, I, too, said, “Why do we have all these
definitions of rural? Surely there must be one gold
standard.” And I have changed my tune over the many, many
years where I do realize the benefit and value to having
all these definitions, even though they can be baffling
and difficult to put together.
My understanding is that there’s not a gold-standard
rural definition. My perspective from the Federal Office
of Rural Health Policy is that we have a pretty darn good
one that takes into consideration all these different
data sources. But there’s so many different priorities
that look at and include rural that it would be very
difficult to identify one gold standard.
One of the examples that I use is the census definition
includes built-up areas and includes buildings. Whereas
there may be other sources that are looking at
agricultural land. And so they’re more focused on how
much of the land is not settled. And so, there’s just so
many different components, so many different programmatic
priorities that make it very difficult to identify one
definition that can be used for everything.
And the example you provided, the Office of Management
and Budget, that one’s at a county level. And so, when we
start looking deeper into counties to see who might have
access where, that kind of dulls the gold shininess of
what the Office of Management and Budget might look like.
And it’s also designed to be used for statistical
purposes. And so when we look at programmatic
implementation, it can start to get much more sticky.
I know that’s not the answer you were hoping for, but
that’s what I have for you.
Kristine Sande: All right. So, the next
question is, “Can we expect that these rural definitions
that you talked about today will be in place until the
next census data is released, or will there be
modifications between now and then?”
Greta Stuhlsatz: Yeah. So, the only
modification that we anticipate is if the Office of
Management and Budget updates their data. And so, when
the underlying data updates, we do incorporate those
updates and publish a new data file. We align it with
programmatic needs. And so, if that happens, when that
happens, we’ll publish the data in a way that is aligned
with our next season of funding opportunities so that
it’s not, “Six months ago, we updated this thing, and now
we have this opportunity. And should we be using the
2024, the 2025, or 2026 definition?” So we try to align
it as well as we can, and we try to make sure to
communicate that information so that it is very clear in
the funding opportunities what should be used. But we do
not anticipate an update until the next… We don’t
anticipate a census tract update until the next census,
decennial census, with the caveat that the Office of
Management and Budget is the one that could update prior
to that.
Kristine Sande: All right. Another
question is, “If an area lost federal rural status but is
still considered rural by the state, can the State Office
of Rural Health still use their federal funding to
support that area?”
Greta Stuhlsatz: So, that would be a
specific programmatic question that you would need to
look into the specifics for the funding mechanism that
you’re thinking about. Sarah came off of face mute, so
she may have something to add.
Sarah Heppner: Yes. Just to say two
enthusiastic thumbs up on your answer. But yeah, for
specific questions about how the State Office of Rural
Health Program or really any of our grants, you should
reach out to your project officer. If you don’t know who
your project officer is, email Greta, only because her
email address is the one on the screen, and we’ll make
sure you get connected to the right person to answer the
question specific to the work plan you’re referring to,
just to make sure we’re giving everyone the most accurate
information possible.
Kristine Sande: “Are shapefiles
available for FORHP’s updated designations at the census
tract level in ArcGIS online if we want to add a layer
with that data to our own mapping projects?”
Greta Stuhlsatz: They are not. And so, I
would encourage you to use the HRSA mapping tool to see
the overlay and see the overlay with your data. Or if
that’s not, you can reach out to me too, and I can get
you connected to potentially different resources. But we
do not have a shapefile that’s available to download
through ArcGIS.
Kristine Sande: Follow-up comment from
one of our attendees related to the Health Professional
Shortage Areas, just suggesting that if anyone has
questions about HPSAs, to contact your state’s Primary
Care Office. There’s a list of those on the HRSA website.
So, good suggestion. The folks at the Primary Care
Offices are very well versed on those definitions.
Sarah Heppner: I believe that I
inaccurately marked this question as having been
answered. And that is, “Could you formally define the
Goldsmith Modification? I’m not sure I fully understand
what it means.”
Greta Stuhlsatz: I can tell you that the
information in legislation is that the Goldsmith
Modification is designed to identify rural areas within
metropolitan counties. And that is the extent to the
information that we work with to fit our rural definition
into being able to identify rural areas within
metropolitan counties.
So, our definition, if you look at our rural health data
files page, there’s a page before it on our website that
says “How We Define Rural.” And it
shows the definition that I stepped through during the
presentation. And so you can see the county-level
information. But then anything beyond that… Is the
county non-metropolitan? That’s our first step. Is the
county non-metropolitan? If it is non-metropolitan, it’s
considered rural.
Anything beyond that is how we identify non-metropolitan
census tracts. Sorry, let me rephrase that. Anything
beyond that is how we identify census tracts in
metropolitan counties. So those four other components
where we look at RUCA codes, and we look at the size and
population density of a census tract or county, and we
look at the Road Ruggedness Scale. Those are how we
identify census tracts that are rural in metropolitan
counties.
Kristine Sande: All right. Maybe a
question for Sarah, asking whether the USDA and HRSA
grant programs and the RHTP program would interface at
all in terms of… says, “This is important from a
grant’s mutual exclusivity standpoint.” Do you have any
thoughts on that?
Sarah Heppner: Yeah. So, I think I’m
going to answer this question, but please reengage if I’m
not answering the question you’re intending to ask.
So, we have relationships with both the USDA ERS folks,
with our colleagues at CMS who are working on the Rural
Health Transformation Program. And so, we are absolutely
working together, talking, talking, making sure we’re all
aware of available resources, making sure that we’re
sharing our knowledge, sharing our work plans for things
that we funded, all sorts of activities, to make sure
that we are not duplicating efforts, to make sure that we
are moving forward in our respective lanes for advancing
our investments that we already have made or will be
making over the next few years in rural communities.
So, if your question is about how we are working together
and how we’re making sure good stewards of federal
dollars, lack of overlap, we are absolutely doing that.
I’ve even had calls today about that. If that’s not the
question you’re asking, I’m happy to try to re-approach.
Kristine Sande: On behalf of the Rural
Health Information Hub, I’d like to thank our speakers
for the great information and insights you’ve shared with
us today. And also, thank you to all of our participants
for being with us.
