October 25, 2022

Manchin Calls on Administration to Finalize Rural Area Classification And Healthcare Funding Eligibility Research

Charleston, WV – U.S. Senator Joe Manchin (D-WV) urged Dr. Spiro Stefanou, Administrator of the Economic Research Service (ERS) of the U.S. Department of Agriculture (USDA), to fulfill congressionally directed research to better classify rural areas in West Virginia and the United States. The ERS develops Rural Urban Commuting Area (RUCA) Codes to help define rural communities across the country, and the Federal Office of Rural Health Policy (FORHP) uses these codes to determine eligibility for certain rural health grants from the Health Resources and Services Administration (HRSA). However, the system for defining rural areas has failed to account for the unique geographic characteristics of Appalachia and has led to the wrongful exclusion of several West Virginia counties from critical federal funding.
 
“West Virginia is the only state that lies completely within the Appalachian Mountain region. It also has a higher mean elevation than any state in the east. According to the Census Bureau, West Virginia is the third most rural state in the nation, with 51.8% of the state’s population living in rural areas,” Senator Manchin said in part. “However, several of West Virginia’s Critical Access Hospitals, Rural Health Clinics, and other rural providers lie in counties HRSA has been designated as urban. This is concerning, as these critical providers have been ineligible for necessary FORHP grant opportunities.”
 
In December of 2019, Congress passed and the President signed into law the Fiscal Year 2020 Consolidated Appropriations Act, which directed the USDA ERS to conduct research to ensure rural communities across the country are correctly classified and have access to the corresponding federal assistance they need and deserve. The same congressional directive was included in the 2021 and 2022 Appropriations bills. However, the ERS has failed to complete even the first phase of the research directed by Congress.
 
Senator Manchin continued, “It has been more than three years since the initial congressional authorization of this project. It is also more than 10 months past the date from when Phase I was initially supposed to be completed. These continued delays are unacceptable. We have several counties in West Virginia that are not seen in the eyes of the federal government as rural, and as a result, have missed out on numerous federal funding opportunities, including aid to recover from COVID-19, rural healthcare grants, and other opportunities that would provide critical resources to West Virginia… The work ERS is doing has the chance to address disparities in rural healthcare, make healthcare more accessible for West Virginians, and potentially change and save lives.”
 
In September of 2020, following Senator Manchin’s efforts, HRSA released a proposed rule to update their classification methodology for rural areas. On October 16, 2020, Senator Manchin submitted comments to HRSA on these proposed changes which applauded the inclusion of several West Virginia counties, while also urging the Administration to provide an exception for mountainous terrain.

The full letter is available below or here.

Dear Administrator Stefanou:
 
I write today to express my frustration with the Economic Research Service’s (ERS) inaction on congressionally directed research to better identify rural areas. Nearly three years ago, Congress passed the Fiscal Year 2020 (FY20) Consolidated Appropriations Act (Public Law 116-94) directing the United State Department of Agriculture (USDA) to conduct this research to ensure the people of West Virginia and elsewhere could be rightfully classified as “rural” and have access to the critical federal funding they need and deserve. The same congressional directive was included in the FY21 and FY22 appropriations bills, and yet the ERS has failed to even complete Phase I of this initiative. Additionally, your office has been inconsistent and slow in providing updates and responses to my office. This is unacceptable.
 
The ERS is charged with anticipating trends and emerging issues in agriculture, food, the environment, and rural America and to conduct high-quality, objective economic research to inform and enhance public and private decision making. To this effect, the USDA ERS develops the Rural Urban Commuting Area (RUCA) Codes to help define rural areas in the United States. The Federal Office of Rural Health Policy (FORHP) uses these codes to determine whether certain areas in the United States are eligible to receive rural health grants from the Health Resources and Services Administration (HRSA). Most recently, HRSA finalized changes to their rural eligibility in a rule entitled, Revised Geographic Eligibility for Federal Office of Rural Health Policy Grants. These changes, which were finalized in January 2021, represent a strong step forward into measuring rural America. However, the final rule did not include an exception for mountainous and difficult terrain in Appalachia.
 
West Virginia is the only state that lies completely within the Appalachian Mountain region. It also has a higher mean elevation than any state in the east. According to the Census Bureau, West Virginia is the third most rural state in the nation, with 51.8% of the state’s population living in rural areas. West Virginia has 52 Rural Health Clinics, 28 Federally Qualified Health Centers and 3 Look-Alike Organizations (including 390 satellite sites, 179 of which are School Based Health Centers), and 6 free clinics. Additionally, there are 59 licensed hospitals in West Virginia, including 21 Critical Access Hospitals. However, several of West Virginia’s Critical Access Hospitals, Rural Health Clinics, and other rural providers lie in counties HRSA has been designated as urban. This is concerning, as these critical providers have been ineligible for necessary FORHP grant opportunities.
 
The FY20 Senate Report 116-110 - Agriculture, Rural Development, Food and Drug Administration, and related Agencies Appropriations Bill, included explicit language for FORHP, along with ERS, to conduct research on identifying tracks with difficult and mountainous terrain:
 
The Committee recognizes the Federal Office of Rural Health Policy’s [FORHP] use of Rural-Urban Commuting Area [RUCA] codes, developed by ERS to define rural populations. While FORHP applies RUCA to Census Tracts inside Metropolitan counties and considers tracts with codes 4–10 rural, it does provide exceptions for tracts with codes 2 or 3. Currently, exceptions are added for tracts with large areas and sparse populations. The Committee directs ERS to coordinate with FORHP to conduct research on the feasibility of identifying tracts with difficult and mountainous terrain. For the purposes of this census tract exception, ‘‘difficult and mountainous terrain’’ means when traveling between a rural hospital and any other hospital in the area, an individual is required to traverse at least 15 miles of roads located in mountainous terrain. Roads shall be deemed to be located in mountainous terrain if such roads are in areas identified as mountains on any official maps or other documents prepared for and issued to the public by the State agency responsible for highways or by the U.S. Geological Survey.
 
Currently FORHP provides exceptions to census tracts with RUCA codes of 2 or 3 that are “400 square miles in area with a population density of no more than 35 people per square mile.” FORHP should consider including an exception aimed at the Appalachian region, which is a highly mountainous and rural region. The Centers for Medicare & Medicaid Services (CMS) recognized the need to provide a shorter distance requirement for rural areas in mountainous terrain with a lack of primary roads and requires critical access hospitals to only have 15 miles to the next nearest like facility, instead of the traditional 35 miles.
 
I wrote to you March 24, 2021 to urge your office to conduct this research immediately. On May 6, 2021, your office informed my staff that we would receive a response from you “soon.” It was not until additional outreach from my office that we finally received your 560-word response letter on June 1, 2021. In your letter, you outlined your proposed use of the Frontier and Remote (FAR) Codes, which are not specifically designed to measure difficult and mountainous terrain, and would in fact make areas of Appalachia appear on paper as less rural. Instead of noting development of new measurements, you specifically noted that you “are exploring the use of FAR code methodology as an alternative approach.” Concerns with using the FAR Codes were shared with your team on June 4, 2021 during a call between our staff. During that same call, your team said that they would be “huddling” to discuss a timeline and scope for reviewing this project.
 
Over a month after the initial call, my staff reached out again on July 14, 2021 to receive an update on the proposed timeline. Your office set up a call on July 21, 2021 to discuss the scope and timeline. At the planned date and time of the call, only one staff member from your office was in attendance. That staff member was unable to provide a detailed update on the project or the topic at hand as was promised. It required outreach from both my senior staff as well as the Senate Appropriations Committee staff to receive an emailed summary of the scope of the project on July 22, 2021. My staff had also been requesting technical assistance from your staff at that stage on updating the FY22 Rural Tract Codes report language. Your staff provided no comments or edits.
 
After the July 21, 2021 meeting, your staff worked to reschedule a meeting and allowed for my staff to bring in academic experts from West Virginia to discuss rural measurements and impact of the RUCA and proposed FAR codes in Appalachia. This meeting took place on August 18, 2021. After this call, my staff connected your researchers directly with the West Virginia experts to offer them as a resource as you continued work on Phase I of the project. In particular, our experts noted that the use of Google drive times was an imprecise measurement to use in measuring rural Appalachia.
 
After the meeting on August 18, 2021, my staff has experienced a series of delays and lack of sufficient updates, which are outlined below:
 
  • On October 26, 2021, my staff requested an update and to inquire if your staff had conducted follow-ups with the West Virginia experts. Your staff noted that they would provide an update on November 10 and that they would not be reaching out to the experts until the end of Phase I.
  • On November 10, 2021, my staff reached out to receive the anticipated update. Five days later, your staff responded saying that no update could be provided until at least December 1, 2021.
  • On December 1, 2021, my staff requested an update and received no response.
  • On December 3, 2021, my staff followed up on their request and received no response.
  • On December 13, 2021, my staff received a response saying that Phase I should be completed by the week of December 20th and a further update would be provided then.
  • On December 22, 2021 my staff received the update that your staff had reached out to the West Virginia experts, but now delayed completion of Phase I to “Spring 2022,” which was estimated to be March/April 2022.
  • On January 5, 2022 I spoke with USDA Secretary Tom Vilsack and noted the continued importance of the research project to the state of West Virginia. This was noted directly to your staff as well.
  • On March 22, 2022, my staff requested an update on the anticipated completion of Phase I. Your staff responded on March 25, 2022, saying that the new deadline would be “end of April.”
  • On May 2, 2022, my staff requested an update on the anticipated completion of Phase I and to request a briefing.
  • On May 13, 2022, my staff received a briefing and update on the status of the project. During this briefing, your staff noted the continued use of Google drive times, despite documented concerns from my staff and experts from West Virginia. The presentation also extended the completion of Phase I to “Summer 2022” and Phase 2 to “Fall 2022.”
  • On June 7, 2022, in response to a request from your staff for additional information to find a potential alternative to using Google drive time measurements, my staff provided various data and resources.
  • On September 6, 2022, my staff requested an update on the anticipated conclusion of Phase I. My staff received no update.
  • On September 12, 2022, my staff requested an update on the conclusion of Phase I. Your staff offered a mid-October briefing on the subject. At this time, my staff asked if this would include the final presentation of Phase I and Phase II of the project.
  • On September 20, 2022, your staff indicated that Phase I would be completed and the report would be released in mid-October. In addition, your staff indicated Phase II would be completed by late December.
  • On September 20, 2022 my staff attempted to schedule a briefing on Phase I for mid-October. My staff received no response.
  • On October 5, 2022, my staff followed up to schedule the mid-October briefing.
  • On October 7, 2022 my staff received confirmation that the briefing on Phase I would take place on October 20, 2022.
  • On October 20, 2022, my staff joined the briefing. Only one member of your staff was present. Neither of the researchers on the project were even invited to the meeting. As of today, your staff are working to find a time that works with their availability.
 
It has been more than three years since the initial congressional authorization of this project. It is also more than 10 months past the date from when Phase I was initially supposed to be completed. These continued delays are unacceptable. We have several counties in West Virginia that are not seen in the eyes of the federal government as rural, and as a result, have missed out on numerous federal funding opportunities, including aid to recover from COVID-19, rural healthcare grants, and other opportunities that would provide critical resources to West Virginia. My staff has done all they can to provide resources, feedback, and has even invited researchers to visit areas of concern in West Virginia. Meanwhile, your staff has continued to push deadlines and miss scheduled meetings.
 
As a member of the Senate Appropriations Committee, I am committed to ensuring ERS has the resources it needs to complete this important project, but I cannot do that without basic information and dialogue with your agency. Within two weeks of receiving this letter, I request the following:
 
  • The confirmed, final and locked in schedule for the completion of Phase I and Phase II.
  • Detailed reasoning for delays behind Phase I completion.
  • Efforts to address concerns raised by both West Virginia experts and my staff on methodologies used by your researchers to determine commute times.
  • Details regarding any obstacles or concerns in completing this research.
 
I also request that you and your research team come visit West Virginia, and in particular Fayette County, which remains improperly labeled “urban”.
 
The unique landscape of West Virginia and Appalachia reflects the need for additional exceptions for mountainous or difficult terrain. The research ERS does has real impact on the lives and wellbeing of individuals in these areas. Travel through secondary roads and mountainous terrain in West Virginia makes access to healthcare more difficult, and requires health providers be more closely located to ensure patients are served in a timely manner, especially for emergent health concerns. The work ERS is doing has the chance to address disparities in rural healthcare, make healthcare more accessible for West Virginians, and potentially change and save lives.

I look forward to your expeditious response to my concerns. Thank you for your attention to ensuring the health and well-being of patients in rural America. I welcome the opportunity to discuss your efforts addressing my concerns.