May 23, 2024

West Virginia Delegation Urges HRSA To Better Classify Rural Appalachia For Federal Healthcare Resources

Washington, DC – Today, U.S. Senators Joe Manchin (D-WV) and Shelley Moore Capito (R-WV), along with U.S. Representatives Carol Miller (R-WV) and Alex Mooney (R-WV), wrote a letter to Health Resources and Services Administration (HRSA) Administrator Carole Johnson, urging HRSA to adequately include terrain factors in their definition of rural. This classification determines communities’ eligibility to receive certain federal healthcare resources, and adopting ruggedness in the definition will ensure that West Virginia communities receive the federal funding they deserve.

“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,” the lawmakers wrote in part. “We appreciate HRSA’s work to better account for difficult and mountainous terrain areas in the definition of rural for purposes of Federal Office of Rural Health Policy (FORHP) grant eligibility. These funds are instrumental to providing access to quality health care and support health professionals in rural communities across the country.”

“This critical addition to HRSA’s proposal to include terrain factors in their definition of rural to be eligible of FORHP grants is important to better capture rugged terrain areas. These counties include Critical Access Hospitals, health centers, clinics, and many other health providers that will greatly benefit from the resources FORHP provides,” the lawmakers continued. “We urge you to take Congressional intent into account and adopt our suggestion to address high density of rugged areas. We look forward to continue working with you to improve health care access and quality across rural America.”

A timeline of Senator Manchin’s recent efforts to improve federal classifications for rural Appalachia is available here.

The full letter is available below or here.

Dear Administrator Johnson,

We appreciate the opportunity to comment on the Health Resources and Services Administration (HRSA), Department of Health and Human Services (HHS) Proposed Inclusion of Terrain Factors in the Definition of Rural Area for Federal Office of Rural Health Policy Grants.  HRSA’s Federal Office of Rural Health Policy (FORHP) establishes methods of defining rural areas in the United States to receive services funded by its rural health grant program. These funds are instrumental to providing access to quality health care and support health professionals in rural communities across the country. We appreciate HRSA’s efforts to address concerns expressed by stakeholders and ensure that the definition of “rural” is properly defined across the United States, especially in West Virginia.

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, 3 Health Center Program Look-Alike Organizations (including 515 satellite sites, 237 of which are School-Based Health Centers), and 6 free clinics. Additionally, there are 69 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 census tracts HRSA has designated as urban. We have found this concerning, as these critical providers have been ineligible for necessary FORHP grant opportunities. We appreciate the extra attention that HRSA has provided to addressing the needs of these providers, acknowledging the topographical characteristics of their locations.

Since Fiscal Year (FY) 2020, Congress has been instructing the United States Department of Agriculture (USDA) Economic Research Service (ERS) to coordinate with FORHP to identify difficult and mountainous terrain areas with an eye towards assessing their eligibility for rural health grants.  In 2021, HRSA updated their definition of rural for purposes of FORHP grant eligibility, which allowed six additional counties in West Virginia to become newly eligible. We were pleased with this change, and underscored at the time that more work was needed to properly identify difficult and mountainous terrain areas as rural.  To support this work we communicated extensively with USDA ERS to ensure a new measurement was created to better capture difficult and mountainous terrain areas. 

The United States Department of Agriculture Economic Research Service on August 1, 2023 released their Characterizing Rugged Terrain in the United States report . The report shares two new measurements for representing relative topography: the Area Ruggedness Scale (ARS) and the Road Ruggedness Scale (RRS). The report found that 11.7% of the United State population lives in a rugged area, with 1.4% living in a highly rugged area. For comparison, West Virginia has the largest shared of resident living in a rugged area, with 80.7% of the population living in a rugged area and 15% in a highly rugged area. While ruggedness alone cannot dictate rurality, we agree with HRSA that it is an important consideration when determining what is rural and what is not.

We are pleased with HRSA’s proposal to designate census tracts with an RRS 5, RUCA 2-3, and with an area over 20 square miles, as newly eligible. These regions represent highly rugged areas, and are rural in nature. We would recommend extending this further to capture areas with a high density of rugged areas. The USDA ERS report found that the “challenges associated with rugged terrain may be more acute in the Appalachian Mountains region than elsewhere.” While Appalachia doesn’t have a large share of RRS 5 due to lower elevation change than found in areas, such as the Pacific Mountain System, it has a higher share of RRS 3-5, supporting the suggestion that Appalachia is more greatly challenged by its rugged terrain than other regions in the United States. The Centers for Medicare & Medicaid Services acknowledged this in their determination of “mountainous terrain” for the purposes of Critical Access Hospital accreditation, noting that “the altitude of the Appalachian Mountains is considerably lower than that of the Rocky Mountains, yet the slope and ruggedness of the terrain in many portions of the Appalachians is mountainous” making travel difficult.

The FY 2024 Labor, Health and Human Service, and Education, and Related Agencies Senate Report 118-000 specifically requested that FORHP review USDA ERS’s research, with a specific mention of Appalachia. As such, we feel this proposal should take particular care to review rugged in Appalachia.

The USDA ERS report outlined that the definition of rugged terrain can be identified as census tracts with RRS 3-5. It also suggested that the RRS does a “thorough job of capturing travel limitations associated with rugged terrain”, which is helpful in understanding the economic and health care delivery challenges associated with these areas.

HRSA has historically used a mixture of the Census Bureau’s urban-rural classification, the Office of Management and Budget’s (OMB) definition of metropolitan, and the USDA ERS’s RUCA codes. None of these measures have adequately accounted for sparsely-populated mountain regions, nor have they adequately measured commuting times for difficult terrain. Compounding this issue, regions in Appalachia have a deficiency of high-speed internet access due to the terrain, making delivery of health care through other means, such as telehealth, even more difficult. While many sites are trying to adopt telehealth services, the mountainous region often makes technology infrastructure inaccessible and unreliable.

While adding census tracts with RRS 5 addresses some of these issues, we feel it would be appropriate to look at counties with high densities of RRS 3-5. Both OMB and FORHP have utilized measures, such as Metropolitan Statistical Area (MSA), which determine metro areas based off entire counties. We suggest HRSA look at counties within an MSA. Specifically, we suggest that HRSA include census tracts greater than 20 square miles with a RUCA of 2-3 within counties that are:

  • Located in a Metropolitan Statistical Area,
  • Have over 80% of census tracts RRS 3-5, and
  • Have 12 or fewer census tracts in total.

While HRSA currently uses RUCA, which is a tract-based measurement to delineate rurality within an MSA, we feel that HRSA can use percentage of census tracts within a county to determine total ruggedness. Under this criterion alone, there are 61 counties in the United States in MSAs that would be eligible. Since census tracts with RUCA 4-10 are already considered rural, and we agree that census tracts with RUCA 1 are not rural in nature, that leaves 59 counties eligible.

Using the census definition that an urbanized area is one with a population of 50,000 or more, we recommend only looking at counties with less than 50,000 individuals. This can also be calculated as counties with 12 or fewer census tracts in total, since census tracts have an optimum population of roughly 4,000 individuals. With this criterion the following counties would be eligible, with only 55 census tracts within these counties being RUCA 2-3:

State:  County Name:

KY      Lawrence County

NC      Madison County

PA       Perry County

PA       Wyoming County

TN       Roane County

TN       Sequatchie County

TN       Unicoi County

VA      Botetourt County

VA      Floyd County

VA      Scott County

WV     Brooke County

WV     Fayette County

WV     Hancock County

WV     Marshall County

WV     Wayne County

We feel this critical addition to HRSA’s proposal to include terrain factors in their definition of rural to be eligible of FORHP grants is important to better capture rugged terrain areas. These counties include Critical Access Hospitals, health centers, clinics, and many other health providers that will greatly benefit from the resources FORHP provides. 

This inclusion, combined with HRSA’s RRS 5 proposal, would extend eligibility to a total of 139 census tracts and approximately 543,538 people to the 60,758,275 people currently living in existing FORHP-designated rural areas, marking a modest increase of 0.89 percent of the total number of people living in rural areas. However, this change to eligibility would have a transformational impact on these regions, especially Appalachia. 

We appreciate HRSA’s work to better account for difficult and mountainous terrain areas in the definition of rural for purposes of FORHP grant eligibility. We urge you to take Congressional intent into account and adopt our suggestion to address high density of rugged areas. We look forward to continue working with you to improve health care access and quality across rural America.