The 2008 Report to the Secretary: Rural Health and Human Service Issues

April 2008

Rural America: 1987 and 2007

General Rural Demographics

This chapter begins by describing the context for considering rural health and human services issues. After defining rural for the purposes of comparisons over time, characteristics of rural places are described: population demographics, immigration, and key economic factors such as employment and poverty.

 

Defining Rural

There are many definitions of ‘rural’ that are used within the context of health care and human services programs and policies.¹ They are based on population density, town size, proximity to cities, and other factors. However it is defined, the hallmark of rural America is the geographic dispersion of its population, which has many implications for the delivery of health and human services. Many rural areas face unique geographic challenges in reaching their population, such as mountainous terrain or other natural barriers. Thus, any assessment of rural health and human services should begin by defining what is meant by ‘rural.’ The two most common definitions are the Office of Management and Budget’s (OMB) county-based definition and the Census Bureau’s census tract-based definition. See the box on the right for further details. For the purposes of this report, the Committee uses the geographic categorization of counties as non-metropolitan or metropolitan developed by the OMB.

 

In 1987, there were 2,390 non-metropolitan counties in the United States. By 2005, this number had dropped to 2,051 counties, reflecting the continuing suburbanization of the country; 366 non-metropolitan counties had become metropolitan during this time period while only 27 transitioned from metropolitan to non-metropolitan (Table 1 and Figure 1, p. 4). The rural population comprises 17 percent of the total U.S. population.² The population within non-metropolitan counties has also diminished, both in total and as a proportion of the total U.S. population.

 

 

 

Table 1. Change in Non-metropolitan Counties and Associated Population, 1987-2005

1987

	Number of counties	Population	Percent of U.S. population
Non-metropolitan	2,390	54,566,948	22.54
Micropolitan
Non-CBSA
Metropolitan	751	187,574,173	77.46

 

2005

	Number of counties	Population	Percent of U.S. population
Non-metropolitan	2,051	49,928,566	16.85
Micropolitan	693	30,407,234	10.26
Non-CBSA	1,358	19,521,332	6.59
Metropolitan	1,090	246,481,838	83.16

Sources: See References.

 

Figure 1: Rural America and Suburbanization: Non-metropolitan Counties, 1987-2005

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Population Demographics

 

Over the last 20 years, aging and migration patterns have changed the composition of the rural population. Both elderly and immigrant populations are on the rise, dramatically affecting the demands for health care and human services in rural areas.

 

The Elderly

 

Approximately 7.5 million of the 50 million people who lived in rural America in 2005 were over age 65.³ Although the difference in percentage of elderly between rural and urban areas is not dramatic (15 percent versus 12 percent), the share of the elderly rural population is growing. In one quarter of all non-metropolitan counties, the percentage of rural elderly already reaches 18 percent.⁴

Two population trends in the United States have contributed to the growth in the percent of elderly Americans living in rural areas. First, the out-migration of young adults from farm-dependent counties has led to an older average age for the remaining residents. In rural counties that experienced population loss in both the 1980s and the 1990s, the percentage of elderly residents averages 17 percent.⁵ Second, rural America is becoming a more popular retirement destination, especially for the baby boomer generation. This influx of retirees, many of whom seek to invest in homes and have private health insurance, brings an immediate boost to local economies and health care providers. However, these individuals represent future expanded demand for health and human services in rural areas that often lack adequate infrastructure such as a workforce with specialized geriatric training. It remains to be seen whether additional resources brought by retirees will result in infrastructure improvements.

 

In addition to these two migration trends, the population of elderly living in rural America stands to increase substantially as the first crest of the baby boomer generation hits age 65. Figure 2 below shows the U.S. birth rate and the correlating year when those people would turn 65 years old, indicating that the U.S. is on the cusp of a significant increase in the number of elderly people. From this demographic change alone, elderly growth rates in non-metropolitan areas are set to triple from 6 percent in 2000-2010 to 18 percent in 2010-2020.⁶ These trends have direct impacts on health and human services delivery.

 

Figure 2. Growth of Population Turning 65 (1,000s), 2000-2060

 

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Note: The first row of dates indicates the number of births (1,000s) each year. The second row dates indicates when those people would turn 65 years old.

Source: See References.

 

While urban areas will also experience significant elderly growth rates, the rural elderly face greater economic and health-related challenges than their urban counterparts. These concerns are particularly directed towards those who are “aging in place” rather than retiring from urban areas. Rural elderly are more likely to have lower educational attainment, worse health outcomes, and incomes below the poverty level than their urban counterparts.⁷ In the year 2000, 13 percent of non-metropolitan elderly residents were poor, compared to 9 percent of the metropolitan elderly. For those aged 85 years and older living in rural areas, the gap was even wider (20 percent versus 12 percent).⁸ Higher poverty rates translate into higher dependence on Social Security and Medicaid. This situation is a problem for the entire nation, but many rural areas with fragile service systems may find it particularly challenging to meet the needs of their growing elderly population.

 

Immigration

 

Immigration patterns in rural America have also changed in the past 20 years. Since 1980, the Hispanic population in non-metropolitan areas of the U.S. has doubled.⁹ In fact, Hispanics are the most rapidly growing segment of the rural population. With a growth rate of 67 percent in the 1990s, the Hispanic population boom in rural areas contributed to an overall rural population growth of 10 percent. Over 100 non-metropolitan counties that would have experienced population loss in those years instead remained stable or grew, because loss in original population was balanced by growth in the Hispanic population.¹⁰

 

Immigration creates other challenges in rural areas. These demographic changes have exacerbated what researchers at the ERS term “residential separation,” a measure of the racial separateness of sub-county places, including neighborhoods and towns. Hispanic immigrants are disproportionately young males, markedly so in the Midwest and Southeast.¹¹ Many of these immigrants lack a high school education, proficient English skills, and naturalized immigration status. These factors contribute to a persistent income gap between Hispanics and non-Hispanic whites, despite higher employment rates for Hispanic residents.¹² The migration of Hispanics may offer an opportunity to revitalize many rural communities as the presence of a younger workforce is a resource that could attract and keep employers in the community. The influx of this population could also bring about increased demands for social services, including prenatal care, child care, and bilingual education programs.¹³ The success with which rural communities prevail over residential separateness through improvements in education and social services may affect their long-term social and economic well-being.

 

The Rural Economy

 

A growing part of the rural economy lies in the service sector. The service sector has consistently grown as a share of rural employment and now accounts for nearly two thirds of all jobs in non-metropolitan counties.¹⁴ However, it is worth noting that even within this overall trend, there is tremendous regional variation. In the Upper Midwest and Great Plains, agriculture remains a dominant part of the economy, whereas the South relies more heavily on manufacturing. Coastal and Mountain areas in the South and West are experiencing more service sector expansion to meet the demands of retirees.¹⁵

 

Figure 3: Change in Employment Sectors in Non-metropolitan Counties, 1980-2000

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 Note: Data are calculated applying the current non-metropolitan status of couties to all three time periods. White collar workers include: Management, professional, and related occupations; and technical, sales and administrative support occupations.

Source: See References.

Table 2. Change in Per Capita Income, Poverty, and Unemployment

	Non-metropolitan	Metropolitan
Per Capita Income
1987	$12,322.75	$17,123.23
2004	$25,103.98	$34,658.74
Percent Unemployed
1987	8.32%	5.93%
2005	5.71%	5.03%
Percent in Poverty
1989	16.19%	12.03%
2004	14.45%	12.44%

Sources: See References.

While regional variations exist, for the most part from 1980 to 2000, rural communities saw a shift in their employment base away from occupations such as agriculture and mining to jobs in the service sectors. White collar jobs grew while manufacturing employment slowly declined (Figure 3). Non-metropolitan unemployment decreased from 8.32 percent in 1987 to 5.71 percent in 2005 (Table 2). The gap in unemployment between rural and urban areas also decreased, with the rate in non-metropolitan counties only slightly exceeding the metropolitan unemployment rate in 2005. Non-metropolitan per capita income, unadjusted for inflation, increased from $12,323 in 1987 to $25,104 in 2004. If adjusted for inflation, the data show that a smaller increase in real per capita income occurred; from $20,491 in 1987 (expressed in 2004 dollars) to $25,104 in 2004. Non-metropolitan per capita income as a percent of metropolitan per capita income remained constant at 72 percent.

Poverty

 

The percent of the rural population in poverty declined from 16.9 percent in 1987 to 14.2 percent in 2003.¹⁶ However, rural poverty rates continue to outpace those in urban areas; 12.5 percent of the urban population was in poverty in 1987 and 12.1 percent in 2003.¹⁷

The Economic Research Service defines “persistent poverty counties” as those with at least 20 percent of the population living in poverty for the previous 30 years. Of the 386 counties in America that meet this definition, 340 are non-metropolitan.¹⁸ The minority populations are greater (51.5 percent as compared to 30.8 percent of all counties) and the unemployment rates are higher (9.3 percent compared to 5.8 percent).¹⁹

 

A pressing issue facing rural America is child poverty. Approximately 2.6 million children, or 20 percent of children living in non-metropolitan areas, are poor, accounting for 35 percent of the non-metropolitan population in poverty and 20 percent of the nation’s child poverty.²⁰ Since 1985, the child poverty rate in non-metropolitan areas has never fallen below 18 percent.²¹ The ERS found that families with related children in a female-led household were worse off in non-metropolitan areas, where 43 percent of such families are poor, compared to 35 percent of similar families in metropolitan counties.²²

 

The non-metropolitan poverty rate varies significantly by region. In the Midwest, the non-metropolitan poverty rate was lower than the metropolitan poverty rate in 2004.²³ However, in every other region the non-metropolitan poverty rate was higher than the metropolitan poverty rate, most markedly in the South and West. Out of the 340 non-metropolitan persistent poverty counties, 280 were in the South.²⁴

 

Transfer Payments

 

A related rural economic trend is the rising level of transfer payments to rural residents compared to the level of transfer payments to urban residents. These transfer payments are “income payments to persons for which no current services are performed” and include payments from government programs such as Temporary Assistance for Needy Families (TANF), Food Stamps, Supplemental Security Income (SSI), Earned Income Tax Credit (EITC), and Medicare and Medicaid, among others.²⁵ Between 1980 and 2004, the percentage of non-metropolitan total income accounted for by transfer payments grew from 16 to 22 percent.²⁶ The continued growth of transfer payments has had a positive impact on the ability of some rural communities to offer and sustain needed health and human service programs. In particular, Medicare has had a strong impact on rural poverty in the years since its implementation, which may be associated with adjustments made in the Medicare payment systems to take account of rural economic factors.

These trends – in aging, immigration, the economy, employment, poverty, and transfer payments – have transformed rural America over the past 20 years. The overall picture has improved, but disparities between rural and urban America endure. These trends comprise the context within which the health and human services sectors function and present diverse opportunities and challenges for service provision in rural America today.

Rural Health Care

The demographics of rural America have a direct impact on many factors of health care delivery and outcomes, including rural residents’ health status, health insurance status, access to health care providers, and their communities’ economic viability. What follows is a retrospective analysis of some of the key health issues facing rural communities.

Health Status

 

Analysis of comprehensive data from the National Health Interview Survey (NHIS) and the Medical Expenditure Panel Survey (MEPS) shows that health status is generally worse among rural residents compared to urban residents and that this situation has persisted for the past two decades. For example, even after adjustments were made for the older age distribution of rural populations, NHIS respondents living in non-metropolitan counties were more likely than metropolitan residents to rate their own health as fair or poor. Similar patterns in self-reported health status were found using the MEPS data. Likewise, most chronic diseases have been, and continue to be, more prevalent in rural areas. Data from the NHIS confirm these patterns for chronic conditions, such as various types of joint pain, lower back and neck pain, and vision and hearing problems. Information from the Centers for Disease Control and Prevention (CDC), which produced a report on rural versus urban health differences using data from the mid-to-late 1990s, also demonstrates the poorer health status of rural residents, particularly for people in the most rural areas.²⁷ The CDC data show higher rates of obesity, cigarette smoking, and total tooth loss in non-metropolitan counties. Poorer health status among rural residents translates into higher rates of health-related activity limitations.

 

Whether poorer rural health status also translates into higher mortality rates is a more nuanced question. Crude, or unadjusted, mortality rates are higher in rural areas and tend to increase as the geography becomes more rural (not adjacent to a metropolitan area and without a city of 2,500 or more people).²⁸ Adjusting for underlying differences in the age and gender composition of the population, however, largely eliminates the observed rural versus urban differences in crude mortality rates.²⁹ One striking exception is that death rates for unintentional injuries and motor vehicle accidents are significantly higher in rural areas, even after adjusting for age differences.³⁰ The aggregate national statistics mask important regional differences, however. In particular, numerous analyses have demonstrated persistently higher mortality rates in the Southeast, along the lower Mississippi River, in central Appalachia, and in a few small areas scattered throughout the West and Upper Midwest.³¹ While not all of this territory is rural, much of it is.

 

Research into whether living in a rural location exacerbates health problems associated with particular races is limited. Findings are mixed but do suggest that rural minorities fare worse on some measures. Analysis of 2004 MEPS data indicates that rural blacks were more likely to rate their health as poor or fair and more likely to report limitations in work and physical activity, relative to both urban blacks and rural whites. A study comparing data from 1991 through 1995 also found similar relative disadvantages for rural minorities regarding the prevalence of diabetes and death rates from diabetes and cardiovascular disease.³²

 

Insurance Coverage

 

Between 1987 and 2005, the number of uninsured non-elderly Americans rose by about 2 percent for both rural and urban residents, a change that preserved higher rates of uninsurance in rural areas (about 20.5 percent versus 19.3 percent in urban, Figure 4). Nearly four million rural families (30 percent) had at least one uninsured member in 2001 or 2002.³³ Additionally, there is growing evidence that even rural residents with private health insurance may face large out-of-pocket costs for care as a result of being ‘underinsured.’³⁴

 

Since 1987, rates of private health insurance have declined for all Americans, but particularly in rural areas, where private coverage fell from 72.4 percent to 60.2 percent (Figure 4). This decline in private coverage is the result of rising premium costs and changes in the rural economy. Since the late 1990s, rural areas have seen a marked decline in manufacturing jobs, which tend to offer higher rates of employer-sponsored health insurance (86 percent), accompanied by a rise in service sector employment, in which access to employer-sponsored health insurance has been much lower (63 percent).³⁵ The lack of employer-sponsored health insurance has been particularly apparent for low-skilled jobs.³⁶

 

Figure 4: Rural and Urban Insurance Coverage (Under Age 65), 1987-2005

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Expansions of Federal- and State-sponsored insurance programs in the past 20 years have been important in filling the gaps in coverage in rural America. Public insurance, primarily Medicaid and the State Children’s Health Insurance Program (SCHIP), has grown from covering 8.7 percent of rural non-elderly residents in 1987 to covering 19.3 percent in 2005 (compared to 14.8 percent of urban individuals in 2005). Nearly 40 percent of families in which one family member is uninsured also have a member with public coverage.³⁷

 

Health Care Workforce

 

Over the past 20 years, workforce shortages have posed a fundamental systemic challenge to the rural health care delivery system. These shortages are a long-standing problem for rural communities and appear likely to continue. Rural areas are vulnerable to workforce shortages, in part because small population size and scale often means that the loss of just one physician can have profound effects on a community’s ability to ensure reasonable access to care.

 

The primary method through which workforce shortages are tracked is through the designation of communities as shortage areas, either as Health Professional Shortage Areas (HPSAs) or as Medically Underserved Areas (MUAs). Both of these designations predate the creation of this Committee and they continue to be the primary standards by which the Federal government assesses the ability of a community to meet its health care provider needs.

 

Underserved areas are defined and designated by the Shortage Designation Branch in the Health Resources and Services Administration’s (HRSA) Bureau of Health Professions. Both geographic areas and population groups can be classified as either shortage areas or underserved. More than 34 Federal programs use shortage designations as a funding preference or to determine eligibility. In addition, there are provisions in Medicare that offer enhanced reimbursement based on these shortage designations, explained in more detail later in the report, on p. 31.

 

HPSA designations are determined by strict population to provider ratios and are used to designate shortages of primary medical care, dental, or mental health providers. Through HPSA designation, communities can become eligible for enhanced Medicare physician payments and National Health Service Corps placements, in addition to eligibility for some Federal grant programs and funding preferences. MUAs are defined geographic areas whose residents have a shortage of personal health services.³⁸ MUAs are primarily associated with the Community Health Center program. Applicants for this designation must qualify based on service area, population to primary medical care physician ratio, infant mortality rate, percent of population living below the Federal poverty level, and percent of population over age 65.

 

Table 3. Change in Shortage Designations Across Time

	Non-metropolitan Number	Non-metropolitan Percent	Metropolitan Number	Metropolitan Percent
Primary Care HPSAs
Whole or Partial County
1987	1,066	51.97%	606	55.60%
2004	1,555	75.82%	783	71.83%
Dental HPSAs
Whole or Partial County
1985	460	22.43%	247	22.66%
2005	1,162	56.66%	618	56.70%
Mental Health HPSAs
Whole or Partial County
1995	1,120	54.61%	321	29.45%
2004	1,616	78.79%	597	54.77%

Sources: See References.

The percentage of both non-metropolitan and metropolitan counties with either a whole or partial county primary care HPSA designation increased from 1987 to 2004 (Table 3). Non-metropolitan counties experienced an increase in counties designated as primary care shortage areas, from 52 percent in 1987 to 76 percent in 2004. A similar increase in the percentage of dental shortage areas occurred in both non-metropolitan and metropolitan counties. From 1981 to 2005, the percentage of non-metropolitan counties designated as either whole or partial county dental shortage areas increased from 22 percent to 57 percent.

 

Counties with mental health HPSA designations have a shortage of psychiatrists and/or other core mental health professionals, such as clinical psychologists and clinical social workers.³⁹ In 1995, the first year for which historical data on mental health HPSAs were available, 54 percent of non-metropolitan areas were classified as whole or partial county mental health HPSAs, compared with 29 percent of metropolitan counties. As of 2004, 79 percent of non-metropolitan counties and 55 percent of metropolitan counties were identified as being either whole or partial county mental health HPSAs.⁴⁰

 

While the percentage of counties with HPSA designations has increased substantially over the last 20 years, there has been little growth in the percentage of counties designated as MUAs (Table 3, p. 11). From 1981 to 2005, the percentage of non-metropolitan counties with an MUA designation increased by approximately 1.5 percentage points. Metropolitan counties saw a similar small increase in the percentage of MUA designations, 2.2 percentage points.

 

Physicians

 

Attracting and retaining practicing physicians in rural areas was a problem in 1987 and continues to be a concern today. Even so, physicians of all specialties practice in rural America, including in some of the nation’s leading diagnostic and treatment centers such as the Mayo Clinic in Minnesota, the Marshfield Clinic in Wisconsin, and the Geisinger Clinic in Pennsylvania. However, the most ubiquitous model of physician care in rural areas is the primary care clinic, which often includes a small number of physicians (e.g., one to six) and other primary care providers (e.g., nurse practitioners or physician assistants).

 

 

Table 4. Non-Federal Physicians in Non-metropolitan and Metropolitan Areas, 1988-2004

1988

	No. of Non-Federal Active MDs	Percent	Rate per 100,000
Non-metropolitan	41,742	8.25%	92.5
Metropolitan	464,044	91.75%	231.8
Total	505,786	100.00%	206.2

2004

	No. of Non-Federal Active MDs	Percent	Rate per 100,000
Non-metropolitan	59,289	7.79%	119.3
Metropolitan	701,452	92.21%	287.5
Total	760,741	100.00%	259.1

Note: Non-Federal Physicians are physicians not employed by the Federal Government. They represent 98 percent of all U.S. physicians and include both allopathic physicians (MDs) and osteopathic physicians DOs.)

Sources: See References.

In 1988, the distribution of all non-Federal physicians in the U.S., regardless of specialty, was heavily weighted to metropolitan areas, where 92 percent of all physicians were located (Table 4). For primary care physicians (family practice, general internal medicine, general pediatrics, obstetrics/gynecology), the distribution was closer to the distribution of the population, 24 percent in non-metropolitan areas and 76 percent in metropolitan areas.

 

 

There has been modest improvement in access to care, as judged by the physician to population ratio. For all physicians, the rate per 100,000 people in non-metropolitan areas has increased from 92.5 per 100,000 in 1988 to 119.3 per 100,000 in 2004. Unfortunately, the increase in non-metropolitan primary care physicians has been less substantial, growing from 28.2 per 100,000 in 1985 to 28.5 per 100,000 in 2004. The actual percentage of general practitioners in non-metropolitan versus metropolitan areas has decreased from 24.0 percent in non-metropolitan areas in 1985 to 19.8 percent in 2004.⁴¹

 

Registered Nurses

 

Both the number of registered nurses and the percentage of total registered nurses in non-metropolitan counties have increased during the past 20 years (Table 5). In 1988, there were approximately 370,000 registered nurses in non-metropolitan areas, representing 18 percent of all registered nurses; by 2004 those numbers increased to nearly 530,000 and 20 percent.

 

 

Table 5. Registered Nurses in Non-metropolitan and Metropolitan Areas, 1988-2004

1988

	No. of Registered Nurses	Percent	Rate per 100,000
Non-metropolitan	366,944	18.06%	813.3
Metropolitan	1,664,331	81.94%	831.5
Total	2,031,275	100.00%	828.1

2004

	No. of Registered Nurses	Percent	Rate per 100,000
Non-metropolitan	528,741	19.69%	1063.9
Metropolitan	2,155,967	80.31%	883.7
Total	2,684,708	100.00%	914.2

Sources: See References.

 

Mental Health Professionals

 

In 1990, a Federal report on rural health care, Health Care in Rural America, noted that more than half of all U.S. counties had no mental health provider (psychiatrist, PhD psychologist, social worker, master’s degree psychologist). That publication also reported that 61 percent of all rural residents—over 34 million people—lived in mental health HPSAs and noted that primary care practitioners provided a significant amount of mental health care in rural areas.⁴² A decade later, Rural Health in the United States reported that 76 percent of the 518 mental health HPSAs were rural, accounting for 30 million rural residents.⁴³

 

Assessing the adequacy of the rural mental health workforce has been hampered throughout these two decades by a lack of reliable data for the five key mental health professions: psychiatry, social work, psychology, marriage and family counseling, and psychiatric nursing. Complete lists of licensed providers with practice locations are not available at the national level, with the exception of psychiatry.

 

Promising developments in workforce include growth in psychiatric nursing and in marriage and family counseling.⁴⁴ Since psychiatric nurses are allowed to prescribe medications in most States, their addition to the rural workforce is particularly valuable. In 2002, New Mexico passed a law authorizing PhD psychologists to prescribe psychotropic medications. Louisiana followed in 2004.

 

Dentists

 

Though the national supply of dentists has grown over the last two decades (Table 6, p. 15), a smaller percentage of dentists practice in rural areas today than 20 years ago. While there are 3.82 general practice dentists per 10,000 urban residents, there are only 2.30 per 10,000 rural residents.⁴⁵ Rural areas have long struggled with access to oral health care, an issue that seems likely to continue.

 

Table 6. Change in Dental Workforce, 1987-2004

1987

	Number	Percent	Rate per 100,000
All Active Dentists
Non-metropolitan	20,004	15.25%	36.6
Metropolitan	111,194	84.75%	59.3
General Practice Dentists
Non-metropolitan	14,543	16.85%	26.6
Metropolitan	71,743	83.15%	38.2

2004

	Number	Percent	Rate per 100,000
All Active Dentists
Non-metropolitan	17,367	10.36%	34.9
Metropolitan	150,254	89.64%	61.7
General Practice Dentists
Non-metropolitan	11,514	10.90%	23.2
Metropolitan	94,083	89.10%	38.6

Sources: See References.

Public Health Workforce

 

Though public health is a key part of rural health care, the public health workforce is difficult to quantify because there is no consistent national provider structure. In addition, the first national analysis of public health workforce by geographic location did not take place until recently, so there is no valid comparison point for 1987.

 

In 2001, the National Association of County and City Health Officials (NACCHO) analyzed public health workforce differences between non-metropolitan and metropolitan Local Health Departments (LHDs), finding that non-metropolitan LHDs report an average of 31 full-time employees, and metropolitan LHDs report an average of 108 full-time employees. These estimates are limited, in that they were not compared to population served and did not include non-governmental public health providers. Nonetheless, a 2000 HHS study did note that public health nurses provide the majority of care in many rural areas, and importantly, that the public health workforce is aging and retiring, especially within public health nursing.⁴⁶

 

Primary Care Infrastructure and Providers

 

Rural residents rely on a variety of providers to meet their primary health care needs, ranging from private physician practices to other Federally-designated ambulatory care sites such as Federally Qualified Health Centers (FQHCs) and Medicare-certified Rural Health Clinics (RHCs).

 

Federally Qualified Health Centers

 

Federally Qualified Health Centers (FQHCs) include several types of entities. Grant-Supported Federally Qualified Health Centers (Section 330 health centers) are public and private non-profit health care organizations that meet certain criteria under the Medicare and Medicaid Programs (respectively, Sections 1861(aa)(4) and 1905(l)(2)(B) of the Social Security Act), and receive funds under the Health Center Program (Section 330 of the Public Health Service (PHS) Act). Section 330 health centers include:

 

Federally Qualified Health Center Look-Alikes are health centers that have been identified by HRSA and certified by the Centers for Medicare and Medicaid Services (CMS) as meeting the definition of “health center” under Section 330 of the PHS Act, although they do not receive grant funding under Section 330. Finally, there are outpatient health programs and facilities operated by Tribal organizations (under the Indian Self-Determination Act, P.L. 96-638) or urban Indian organizations (under the Indian Health Care Improvement Act, P.L. 94-437).

 

Section 330 health centers are private, non-profit, and public consumer-directed entities that provide primary and preventive health care, as well as services such as transportation and translation for the underserved and the uninsured, regardless of their ability to pay. HRSA grants provide approximately 20 percent of Section 330 health centers’ revenue, with most of the remaining revenue coming from Medicaid, Medicare, other public and private insurance payers, and State and local grants and contracts.⁴⁷

 

In 1984, the Bureau of Health Care Delivery and Assistance (now HRSA’s Bureau of Primary Health Care) listed a total of 608 rural and urban FQHCs funded under the Health Center Program.⁴⁸  The number of rural FQHCs has increased substantially in the past 20 years, making the centers a significant component of America’s health care safety net.  HRSA currently funds 1,071 health center grantees under Section 330 of the PHS Act, of which approximately half have a majority of their patients coming from rural areas.⁴⁹  The President’s Health Center Initiative provided grant support for over 1,200 new and expanded health center sites from 2002 through 2007, significantly expanding access in rural areas.  Between 2002 and 2007, the number of HRSA-supported health centers serving rural areas increased by 35 percent to 526 and the number of patients served by these centers increased by 38 percent to 6.7 million.⁵⁰

 

The number of Health Center Program grantees, though large, fails to reflect the total number of service delivery sites. Many Section 330 health centers operate multiple service delivery sites, and some service delivery sites serve both rural and urban areas. A definitive count of the number of rural service delivery sites will be available in mid-2008. In addition, there are 236 FQHC look-alike service sites, 40 of which are located in non-metropolitan counties.⁵¹

 

Rural Health Clinics

 

The Rural Health Clinic (RHC) is another provider type that has become increasingly important to rural areas during the past 20 years. Established in 1977, the goal of the RHC designation was to expand rural access to primary care services by providing Medicare and Medicaid cost-based reimbursement to RHCs and extending that reimbursement to mid-level health professionals. An RHC must be located in a rural HPSA, deliver outpatient primary care, employ at least one mid-level health professional active during half of its operating hours, and operate under the medical direction of a licensed physician.⁵²

 

RHCs have seen significant growth since the designation was first established. In 1980, there were only 285 designated clinics nationwide, as compared to the 2,801 clinics designated in rural areas in 2006.⁵³ Many rural hospitals use provider-based RHCs to employ physicians and improve recruitment and retention in their communities.

 

Inpatient Care

 

Across the U.S., the number of hospitals and hospital beds has decreased over the last 20 years, reflecting a national trend toward shorter lengths of stay and movement of services to outpatient facilities. In 1987, there were 2,343 rural acute care hospitals, compared to 3,401 urban facilities. In 2007, there were 2,032 rural hospitals, compared to 2,723 urban hospitals.

 

Rural hospitals have struggled over time to remain financially viable. The median operating margin in 1987 was -3.63 percent, reflecting a financial loss from the provision of patient care. Losses improved to -2.04 percent in 2004, but remained inadequate to ensure financial stability. It is also important to note that in 1987, all hospitals, both rural and urban, were paid under the Medicare Inpatient Prospective Payment System (IPPS), whereas many rural hospitals are now paid under a variety of alternative reimbursement methodologies that emerged to address rural hospital viability under prospective payment methodology. These payment designations include Sole Community Hospitals (SCHs), Medicare-Dependent Hospitals (MDHs), Rural Referral Centers (RRCs), and Critical Access Hospitals (CAHs). The designation of CAHs proved to be the biggest change for rural hospitals over the past 2 decades, as it created a cost-based reimbursement system for hospitals located in a rural area with 25 beds or fewer. The CAH model has proven to be successful in ensuring access to inpatient, outpatient, and emergency medical services in rural communities. The primary benefit of conversion to CAH status has been that these facilities no longer lose money on Medicare because they are paid for 101 percent of costs. However, the designation does not address any financial shortfalls that occur when Medicaid or private pay reimbursement falls below hospital costs. For more information, see Key Changes, p. 31.

 

Post-Acute Care

 

Post-acute care services can be defined as skilled services rendered to patients after an episode of acute illness, as part of the rehabilitation or recuperative phase of a patient’s recovery.⁵⁴ Post-acute care includes but is not limited to care provided by home health agencies (HHAs), skilled nursing facilities (SNFs), and nursing facilities (NFs).

 

Data on the prevalence of rural HHAs or SNFs in 1987 were not available. HHAs provide a variety of services within patients’ homes, such as skilled nursing care, physical therapy, occupational therapy, and speech therapy.⁵⁵ In 2006 there were 2,116 HHAs located in non-metropolitan counties, although it is quite likely that many rural areas were also served by agencies with a home office in a metropolitan county.

 

In addition to HHAs, Medicare records show that in 2006, rural areas contained 130 stand-alone SNFs, 3,708 facilities that were dually certified for SNF and NF care, and 766 SNF or NF facilities that were units of rural hospitals.

 

In rural hospitals and CAHs, skilled nursing care is increasingly provided with swing beds, arrangements which allow a facility to use its beds to provide either acute or skilled nursing care as needed. The proportion of small, under 100-bed hospitals that used swing beds increased from 50 percent in 1996 to 68 percent by 2003. Data on swing bed utilization prior to 1996 do not exist. The largest increase in swing bed use occurred in hospitals that had converted or were converting to CAH status, with 95 percent of CAHs using swing beds by 2003.⁵⁶

Emergency Medical Services

 

Access to emergency medical services (EMS) is an important issue for rural communities given the realities of geographic isolation and travel time to care. Half of the nation’s ambulance services provide care to the 75 percent of Medicare beneficiaries living in urban areas while the other half of services provide care to the 25 percent living in rural areas.⁵⁷ Unfortunately, there is little data available to analyze the current rural EMS system or how it has evolved in the past two decades. A 1989 study of rural EMS by the U.S. Congress Office of Technology Assessment (OTA) noted that the ability of rural communities to provide EMS services was made more difficult by struggling rural economies, a lack of an adequate workforce, and a reliance on volunteers to provide needed services. The role of EMS as a front-line health care service is more significant in rural areas where access to preventive, primary, and specialty health care services is limited and EMS is often the only source of health care for miles.⁵⁸

 

In 2007, the Institute of Medicine (IOM) published The Future of Emergency Care in the United States Health System. The report notes that while there have been some advances, such as broadened 911 coverage, there was an abrupt decline in Federal funding and leadership in the early 1980s. Since then, “the push to develop more organized systems of EMS delivery has diminished, and EMS systems have been left to develop haphazardly across the United States.”⁵⁹ In addition to the OTA’s listed challenges, the IOM report cited low patient volume, vast distances to travel, limited infrastructure, and inadequate support funding as complications to progress in rural EMS. Meanwhile, the challenges recognized by the OTA in 1989 remain challenges today.⁶⁰

 

Including first responders, there are an estimated 1 million EMS personnel nationally serving over 18,000 EMS agencies.⁶¹ Roughly 10 percent of all Emergency Department care is initially provided by EMS providers and millions more EMS encounters occur annually for non-emergent needs.⁶² EMS utilization has increased 16 percent from 2001 to 2004 and is expected to increase more dramatically as the population ages.⁶³

 

Costs of providing services are higher for rural-based EMS agencies.⁶⁴ These cost disparities derive from low call volume and thus less opportunity to bill for services, and high staff turnover. The GAO recently reported that rural ambulance Medicare payments were 17 percent less than the actual cost to provide them.⁶⁵

 

Public Health Infrastructure

 

As noted earlier, rural public health comparisons over the past two decades cannot be quantified due to a lack of data. The primary source for understanding rural public health infrastructure comes from the 2001 NACCHO study, Local Public Health Agency Infrastructure: A Chartbook, which included the first non-metropolitan versus metropolitan comparison of Local Health Departments (LHDs).⁶⁶ The NACCHO report notes that the scale of resources available to LHDs varies greatly; mean annual expenditures in 2001 were $1.2 million for non-metropolitan agencies compared to $8.9 million for metropolitan agencies (median expenditures were $0.5 million and $1.2 million, respectively).

 

Contrasts in the source of funding were also found, with non-metropolitan LHDs deriving a smaller proportion of their overall resources from the local government and a larger proportion from State reimbursement for services.⁶⁷ Given that local resources are traditionally accompanied by fewer restrictions than State categorical funding, the disproportionate reliance on Federal and State sources may limit the ability of rural LHDs to address serious local health threats that fall outside of categorical grant guidelines.

 

Despite the dependence of rural LHDs on service reimbursement, far fewer LHDs are directly providing clinical services today than 20 years ago.⁶⁸ Indeed, while the 1992 NACCHO study reported that 30 percent of all LHDs provided primary care services, that percentage had dropped to 14 percent by 2005. This trend is particularly salient in non-metropolitan areas, as only 11 percent of the LHDs within the smallest jurisdictions (less than 25,000 people) reported providing primary care services in 2001, compared to 43 percent of the LHDs within the largest jurisdictions (over 500,000 people).⁶⁹

 

Rural Human Services

Human Services are provided by a patchwork of Federal programs that support specific populations from young children to families to the elderly.Unlike most health services, which address the entire population including the healthy, human services cater to only those people with specific needs, such as housing, employment, or child care.Human services emerge in order to address these needs, which may differ by community in both the type of need and the best way to address it.Thus, the resulting Federal human services infrastructure is a composite of Federal and State solutions to a variety of local needs. There is no rural focal point for human services at either the State or Federal level.While HHS has an Office of Rural Health Policy, there is no similar entity that focuses on rural human services issues. The array of programs targeted to human services needs is vast and their administration is fragmented and incompletely documented and reported from a rural perspective.Therefore, for this retrospective, we have only been able to consider the larger programs that significantly affect rural residents.

 

Publicly available data and published analyses on rural human services programs are limited. Therefore, the following comparison between 1987 and 2007 lacks some rural-specific data. Because human services often target individuals and families with low incomes, one proxy for human services need is degree of poverty. While there may not be specific rural data from Federal human services programs, extensive data document the scope of rural poverty. As discussed in the first part of this chapter, overall poverty is higher in rural areas, child poverty is especially pronounced, and fully 88 percent of persistent poverty counties are in rural areas. Given this extensive poverty, it is clear that human services are essential to the well-being of millions of rural Americans.

 

Human Services Provider Infrastructure

 

Many Federal human services funds are distributed by formula or block grants to States. Block grants were specifically designed to allow for State flexibility in spending Federal funds and thus, many human services block grant programs may structure their services differently. Thus, a medley of State departments, non-profit organizations, faith-based organizations, and other entities provide human services nationwide; there is no consistent delivery system as with hospitals, rural health clinics, community health centers, and the other providers discussed in the health care section. While health services are coordinated in terms of the provider, human services delivery is designed around the individual client. Thus, as a corollary to the health care section’s explanation of provider structures, this section considers a variety of Federal programs themselves.

 

What follows is a brief analysis of some of the key human services programs that benefit rural residents. Some of these programs are administered by HHS while others are targeted anti-poverty/income support programs situated in other Cabinet-level Departments. At their core, however, these programs provide important services to rural low-income families, individuals, children, and seniors.

 

Economic Assistance

 

In 1987, the most significant form of cash assistance to low-income families was Aid to Families with Dependent Children (AFDC), an entitlement program. There were over 11 million recipients, 7.4 million of whom were children, who received nearly $10 billion ($18.5 billion in 2007 dollars) in benefits.⁷⁰ After welfare reform in 1996, this cash assistance was replaced by Temporary Assistance for Needy Families (TANF), a block grant for States to distribute, with a five-year life-time participation limit and stringent work requirements. In 2007, TANF was appropriated $16.5 billion and aided an average monthly total of four million people nationwide, just one third of the 1987 caseload.⁷¹

 

In 2003, an average of 293,000 rural families received payments from TANF each month, which represented 14.5 percent of all TANF recipient families.⁷² These numbers are disproportionately low considering the proportion of rural people who live in poverty compared to the broader population.⁷³ TANF has low utilization rates in rural areas in part because of job scarcity, lack of public transportation, low wages, and few services such as job readiness programs or child care. These factors combine to make the TANF welfare-to-work model particularly trying for rural residents.⁷⁴ The Administration for Children and Families (ACF) in HHS supported a seven-year demonstration project that evaluated strategies to address these rural challenges. While this demonstration yielded mixed success, it did find that effective local staffing is vital to program success, collaboration with other programs is crucial, and data for evaluation are difficult to gather.⁷⁵ A discussion of the transformation from AFDC to TANF is provided in the next chapter on p. 37.

 

Energy Assistance

 

The Low Income Home Energy Assistance Program (LIHEAP), also administered through ACF and initiated in 1981, provides block grants to States for financial assistance to help low-income households cover heating and cooling costs. LIHEAP provided $1.88 billion in energy assistance in 1987 and $1.98 billion in 2007.⁷⁶ Adjusted for inflation, 1987 LIHEAP funding was $3.48 billion in 2007 dollars, reflecting a 34 percent relative decrease to 2007. Although there is no documentation of the expenditure of LIHEAP funds in rural areas, LIHEAP is an important program for low-income households and anecdotal evidence suggests that LIHEAP is a significant source of financial assistance for rural low-income households.

Head Start

 

Head Start, administered through ACF, provides grants to local institutions to provide comprehensive child development services to economically disadvantaged children and families. These local institutions provide education, nutrition, health services, parent training, and other services. Head Start, which serves children from age 3 until they start school, began in 1965, and Early Head Start, for children ages 0 to 3, was created in 1994.

 

The Committee examined Head Start in its 2007 report, discussing the limitations of rural data while noting that Head Start and Early Head Start serve millions of rural children and families.⁷⁷ In both Head Start and Early Head Start, rural programs are more likely than urban programs to utilize a home-based approach rather than a center-based one.⁷⁸ Rural communities have struggled to meet the enrollment requirements for sustaining a Head Start center.⁷⁹ In its 2007 report, the Committee found that minor population shifts or modest changes in family income could change enrollment numbers and jeopardize the continuation of a Head Start program.

 

Eligibility for participation in Head Start is determined by family income; to enroll, the family income must either be below the Federal poverty level or at a level eligible for public assistance.⁸⁰ Given that poverty rates are higher in rural areas, it can be inferred that Head Start remains critically important to rural children, especially considering the lack of high quality preschool centers or licensed child care as well as the distances families must travel to access such services. The Committee could not find rural enrollment data for 1987 but in 2000, 30 percent of children enrolled in Head Start lived in rural areas.⁸¹ Nationally, in 1987 Head Start spent $1.13 billion ($2.01 billion in 2006 dollars) for 446,523 children and in 2006 Head Start spent $6.78 billion on 909,201 enrolled children.

Child Care

 

Affordable child care remains a concern in rural areas. Rural areas may not be able to support localized child care providers because of smaller population bases. Parents may have difficulty finding alternative care options due to long distances, limited hours of operation, and fewer qualified caretakers.⁸² Nationally, child care support for parents on welfare began with enactment of the Family Support Act of 1988 and was expanded in 1990 into the Child Care and Development Block Grant and the At-Risk Child Care Program.⁸³ In 1996, the Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA) synthesized previous Social Security Act child care opportunities and the Child Care and Development Block Grant into the Child Care and Development Fund (CCDF). Families receive cash assistance for child care from State dispensers of CCDF.⁸⁴ CCDF is the nation’s largest child care resource for low-income parents engaged in work or job readiness activities.

 

 

Table 7. Number and National Percentage of Children in CCDF by County Type*, 2004

Children in CCDF**

	Number	Percent of U.S. Total
U.S. Total	1,737,000	100%
Rural	133,000	8%
Mixed-Rural	542,000	31%
Mixed-Urban	239,000	14%
Urban	823,000	47%

 

All Children Ages 0 to 9

	Number	Percent of U.S. Total
U.S. Total	39,675,000	100%
Rural	3,646,000	9%
Mixed-Rural	12,131,000	31%
Mixed-Urban	5,903,000	15%
Urban	18,177,000	46%

Sources: See References.

Note: Numbers rounded to the nearest thousand.

*Based on the Census Bureau's definition of rural and urban, "Counties that almost entirely consist of either urban or rural areas are designated simply as urban or rural. Counties that are not readily defined as primarily urban or rural are designated as mixed-urban or mixed-rural, depending on their popu;ation density." See table reference, p.2.

** CCDF funding is available for children through age 13, or through age 19 if the child is incapable of self-care or under court supervision.

Source: See References.

The earliest publicly available data on child care from CCDF are from 1998, when 1.5 million children received child care through CCDF on average each month. In fiscal year 2005, CCDF spent almost $9.4 billion to provide child care for approximately 1.75 million children each month, reflecting modest growth over the past 10 years. While the percentages of children in rural and urban areas supported by CCDF were roughly the same (Table 7), the site of care differed. Compared to urban areas, rural areas were less likely to use center-based care and more likely to use family-based care.⁸⁵

 

Elderly Services

 

As discussed earlier in this report, a disproportionate number of elderly individuals live in rural areas and this number continues to rise. Statistics show that rural elderly are less healthy, less educated, more isolated, have lower incomes, and have fewer transportation options than their urban counterparts. In non-metropolitan areas, 15.3 percent of seniors have at least one limitation in Activities of Daily Living (ADL) compared to 12.7 percent in metropolitan areas. ADL difficulty provides a good proxy for human services need, suggesting that rural elderly need some human services even more than urban elderly.⁸⁶

 

President Lyndon B. Johnson signed the Older Americans Act (OAA) into law on July 14, 1965. The OAA created the Administration on Aging (AoA) and authorized grants to States for community-based nutrition programs, as well as research, demonstration, and training projects in the field of aging. With authority from the OAA, the AoA funds services for the elderly including personal care, homemaker assistance, chores, home delivered meals, adult day care, case management, assisted transportation, congregate meals, nutrition counseling, legal assistance, and other services. Data could not be located from 1987 on rural participation but in fiscal year 2005, 979,954 rural clients were registered, comprising 33.4 percent of OAA program recipients.⁸⁷

 

Key Non-HHS Human Services Programs

 

In addition to the HHS programs discussed above, other Federal Departments provide much needed human services support, in large part through anti-poverty programs.

 

 [D]

Earned Income Tax Credit (EITC)

The Internal Revenue Service (IRS) in the U.S. Department of the Treasury administers the Earned Income Tax Credit (EITC), a Federal refundable tax credit available to taxpayers with low earnings. The EITC functions as a wage supplement and work incentive for low-income workers. Taxpayers receive a percentage of their earnings; the more one makes, the more one receives in cash credit, until the income level at which the EITC phases out (Figure 5). EITC payments do not count when determining income eligibility for most other benefits. The EITC has become one of the largest Federal programs providing cash supports to low-income families and has grown in both absolute value and relative importance in the past 20 years (Figure 6).

 

The EITC was originally enacted in 1975.⁸⁸ Rural Americans rely particularly heavily on the EITC and there are higher rural rates of EITC receipt.⁸⁹ Although the Committee could not find rural data from 1987, in 2004, while only 16 percent of U.S. tax filers lived in rural areas, 20 percent of the $39.8 billion EITC went to rural Americans. In 42 of 48 States with rural populations, a higher percentage of rural taxpayers received the EITC compared to urban.⁹⁰ Rural families receiving the EITC were credited with $1,850, on average.⁹¹

 

Section 8 Certificates and Vouchers

Low-income families, the elderly, and the disabled are eligible to receive Section 8 certificates and vouchers administered through the U.S. Department of Housing and Urban Development (HUD) to help them lease or purchase decent, safe, sanitary, and affordable housing.⁹² These certificates and vouchers were created through the Housing and Community Development Act of 1974 and require that individuals spend 30 percent of their income on rent with the remainder of the cost made up by the Federal government. Although 1987 data were not publicly available, the Committee found that in 2000, 630,300 individuals in non-metropolitan areas lived in housing through Section 8 certificates and vouchers, representing 15.8 percent of national Section 8 certificate and voucher recipients.⁹³ The program remains an important component in the rural human services safety net.

 

Food Stamps

The first Food Stamp Program started in 1939, ended in 1943, and became permanent with the Food Stamp Act of 1964. It is administered by the U.S. Department of Agriculture’s (USDA) Food and Nutrition Service. In 1987, 19.1 million people received an average of $45.78 per person in food stamp benefits each month ($81.24 in 2006 dollars).⁹⁴ That number rose to nearly 26.7 million people receiving an average of $94.31 per month in 2006.⁹⁵ In that same year, approximately 22.4 percent of food stamp beneficiaries lived in non-metropolitan areas.⁹⁶ Participation rates in the food stamp program are higher in non-metropolitan areas, where 78 percent of those eligible receive food stamps, compared to 62 percent of those eligible in metropolitan areas.⁹⁷

 

Figure 6: Sources of Income for Low-Income Households with Children, 1991-2005

Thousands of 2005 dollars

[D]

Note: Annual cash income was adjusted for inflation using the research series for the consumer price index for all consumers. Other income consists of Social Security, Supplemental Security Income, child support, unemployment compensation, workers’ compensation, disability benefits, pension or retirement income, educational assistance, financial assistance from outside of the household and other cash income.

 

 

Women, Infants, and Children (WIC)

Women, Infants, and Children (WIC) is also administered by the USDA Food and Nutrition Service and provides grants to States for “supplemental foods, health care referrals, and nutrition education for low-income pregnant, breastfeeding, and non-breastfeeding postpartum women, and to infants and children up to age five who are found to be at nutritional risk.”⁹⁸ Started in 1974, WIC had 3.4 million participants in 1987 and nearly 8.1 million in 2006.⁹⁹ National participation increased 3.3 percent between September 2006 and September 2007, continuing the upward trend.¹⁰⁰ The average monthly food cost per person allotment has increased in the past 20 years, from $32.68 in 1987 to $37.08 in 2006.¹⁰¹  However, in real terms the per person allotment has decreased, since the 1987 allotment represents $58.00 in 2006 dollars. WIC is not an entitlement program and each year Congressional appropriations determine funding levels. While data were not publicly available for a comparison of rural and urban areas, the previously discussed socio-economic factors facing rural areas indicate that WIC may play an important role for low-income rural women, infants, and children.

 

Workforce

The Committee is not aware of any significant and targeted Federal programs that focus on human services workforce development and training. There is no basis for a comparison between 1987 and 2007 because there are no standards by which to measure the human services workforce and no programs to promote it. Anecdotal reports indicate that the rural human services workforce suffers from professional isolation, low wages, and increasing stress and caseloads.

 

References

¹ Ricketts, T.C., Johnson-Webb, K.D. & Taylor, P. (1998). Definitions of Rural: A Handbook for Health Policy Makers and Researchers. (Working Paper 62). Chapel Hill, NC: North Carolina Rural Health Research and Policy Analysis Center; and Coburn, A.F., MacKinney, A.C., McBride, T.D., Mueller, K.J., Slifkin, R.T. & Wakefield, M.K. (2007). Choosing Rural Definitions: Implications for Health Policy. (Issue Brief no. 2). Columbia, MO: RUPRI Rural Policy Research Institute Health Panel.

² Ibid.

³ Jones, C.A., Kandel, W. & Parker, T. (April 2007). “Population Dynamics Are Changing the Profile of Rural America.” Amber Waves. Vol. 5, Issue 2. Washington, D.C.: U.S. Department of Agriculture, Economic Research Service.

⁴ Ibid.

⁵ Ibid.

⁶ Economic Research Service. (February 2007). “Nonmetro America Faces Challenges From an Aging Population.” (Rural Population and Migration Briefing). U.S. Department of Agriculture. http://www.ers.usda.gov/Briefing/Population/Challenges.htm

⁷ Cromartie, J. & Gibbs, R. (February 28, 2007). “Rural America: Then, Now, and in the Future.” Remarks to the NACRHHS February Meeting.

⁸ Rogers, C.C. (2002). “The Older Population in 21st Century Rural America.” Rural America. Vol. 17, no. 3. Washington, D.C.: U.S. Department of Agriculture, Economic Research Service.

⁹ Kandel, W. & Cromartie, J. (2004). New Patterns of Hispanic Settlement in Rural America. (Rural Development Research Report no. 99). Washington, D.C.: U.S. Department of Agriculture, Economic Research Service. 2.

¹⁰ Ibid, 11.

¹¹ Ibid, 31.

¹² Ibid, 23.

¹³ Whitener, L.A. & Parker, T. (May 2007). “Policy Options for a Changing Rural America.” Amber Waves - Perspectives on Food and Farm Policy. Vol. 5, Special Issue. Washington, D.C.: U.S. Department of Agriculture, Economic Research Service. 61.

¹⁴ Cromartie, J. & Gibbs, R. (February 28, 2007). “Rural America: Then, Now, and in the Future.” Remarks to the NACRHHS February Meeting.

¹⁵ Economic Research Service. (February 1995). “Retirement-Destination Counties.” Understanding Rural America. (Agriculture Information Bulletin no. 710). Washington, D.C.: U.S. Department of Agriculture.

¹⁶ Economic Research Service. (November 2004). Figure: “Poverty Rates by Residence, 1954-2003.” Rural Poverty. (Rural Income, Poverty, and Welfare Briefing). U.S. Department of Agriculture. http://www.ers.usda.gov/briefing/IncomePovetyWelfare/ruralpoverty

¹⁷ Ibid.

¹⁸ Jolliffe, D. (September 2004). “Persistent Poverty Is More Pervasive in Nonmetro Counties.” Amber Waves. Vol. 2, Issue 4. Washington, D.C.: U.S. Department of Agriculture, Economic Research Service.

¹⁹ Dabson, B. (February 28, 2007). “Rural Poverty and Its Impact on Future Health and Human Service Delivery” Remarks to the NACRHHS February Meeting.

²⁰ Economic Research Service. (July 2004). Pamphlet: Rural Poverty at a Glance. (Rural Development Research Report no. 100). Washington, D.C.: U.S. Department of Agriculture.

²¹ Ibid.

²² Economic Research Service. (2007). Pamphlet: Rural America at a Glance. Economic Information Bulletin No. (EIB-31). U.S. Department of Agriculture.

²³ Economic Research Service. (November 2004). “Rural Poverty.” (Rural Income, Poverty, and Welfare Briefing). U.S. Department of Agriculture. http://www.ers.usda.gov/briefing/IncomePovertyWelfare/ruralpoverty

²⁴ Ibid.

²⁵ Bureau of Economic Analysis. (February 2004). “Transfer Payments.” State Personal Income Methodology, 1996-2001. U.S. Department of Commerce. http://www.bea.gov/regional/docs/spi2001/transfer.cfm

²⁶ Cromartie, J. & Gibbs, R. (February 28, 2007). “Rural America: Then, Now, and in the Future.” Remarks to the NACRHHS February Meeting.

²⁷ National Center for Health Statistics. (2001). Health, United States, 2001, With Urban and Rural Health Chartbook. (Pub. no. PHS 01-1232). Hyattsville, MD: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention.

²⁸ Ricketts, T.C., III, Johnson-Webb, K.D. & Randolph, R.K. (1999). “Populations and Places in Rural America.” In Ricketts, T.C., III. (Ed.). Rural Health in the United States. New York, NY: Oxford University Press. 19-20.

²⁹ Miller, M.K., Farmer, F.L. & Clarke, L.L. (1994). “Rural Populations and their Health.” In Beaulieu, J.E. & Berry, D.E. (Eds.). Rural Health Services: A Management Perspective. Ann Arbor, MI: AUPHA Press/Health Administration Press. 3-26.

³⁰ National Center for Health Statistics. (2001). Health, United States, 2001, With Urban and Rural Health Chartbook. (Pub. no. PHS 01-1232). Hyattsville, MD: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention.

³¹ Miller, M.K., Farmer, F.L. & Clarke, L.L. (1994). “Rural Populations and their Health.” In Beaulieu, J.E. & Berry, D.E. (Eds.) Rural Health Services: A Management Perspective. Ann Arbor, MI: AUPHA Press/Health Administration Press. 3-26; Cossman, R.E., Blanchard, T., James, W., Jackson-Belli, R. & Cosby, A. (2002). “Healthy and Unhealthy Places in America: Are These Really Spatial Clusters?” Proceedings of the 22nd Annual ESRI International User Conference. http://gis.esri.com/library/userconf/proc02/pap1064/p1064.htm; Pickle, L.W., Mungiole, M., Jones, G.K. & White, A.A. (1997). Atlas of United States Mortality. (Pub. no. PHS 97-1015). Hyattsville, MD: U.S. Department of Health and Human Services, National Center for Health Statistics; and Halverson, J.A. (2007). Underlying Socioeconomic Factors Influencing Health Disparities in the Appalachian Region. (Prepared for the Appalachian Regional Commission, contract no. C0-128840). Draft Final Report.

³² Slifkin, R.T., Goldsmith, L. J. & Ricketts, T.C., III. (2000). Race and Place: Urban-Rural Differences in Health for Racial and Ethnic Minorities. (Findings Brief 61). Chapel Hill, NC: University of North Carolina at Chapel Hill.

³³ Ziller, E. (2007). Rural Families More Likely to be Uninsured and Have Different Sources of Coverage (Research & Policy Brief). Portland, ME: University of Southern Maine, Maine Rural Health Research Center.

³⁴ Ziller, E.C., Coburn, A.F. & Yousefian, A.E. (2006). “Out-of-Pocket Health Spending and the Rural Underinsured.” Health Affairs. Vol. 25, no. 6. 1688-1699.

³⁵ Clemens-Cope, L. & Garrett, B. (2006). Changes in Employer-Sponsored Health Insurance Sponsorship, Eligibility, and Participation: 2001-2005. Washington, D.C.: Kaiser Commission on Medicaid and the Uninsured.

³⁶ Gibbs, R. & Parker, T. (2007). “Rural Low-Wage Workers Face Multiple Economic Disadvantages.” Amber Waves. Vol. 5, Issue 3. Washington, D.C.: U.S. Department of Agriculture, Economic Research Service.

³⁷ Ziller, E. (June 2007). Rural Families More Likely to be Uninsured and Have Different Sources of Coverage (Research & Policy Brief). Portland, ME: University of Southern Maine, Maine Rural Health Research Center.

³⁸ Bureau of Health Professions. (n.d.). “Shortage Designation.” U.S. Department of Health and Human Services, Health Resources and Services Administration. http://bhpr.hrsa.gov/shortage/

³⁹ Bureau of Health Professions. (n.d.). “Health Professional Shortage Area Mental Health Designation Criteria.” U.S. Department of Health and Human Services, Health Resources and Services Administration. http://bhpr.hrsa.gov/shortage/hpsacritmental.htm

⁴⁰ Cecil G. Sheps Center for Health Services Research calculations, using (1) Office of Research and Planning. (February 1999). “Area Resource File, 1999.” Washington, D.C.: Department of Health and Human Services, Health Resources and Services Administration. (2) National Center for Health Workforce Analysis. (February 2005). “Area Resource File, 2005.” Washington, D.C.: U.S. Department of Health and Human Services, Health Resources and Services Administration.

⁴¹ National Center for Health Workforce Analysis. (February 2005). “Area Resource File, 2005.” Washington, D.C.: U.S. Department of Health and Human Services, Health Resources and Services Administration.

⁴² U.S. Congress, Office of Technology Assessment. (September 1990). Health Care in Rural America. (Pub. no. OTA-H-434). Washington, D.C.: U.S. Government Printing Office.

⁴³ Hartley, D., Bird, D. & Dempsey, P. (1999). “Rural Mental Health and Substance Abuse.” In Ricketts, T.C., III. (Ed.). Rural Health in the United States. New York, NY: Oxford University Press. 159-178.

⁴⁴ Hanrahan, N. & Hartley, D. (2004) Are Advanced Practice Psychiatric Nurses a Solution to Rural Mental Health Workforce Shortages? (Working Paper no. 31). Portland, ME: University of Southern Maine, Maine Rural Health Research Center.

⁴⁵ North Carolina Rural Health Research & Policy Analysis Center calculations using (1) American Dental Association. (2004) Database: “The American Dental Association Database of Dentists.” (2) Bureau of the Census. (2006). Historical Metropolitan Area Definitions. U.S. Department of Commerce.

⁴⁶ National Center for Health Workforce Information and Analysis. (2000). The Public Health Workforce, Enumeration 2000. Washington, D.C.: U.S. Department of Health and Human Services, Health Resources and Services Administration, Bureau of Health Professions.

⁴⁷ Bureau of Primary Health Care. (n.d.). “What is a Health Center?” U.S. Department of Health and Human Services, Health Resources and Services Administration. http://bphc.hrsa.gov/about/; and Personal Communication, Data Branch, Bureau of Primary Health Care, Health Resources and Services Administration. (February 2008).

⁴⁸ U.S. Congress, Office of Technology Assessment. (September 1990). Health Care in Rural America. (Pub. no. OTA-H-434). Washington, D.C.: U.S. Government Printing Office.

⁴⁹ Personal Communication, Data Branch, Bureau of Primary Health Care, Health Resources and Services Administration. (October 2007).

⁵⁰ HRSA Press Office. (December 5, 2007). HHS Marks Expansion of 1200^th Health Center, Meeting Key Bush Goal. Rockville, MD: U.S. Department of Health and Human Services, Human Resources and Services Administration; and Personal Communication, Data Branch, Bureau of Primary Health Care, Health Resources and Services Administration. (February 2008).

⁵¹ Federal Office of Rural Health Policy calculations, using (1) Bureau of the Census. (n.d.). Database: “Locate a County by Place Name.” City and County Quickfacts portal. U.S. Department of Commerce. http://quickfacts.census.gov/cgi-bin/qfd/lookup?state=06000; (2) Office of Rural Health Policy. (n.d.). Database: “Geographic Eligibility for Rural Health Grant Programs.” U.S. Department of Health and Human Services. http://ruralhealth.hrsa.gov/funding/eligibilitytestv2.asp

⁵² Niemeier, M. (2006). “Rural health clinics: Frequently Asked Questions.” Rural Assistance Center (RAC). http://www.raconline.org/info_guides/clinics/rhcfaq.php#whatis

⁵³ Ibid.

⁵⁴ Dalton, K., Park, J., Howard, A. & Slifkin, R.T. (2005). Trends in Skilled Nursing and Swing-bed Use in Rural Areas. (Working Paper 83). Chapel Hill, NC: North Carolina Rural Health Research and Policy Analysis Center.

⁵⁵ Centers for Medicare and Medicaid Services. (n.d.). “Home Health Compare.” U.S. Department of Health and Human Services. http://www.medicare.gov/HHCompare/Home.asp?dest=NAV|Home|About|WhatIs#TabTop

⁵⁶ Dalton, K., Park, J., Howard, A & Slifkin, R.T. (2005). Trends in Skilled Nursing and Swing-bed Use in Rural Areas (Working Paper 83). Chapel Hill, NC: North Carolina Rural Health Research and Policy Analysis Center.

⁵⁷ North Central EMS Institute calculations, using (1) Technical Assistance and Services Center (TASC). (n.d.). Database: “Ambulance Service Database, with Zip Code Analysis.” National Association of State EMS Officials (NASEMSO) and American Ambulance Association (AAA); (2) Centers for Medicare and Medicaid Services. (n.d.). Database: “Location of Medicare Beneficiaries.” Baltimore, MD: U.S. Department of Health and Human Services.

⁵⁸ U.S. Congress, Office of Technology Assessment. (1989). Rural Emergency Medical Services - Special Report. (Pub. no. OTA-H-445). Washington, D.C.: U.S. Government Printing Office.

⁵⁹ Committee on the Future of Emergency Care in the United States Health System. (2007). Emergency Medical Services: At the Crossroads. Institute of Medicine. Washington, D.C.: National Academies Press.

⁶⁰ Reinertson-Sand, M. (2007). “Emergency Medical Services Information Guide.” Rural Assistance Center (RAC). http://www.raconline.org/info_guides/ems

⁶¹ Lindstrom, A. & Losavio, K. (2007). “JEMS 2006 Platinum Resource Guide.” Journal of Emergency Medical Services. Vol. 31, no. 1; and Personal Correspondence, EMS Provider/Ambulance Services Mailing List, National Association of State EMS Officials. (May 17, 2007).

⁶² McCaig, L.F. & Burt, C.W. (March 2004). “National Hospital Ambulatory Medical Care Survey: 2002 Emergency Department Summary.” Advance Data from Vital and Health Statistics, no. 340. (Pub. no. PHS 2004-1250). Hyattsville, MD: Centers for Disease Control and Prevention, National Center for Health Statistics; and Cady, G. & Scott, T. (1995). “EMS in the United States. 1995 Survey of Providers in the 200 Most Populous Cities.” Journal of Emergency Medical Services. Vol. 20, Issue 1. 76-82.

⁶³ U.S. Government Accountability Office. (May 2007). Ambulance Providers: Costs and Expected Medicare Margins Vary Greatly. (Pub. no. GAO-07-383.). Washington, D.C.

⁶⁴ Ibid.

⁶⁵ Ibid.

⁶⁶ Hajat, A., Brown, C. & Fraser, M. (2001). Local Public Health Agency Infrastructure: A Chartbook. Washington, D.C.: National Association of County and City Health Officials (NACCHO) and the Robert Wood Johnson Foundation.

⁶⁷ Ibid, 16.

⁶⁸ Ibid, 44.

⁶⁹ National Association of County and City Health Officials (NACCHO). (July 2006). 2005 National Profile of Local Health Departments. Washington, D.C.: National Association of County and City Health Officials. 59.

⁷⁰ Office of Family Assistance. (December 19, 2004). Table: “1987 AFDC Total Caseload: Average Monthly Numbers for Fiscal and Calendar Years.” U.S. Department for Health and Human Services, Administration for Children and Families. http://www.acf.hhs.gov//programs/ofa/caseload/afdc/1987/fycytotal87.htm; and Office of Human Services Policy. (June 1998). “Federal and State Expenditures for AFDC.” Aid to Families with Dependent Children: The Baseline. Washington, D.C.: U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation. 61-70.

⁷¹ Administration for Children and Families. (October 2006). “Office of Family Assistance (OFA) Fact Sheet.” Washington, D.C.: U.S. Department of Health and Human Services. http://www.acf.hhs.gov/opa/fact_sheets/tanf_factsheet.html; and Office of Family Assistance. (November 7, 2007). Table: “TANF: Total Number of Recipients: Fiscal and Calendar Year 2007.” Washington, D.C.: U.S. Department of Health and Human Services. http://www.acf.hhs.gov//programs/ofa/caseload/2007/2007_recipient_tan.htm

⁷² U.S. Government Accountability Office. (September 2004). Welfare Reform: Rural TANF Programs Have Developed Many Strategies to Address Rural Challenges. (Pub. no. GAO-04-921). Washington, D.C.: 1; and Office of Family Assistance. (November 7, 2007). Table: “TANF: Total Number of Recipients: Fiscal and Calendar Year 2007.” Washington, D.C.: U.S. Department of Health and Human Services. http://www.acf.hhs.gov//programs/ofa/caseload/2007/2007_recipient_tan.htm

⁷³ U.S. Government Accountability Office. (September 2004). Welfare Reform: Rural TANF Programs Have Developed Many Strategies to Address Rural Challenges. (Pub. no. GAO-04-921). Washington, D.C.

⁷⁴ Ibid.

⁷⁵ Meckstroth, A., Burwick, A., Ponza, M., Marsh, S., Novak, T., Phillips, S., Diaz-Tena, D. & Ng, J. (March 22, 2006). Paths to Work in Rural Places: Key Findings and Lessons from the Impact Evaluation of the Future Steps Rural Welfare-to-Work Program. (MPR Reference no.: 8762-192, 202). Princeton, NJ: Mathematic Policy Research, Inc. xii.

⁷⁶ Low Income Home Energy Assistance Program (LIHEAP) Clearinghouse. (September 27, 2007). Table: “Low-Income Energy Programs Funding History 1977-2007.” U.S. Department of Health and Human Services, Administration for Children and Families. http://www.liheapch.acf.hhs.gov/Funding/lhhist.htm

⁷⁷ Colker, L. & Dewees, S. (November 2000). Childcare for Welfare Participants in Rural Areas. (Rural Welfare Issues Brief). U.S. Department for Health and Human Services, Administration for Children and Families.

⁷⁸ U.S. House of Representatives, Committee on Ways and Means. (October 6, 2000). “Section 9: Child Care.” The 2000 Green Book: Background Material and Data on Programs Within the Jurisdiction of the Committee on Ways and Means. (Committee Print 1028-A). 106th Congress, 2nd Session. http://aspe.hhs.gov/2000gb/sec9.txt

⁷⁹ Child Care Bureau. (October 2006). “Overview of the Child Care and Development Fund (Fiscal Years 2006-2007).” U.S. Department of Health and Human Services, Administration for Children and Families. http://www.acf.hhs.gov/programs/ccb/ccdf/ccdf06_07desc.htm

⁸⁰ Swenson, K. (July 2007). Child Care Subsidies in Urban and Rural Counties. Washington, D.C.: U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation.

⁸¹ National Advisory Committee on Rural Health and Human Services. (March 2007). The 2007 Report to the Secretary: Rural Health and Human Service Issues. Rockville, MD: U.S. Department of Health and Human Services. 18.

⁸² Office of Planning, Research and Evaluation. (December 2006). Findings From the Survey of Early Head Start Programs: Communities, Programs, and Families. Washington, D.C.: U.S. Department of Health and Human Services. Administration for Children and Families. p. xxii.

⁸³ National Advisory Committee on Rural Health and Human Services. (March 2007). “Head Start in Rural Communities.” The 2007 Report to the Secretary: Rural Health and Human Service Issues. Rockville, MD: U.S. Department of Health and Human Services. 17-26

⁸⁴ “Head Start Act.” 42 U.S.C. 9801, Sec. 635, (a)(1)(A).

⁸⁵ Zill, N., Resnick, G., et al. (February 2006). Family and Child Experiences Survey (FACES 2000): Technical Report. Washington, D.C.: U.S. Department of Health and Human Services, Administration of Children and Families. 1-3.

⁸⁶ Ham, R.J., Goins, R.T. & Brown, D.K. (March 2003). Best Practices in Service Delivery to the Elderly. (Prepared for the Administration on Aging). Morgantown, WV: West Virginia University Center on Aging. 14; and Wiener, J.M., Hanley, R.J., Clark, R. & Van Nostrand, J.F. (November 1990). “Measuring the Activities of Daily Living: Comparisons Across National Surveys.” (Prepared for the DHHS Office of Disability, Aging and Long-Term Care Policy). Journal of Gerontology: Social Sciences. Vol. 45, no. 6. S229-237.

⁸⁷ U.S. Administration on Aging. (March 2007). Table: “FY 2005 US Profile of OAA Programs.” Older Americans Act Program Results and Program Evaluation. U.S. Department of Health and Human Services. http://www.aoa.gov/PROF/agingnet/NAPIS/SPR/2005SPR/Profiles/us.pdf. 1; and U.S. Administration on Aging. (2006). Celebrate Long-Term Living: Annual Report 2005. Washington, D.C.: U.S. Department of Health and Human Services. 6.

⁸⁸ Internal Revenue Service. (n.d.). “It’s Easier Than Ever to Find Out If You Qualify for EITC.” U.S. Department of the Treasury. http://www.irs.gov/individuals/article/0,,id=96406,00.html

⁸⁹ O’Hare, W. & Kneebone, E. (Fall 2007). EITC is Vital for Working-Poor Families in Rural America. (Fact Sheet 8). Durham, NH: University of New Hampshire, Carsey Institute. http://carseyinstitute.unh.edu/FS_EITC_07.htm

⁹⁰ Ibid. Note: Only 48 States have rural counties.

⁹¹ Ibid.

⁹² Office of Public and Indian Housing. (n.d.). “Housing Choice Vouchers Fact Sheet.” U.S. Department of Housing and Urban Development. http://www.hud.gov/offices/pih/programs/hcv/about/fact_sheet.cfm

⁹³ HUD User. “A Picture of Subsidized Households - 2000.” (Custom Query). U.S. Department of Housing and Urban Development. http://www.huduser.org/picture2000/index.html

⁹⁴ Food and Nutrition Service. (September 26, 2007). Table: “Food Stamp Program Participation and Costs.” Food Stamp Program Data. U.S. Department of Agriculture. http://www.fns.usda.gov/pd/fssummar.htm

⁹⁵ Ibid.

⁹⁶ Wolkwitz, K. (September 2007). Characteristics of Food Stamp Households: Fiscal Year 2006. Nutrition Assistance Program Report no. FSP-07-CHAR. (Prepared for the U.S. Department of Agriculture). Washington, D.C.: Mathematica Policy Research, Inc.

⁹⁷ Wolkwitz, K. (June 2007). “Trends in Food Stamp Participation Rates 1999 to 2005.” Current Perspectives on the Food Stamp Program series. (Prepared for the U.S. Department of Agriculture, contract number FNS-03-030-TNN). Washington, D.C.: Mathematica Policy Research, Inc.

⁹⁸ Food and Nutrition Service. (n.d.). “Women, Infants, and Children (WIC): About.” U.S. Department of Agriculture. http://www.fns.usda.gov/wic/

⁹⁹ Food and Nutrition Service. (n.d.). “WIC Program Participation and Costs.” U.S. Department of Agriculture http://www.fns.usda.gov/pd/wisummary.htm

¹⁰⁰ Food and Nutrition Service. (n.d.). “WIC Program: Total Participation.” U.S. Department of Agriculture http://www.fns.usda.gov/pd/27wilatest.htm

¹⁰¹Food and Nutrition Service. (n.d.). “WIC Program Participation and Costs.” U.S. Department of Agriculture http://www.fns.usda.gov/pd/wisummary.htm

References for Figures

^{Figure 1} North Carolina Rural Health Research & Policy Analysis Center calculations, using (1) U.S. Bureau of the Census. (2006). Historical Metropolitan Area Definitions. U.S. Department of Commerce. http://www.census.gov/population/www/estimates/pastmetro.html (2) U.S. Bureau of the Census. (2006). Metropolitan and Micropolitan Statistical Areas and Components, December 2005, With Codes. U.S. Department of Commerce. http://www.census.gov/population/estimates/metro_general/List1.txt (3) U.S. Bureau of the Census. (2006). Population Estimates, Archives. U.S. Department of Commerce. http://www.census.gov/popest/archives/

^{Figure 2} U.S. Department of Agriculture, Economic Research Service. (2007). Disseminated in Cromartie, J. & Gibbs, R. (February 28, 2007). “Rural America: Then, Now, and in the Future.” Remarks to the NACRHHS February Meeting.

^{Figure 3} North Carolina Rural Health Research & Policy Analysis Center calculations, using (1) U.S. Bureau of the Census. (2006). Historical Metropolitan Area Definitions. U.S. Department of Commerce. http://www.census.gov/population/www/estimates/pastmetro.html (2) U.S. Bureau of the Census. (2006). Metropolitan and Micropolitan Statistical Areas and Components, December 2005, With Codes. U.S. Department of Commerce. http://www.census.gov/population/estimates/metro_general/List1.txt (3) Bureau of Health Professions, Office of Health Professions Analysis and Research. (September 1993). “Area Resource File, 1993.” Rockville, MD: U.S. Department of Health and Human Services. (4) National Center for Health Workforce Analysis. (February 2005). “Area Resource File, 2005.” Rockville, MD: U.S. Department of Health and Human Services, Health Resources and Services Administration.

^{Figure 4} U.S. Congress, Office of Technology Assessment. (1990). Health Care in Rural America (Pub. no. OTA-H-434). Table 2.14. Washington, D.C.: U.S. Government Printing Office; and Agency for Healthcare Research and Quality. Datafile: “Medical Expenditure Panel Survey.” U.S. Department of Health and Human Services. http://www.meps.ahrq.gov/mepsweb/

^{Figure 5} Tax Policy Center. (November 6, 2007). Table: “Historical EITC Parameters, 1975-2008.” Urban Institute and Brookings Institution. http://www.taxpolicycenter.org/taxfacts/displayafact.cfm?Docid=36

^{Figure 6} Congressional Budget Office. (May 2007). Changes in the Economic Resources of Low-Income Households with Children. (Pub. no. 2602). Washington, D.C.: U.S. Congress. 2.

References for Tables

^{Table 1} North Carolina Rural Health Research & Policy Analysis Center calculations, using (1) U.S. Bureau of the Census. (2006). Historical Metropolitan Area Definitions. U.S. Department of Commerce. http://www.census.gov/population/www/estimates/pastmetro.html (2) U.S. Bureau of the Census. (2006). Metropolitan and Micropolitan Statistical Areas and Components, December 2005, With Codes. U.S. Department of Commerce. http://www.census.gov/population/estimates/metro_general/List1.txt (3) U.S. Bureau of the Census. (2006). Population Estimates, Archives. U.S. Department of Commerce. http://www.census.gov/popest/archives

^{Table 2} North Carolina Rural Health Research & Policy Analysis Center calculations, using (1) U.S. Bureau of the Census. (2006). Historical Metropolitan Area Definitions. U.S. Department of Commerce. http://www.census.gov/population/www/estimates/pastmetro.html (2) U.S. Bureau of the Census. (2006). Metropolitan and Micropolitan Statistical Areas and Components, December 2005, With Codes. U.S. Department of Commerce. http://www.census.gov/population/estimates/metro_general/List1.txt (3) U.S. Bureau of the Census. (2006). Small Area Income & Poverty Estimates 1989-2004. U.S. Department of Commerce. http://www.census.gov/hhes/www/saipe/tables.html (4) U.S. Bureau of Economic Analysis. (2006). Local Area Personal Income, 1969-2004. U.S. Department of Commerce. http://www.bea.gov/bea/regional/reis (5) U.S. Bureau of Labor Statistics. (2006). Local Area Unemployment Statistics (LAUS), 1990-2005. U.S. Department of Labor. http://www.bls.gov/lau

^{Table 3} North Carolina Rural Health Research & Policy Analysis Center calculations, using (1) U.S. Bureau of the Census. (2006). Historical Metropolitan Area Definitions. U.S. Department of Commerce. http://www.census.gov/population/www/estimates/pastmetro.html (2) U.S. Bureau of the Census. (2006). Metropolitan and Micropolitan Statistical Areas and Components, December 2005, With Codes. U.S. Department of Commerce. http://www.census.gov/population/estimates/metro_general/List1.txt (3) Bureau of Health Professions, Office of Health Professions Analysis and Research. (September 1993). “Area Resource File, 1993.” Rockville, MD: U.S. Department of Health and Human Services. (4) Bureau of Health Professions, Shortage Designation Branch. (June 2006). Health Professional Shortage Area (HPSA) Designation File, 2006. Rockville, MD: U.S. Department of Health and Human Services.

^{Table 4} National Center for Health Workforce Analysis, using Health Resources and Services Administration. (February 2005). “Area Resource File, 2005.” Rockville, MD: U.S. Department of Health and Human Services.

^{Table 5} Health Resources and Services Administration. (March 2004). National Sample Survey of Registered Nurses, 2004. Rockville, MD: U.S. Department of Health and Human Services; and Health Resources and Services Administration. (March 1988). National Sample Survey of Registered Nurses, 1988. Rockville, MD: U.S. Department of Health and Human Services.

^{Table 6} North Carolina Rural Health Research & Policy Analysis Center calculations, using (1) American Dental Association. (2004). The American Dental Association Database of Dentists, 2004. Chicago, IL: American Dental Association. (2) U.S. Bureau of the Census. (2006). Historical Metropolitan Area Definitions. U.S. Department of Commerce. http://www.census.gov/population/www/estimates/pastmetro.html (3) U.S. Bureau of the Census. (2006). Metropolitan and Micropolitan Statistical Areas and Components, December 2005, With Codes. U.S. Department of Commerce. http://www.census.gov/population/estimates/metro_general/List1.txt (4) and Bureau of Health Professions, Office of Health Professions Analysis and Research. (September 1990). “Area Resource File, 1990.” Rockville, MD: U.S. Department of Health and Human Services.

^{Table 7} Swenson, K. (July 2007). Child Care Subsidies in Urban and Rural Counties. Washington, D.C.: U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation.

 

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