A state definition of rural for use in the context of health care, health data and the location of health care services.
“Rural” encompasses all population, housing, and territory not included within a United States Census Bureau Alabama Urbanized Area of 50,000 or more people
“Rural” encompasses all population, housing and territory designated by the United States Census Bureau as Urban Clusters and rural areas.
The United States Census Bureau defines “rural” by first defining “urban”. The Census Bureau uses the term Urbanized Area (UA) to quantify “urban”. It defines UAs as densely settled cores of census tracts and/or census blocks that meet the minimum population density requirement of 50,000 of more people. When used in the context health care, a health care provider practicing in a UA is an urban health care provider medical care facility located within a UA is an urban facility, or a community located within a UA is an urban community. The Census Bureau then defines “Rural” as all population, housing, and territory not included within an urbanized area. In addition the Census Bureau recognizes the designation Urban Cluster(s) (UC). Where UCs are identified cores of census tracts and/or census blocks that have a least 2,500 people and less than 50,000 people and located outside of Urbanized Areas. When used in the context health care, a health care provider practicing in a UC or rural area is a rural health care provider, a medical care facility located in a UC or rural area is a rural facility, or a named city, town or place that is a UC or located in a UC rural area is a rural Alabama place.
(green), shows the more densely populated rural areas (green areas). The U.S. Census Bureau identifies more densely populated rural areas as UCs. The most densely populated UC is the green area labeled Boaz. The population within its footprint is 38,615. It includes three cities that are considered rural cities (Guntersville, Albertville and Boaz) and is significantly less than the urban designation of 50,000 people or greater. The most densely populated town associated with any UC is Enterprise with a population of 26,562
Most medical related studies, programs and analyses of medical workforce and access issues use individual cities, towns and places. The cities and towns labeled on this map are the practice locations of 99.5% of all of non-urban family physicians, primary care pediatricians, and primary care internists
This definition is the perfect fit for identifying Alabama’s urban vs rural health care geographic landscape. Alabama has 15 Urbanized Areas where populations have multiple options for access to primary care and medical facilities. In contrast Alabama’s rural population has access to primary care, and medical facilities though clusters of physicians and general admission hospitals located in 86 cities, towns or Alabama places.
The Bureau’s definition is the only federal definition that applies the term “rural” in an official, statistical capacity, allowing it to be viewed as the official or default definition of rural.
Rural definitions are used to identify rural people, places and/or health care providers. Methods for defining rural must be based on geographic units that allow the identification of population or provider characteristics. Alabama’s definition satisfies these criteria.
For those concerned with rural healthcare and human services, that which constitutes rural must be precisely defined. Federal and state policymakers, as well as service providers and researchers, need a clearly stated definition that is current in its interpretation. This definition is based on the 2010 census and will not be subjected to change until after 2020.Thus it is precisely defined, clearly stated and current.
Precedence has been set in that the Centers for Medicare and Medicaid Services (CMS) currently uses a definition that is based on UAs, UCs and rural.” Rural Health Clinics (RHCs) which receive enhanced reimbursement rates from CMS may not be located in a UA, but they may be located in a UC.”
The Rural Health Information Hub, a national publisher of rural health information uses the U.S. Census Bureau designation of urbanized areas in Alabama to designate rural health centers in Alabama. See attached map Selected Rural Health Care Facilities in Alabama.
Furthermore, using the national U.S. Census Bureau definition for urbanized areas as the Alabama definition for urbanized areas not only sharply delineates Alabama’s urban population from its rural population geographically but it also allows specificity relative to state health policy considerations such as; health status, medical workforce distribution, access to primary care and specialty medicine, identifying potential future rural physicians and identifying and designating practice sites as rural.
Alabama’s UCs and the towns located in them are the location of Alabama’s rural general admission hospitals and clusters of our primary care physicians. They are the rural locations that have the capacity to recruit and retain primary care physicians. Their spatial location allows Alabama’s rural population access to primary care, hospital services and emergency care 24 hours per day. In contrast to an UA, Alabama’s largest UC is the Albertville UC with a population of 38,615 and the city with the largest population in rural Alabama is Enterprise with a population of 26,562.Thus this definition more clearly separates Alabama urban from Alabama rural when considering even the most densely populated rural area. Since many of our state rural recruitment and placement programs identify sites as cities, towns and places small urban cities and towns cannot be confused with rural cities, towns and places.
This definition has application for determining if applicants to Alabama’s medical schools and/or medical school rural admissions programs are rural, for determining if medical practice locations are rural, for determining if practice locations for Board of Medical Scholarship’s loans are rural, for determining if physicians applying for rural state tax credits are practicing in a rural community. It allows for health care needs to be based on accessible populations and for developing data and health policy that is appropriate for both rural and urban residents.
The application of this definition to Alabama results in Alabama having 15 urbanized areas (urban Alabama). These urbanized areas include all of Alabama’s largest cities, concentrations of Alabama medical assets and physicians.
The accompanying Alabama map, U.S. Census Bureau; Alabama Urbanized Areas, shows the footprint of Alabama’s 15 urbanized areas. All cities, towns and communities that are within the urban footprints are by U.S. Census Bureau definition and Alabama definition urban. All cities, towns and communities that are not located within the urbanized footprint are likewise by the same definitions rural.
MAP: US Census and Urban Clusters
MAP: Rural Healthcare Facilities in Alabama