What is rural and why is it important?
This question is asked frequently by scholars, practitioners, and policy-makers alike. Each group has different motives for asking it, and adopts different approaches to answer it. Most people agree that being removed from population centers can result in unique disadvantages. As evidence continues to suggest, rural places in the United States demonstrate pronounced needs in the areas of health, education, and economic security. It remains important to be conscious of urban/rural distinctions so that we can continue to address these disparities by effectively targeting social programs and services. It is for this reason that we rely on classification systems to identify the country’s rural places, even as that task becomes increasingly complex.
Wisconsin is both an urban and a rural state. In terms of its people, less than a third live in census designated rural areas. Most are spread into 13 Metropolitan Statistical Areas (MSA), which means Wisconsin ranks in the top 10 states for its number of urban places. But at the same time, the state has vast areas of low population density that are home to more than one million people. The Office of Rural Health uses rural classifications to identify the state’s people, places, and facilities that experience unique healthcare needs by virtue of their rural location. Though our mission is straightforward, identifying our target populations can be very complex. Some of the most important dimensions of rural can be measured and mapped, while others cannot.
What the measurement experts say…
Rural classification schemes have been developed by first accounting for what constitutes a city. For example, the US Census Bureau classifies rural as the territory outside of urban places. Urban places can either be continually settled “urban areas” that exceed a population of 50,000, or centers exceeding 2,500 inhabitants falling outside of those areas. Census distinctions use a standard gradient of population density to create their urban boundaries, while other distinctions observe municipal or jurisdictional boundaries. The Federal Office of Management and Budget (OMB) defines metropolitan areas as county groupings in which an urban area of 50,000 or greater is at the center, and economically connected counties are at the periphery. As the two primary federal distinctions, the Census and OMB schemes receive criticism for either including or excluding rural populations.
Attempts to refine the criterion used for rural designations have been many and varied. One popular alternative is a hierarchical ranking of counties, beginning with city centers, and extending on a continuum stretching from urban-adjacent to remote. The Urban Influence Codes and Rural Urban Continuum Codes calculated by the USDA’s Economic Research Service are examples of county-level classification schemes. County-based signifiers are particularly useful for analyzing and interpreting data aggregated to the county level.
Because counties tend to be quite large, county-based classification schemes can over-generalize the populations living within counties. One can attempt to address this by more thoughtfully categorizing counties. Map 2, for example, shows how Wisconsin counties rank on the “Index of Relative Rurality” which accounts for counties’ population size and density, the extent of their urbanized areas, and the distance to the nearest metro area.
Nonetheless, in large counties there remains a distinct risk of overlooking rural populations, which means county-level classifications should be avoided when possible. Accordingly, alternatives to these schemes can entail targeting rural people more precisely by using smaller scaled boundaries, such as census tracts and ZIP codes. In Wisconsin, one can see the differences between these scales and begin to understand why they may be contested: most of Wisconsin’s urban counties (Map 1) contain census tracts that are rural by census standards (Map 3).
Scholars have also adopted more nuanced ways of capturing urban influence in rural places. For example, researchers have looked at commuting patterns that distinguish economically isolated rural places from those that are home to people working daily in cities. Map 4 illustrates that some of Wisconsin’s very rural places by census standards are home to a large proportion of workers who commute to cities every day for their jobs.
Even the commuter-based approach can be contested. It suggests that locations where people commute to cities for work are less rural than locations where commuting does not occur, but in terms of indicating needs, the opposite may be true. While places with few local jobs may be more closely tied with cities, they are not necessarily better-off than similar counties with employment opportunities of their own. In reality, their lack of local jobs may be a symptom of more serious socioeconomic problems and be an indicator of hardship.
Complications that can’t be measured…
Even as we refine our measurements, the rural concept is becoming more difficult to generalize because of its variation. As cities sprawl outward, highways widen, and jobs accumulate in urban areas, many rural people and places see their defining characteristics disappear. That a community is within commuting distance of a major city can impact an array of indicators, even as the physical landscape and population density remains the same. To some extent, the same is true of communities close to small cities; and even remote communities fortunate enough to have broadband internet access benefit from their virtual connectivity. But increases in connectivity have not been uniform. Some rural communities remain so spatially and technologically peripheral that their issues and challenges have remained the same for decades. In sum, being aesthetically rural is now an unreliable indicator of material inequities because rural places are changing at different speeds and in different ways. This variability poses tremendous challenge when targeting populations in need of support, whether hospitals, households, or communities.
What it means to be rural is also becoming a matter of public perception. Scholars of rural studies suggest that the term “rural” now connotes three layers of meaning. In addition to what we can quantify in space and through experience, the rural concept lives in our perceptions. In other words, what it means to be rural in the United States is decided in part by the thinking of an increasingly urban and suburban society, which means that the spatial or physical boundaries of rural can differ from the boundaries we assign in our collective imagination. These imagined boundaries are important because they map social and cultural marginalization that can have tangible impacts. The mere perception of places now influence where people decide to live, invest, retire, vacation and work. Ultimately these things do impact the experience of people who continue to live and work in rural places.
The Case of Healthcare in Wisconsin
For the reasons explained above, determining exactly which parts of the state are rural can get extremely complicated. Consider the case of healthcare in Wisconsin. While rural classifications are useful for some of our programs, they fall short for others.
Despite their large size, county-level designations are necessary for interpreting the wealth of health data that are only available in county aggregations. As imprecise as they may be, simple county groupings still reveal persistent differences in urban and rural health measures, underscoring their continued importance. Which rural classification WI-ORH follows depends on our objective at hand. If we need a ranking of counties based on their population size and proximity to metropolitan areas of various extremes, ERS rankings usually suffice. However, if we need a ranking that can be used as a continuous variable in statistical analyses, the IRR is most appropriate. No matter what, we still prefer smaller-scale classifications whenever possible.
Commuting patterns, such as those reflected in RUCA codes (Map 3), are important to consider when discussing healthcare quality and cost. We know that rural hospitals treating patients who work in cities enjoy a distinct financial advantage because more rural-urban commuters have health insurance, as well as better health outcomes. Urban-adjacent rural hospitals are likely to be in direct competition with more urban hospitals, incentivizing high quality performance. Hospitals outside the reach of larger cities find themselves at a distinct disadvantage in these regards. In these communities, wages tend to be lower, poverty rates higher, and health outcomes more negative.
Seasonal populations, migrant populations, and undocumented populations can complicate matters. Their numbers are not always included in official census counts, but they have significant and varying impacts on local health care resources and needs. For example, the map of Wisconsin’s housing density (Map 5) shows that many remote communities actually have relatively dense neighborhoods, which in most cases means an abundance of second or vacation homes. These communities and their healthcare providers are likely to have some degree of advantage given the financial status of second home owners. Alternatively, facilities that treat migrant and seasonal laborers face a pronounced disadvantage because they have no insurance and limited English proficiency.
In certain scenarios, none of the existing classifications are relevant. For example, the importance of hospitals can depend on who they serve, not necessarily where they are located. In the event of a health emergency, miles and minutes can mean the difference between life and death. Over 250,000 people live beyond 15 miles of a hospital in Wisconsin, all of them in rural census tracts, most without major roadways. Even an urban hospital’s proximity to these remote pockets of rural people can make it critically important to rural health. And in an emergency, it probably matters very little how many people in the hospitals neighborhood commute to a nearby city for work.
Finally, healthcare has become increasingly dependent on appropriate staffing, which means that recruiting health professionals is essential to maintaining quality rural healthcare. This is where differences in perceptions further complicate the task of delineating rural. In the minds of prospective doctors, it may matter very little where a community falls on a classification scheme. What is often important for their decision is their own perception of isolation from or connectivity to urban centers, with regard to both their personal and professional interests. To illustrate, while remote communities may be less appealing to prospective health providers than bustling cities, some of the country’s most renowned and successful healthcare facilities are located in relatively remote places. While they are rural by most conventional standards, to a prospective physician they are prestigious, well-connected, and enriching professional communities on the cutting-edge of medicine. Such hospitals may serve largely rural populations, but they are likely to have greater appeal to prospective doctors and more resources to devote to recruitment. This reiterates that not all rural hospitals face the same sets of challenges.
Concluding Thoughts
When it comes to healthcare, are we concerned with access or quality, and do the communities and institutions in need of support even align along measurable characteristics reflected in our maps? Though rural/urban delineations are needed to distribute the resources meant to address rural problems, we must be mindful that the most appropriate delineation may not be simple or obvious.
Although having multiple classification schemes may seem unnecessarily complex, this complexity underscores the importance of using thoughtful and individualized approaches to administer rural services and programs. With an increasingly perception-based definition of rural, it is more important than ever to be aware of how the lived experience of rural people and institutions contrast from what we might expect given our measurement schemes. It is rural people that direct our mission as practitioners and administrators of social programs and policy. In order to target them effectively, we stay in tune with the challenges they experience, whether they can be conveniently mapped or not.