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Rural Access to Health Care Services Request for Information

Type of Notice: Request for Information

Title: Rural Access to Health Care Services Request for Information

Response Date: October 9, 2019

Summary: The Health Resources and Services Administration (HRSA) seeks information about measuring access to health care in rural communities. HRSA seeks responses to the “Questions for Public Comment” section of this Request for Information (RFI). HRSA may use the responses collected to inform policy development and program decision making, among other purposes. The responses and/or a summary of the responses may be shared with the Department of Health and Human Services (HHS) and its Rural Health Task Force.

Dates: Submit comments to the email listed in the “Response Format” section by 11:59 p.m. Eastern Time on October 9, 2019.

Response Format: Responses to this RFI must be provided via email to and must reference “Rural Access to Health Care Services RFI” in the title. Submissions are due no later than 11:59 p.m. Eastern Time on October 9, 2019. HRSA will not accept hard-copy responses or other formats.


Rural areas face particular challenges related to accessing health care services. The question of how to provide high quality, affordable, sustainable health care to the 57 million Americans living in rural areas has become paramount.

Secretary Alex M. Azar II created a Rural Health Task Force at HHS, with key leaders and stakeholders from across the Department, to identify the needs of rural communities, how to meet those needs, and what HHS policy changes can address those needs. The intent is to determine not only how to deliver care in rural areas in a sustainable manner but also how rural health care may change in the future to ensure that it is accessible, high quality, value-based, and provided at the lowest cost possible.

As part of the Rural Health Task Force, HRSA is soliciting public input on how best to conceptualize and measure access to health care in rural communities. We encourage input from a broad range of stakeholders, including health care providers, researchers, community members, patients, consumers, families, caregivers, advocates, and other interested parties.


Rural communities continue to face a number of systemic and long-standing health care challenges. Rural areas often have fewer primary and specialty care physicians and mental health professionals as well as fewer home and community-based service providers compared to urban areas. They face a range of health disparities, including greater obesity and disease burden in children and adults, higher mortality rates, and shorter life expectancy compared to urban areas. Furthermore, rural communities can face particular social risk factors, such as limited employment and education opportunities. In combination, these challenges can exacerbate (or be precipitated by) population health crises, such as the opioid crisis or outbreaks of HIV transmission.

Rural hospitals face financial and operational difficulties. Approximately 2,000 of the country’s 5,000-plus acute care hospitals are located in rural areas, and 112 rural hospitals closed between January 2010 and July 2019.1 The U.S. Government Accountability Office found that rural hospital closures were generally preceded and caused by financial distress, which was related to multiple factors including decreased numbers of patients seeking inpatient care at rural hospitals and reductions in payments.2 Researchers found that 165 rural hospital obstetric units (PDF - 534 KB) closed between 2004 and 2014, leaving over half of rural counties without obstetric services.3

Despite these challenges, some rural communities have developed innovative approaches to health care delivery along with creative solutions to address local challenges. Rural areas have embraced telehealth use 4 and the broader use of non-physician primary care clinicians , such as nurse practitioners and physician assistants.5 Rural communities have developed grow-your-own approaches to recruitment and retention of needed clinicians, formal and informal networks to overcome limited economies of scale, promising strategies for reducing opioid use (PDF - 350 KB),6 and partnerships for addressing key social determinants of health.

As health care continues to evolve and to transition toward a system based on value, we need to better understand what constitutes access to core health care services and how to define that care, particularly in rural areas. Access to health care is a complex concept incorporating different components, including availability of services and providers, timeliness of care, affordability of care, insurance coverage, provision of health care across one’s lifetime, and considerations for children with special health care needs, people with disabilities, older adults, and other distinctive populations. In thinking about access to care, there are also other relevant rural considerations, such as population size and characteristics, travel time, transportation options, geographic isolation, broadband access, economic factors (such as employment, insurance status, and income), and the unique nature of specific rural health care markets. We are interested in understanding the connection between health care needs in rural areas and how people access care. We are also interested in whether current and projected population size and other characteristics of a rural community can or should inform access to particular services (ambulatory, general acute, specialty, etc.) to ensure a basic level of care.

We note that various federal and state-level programs use different definitions of “rural”. The three federal definitions used most widely include those from the U.S. Census Bureau, the Office of Management and Budget, and the Rural-Urban Commuting Area codes developed by the U.S. Department of Agriculture’s Economic Research Service in collaboration with HRSA. We encourage commenters to identify the definition of rural applicable to their responses to the extent that it is relevant to their comment.

Below are several questions for public comment to help inform the work of the HHS Rural Health Task Force. We are interested in public input to better understand what constitutes health care access in rural communities; whether measures of access should vary by current and projected population size, population characteristics, or geographic unit; what factors should be considered related to access (i.e., affordability, availability, accessibility, sustainability); and how to measure access and quality. Comments should expand on the resources cited below, suggest new and different ideas to assess rural access challenges, and help further clarify how to define the issue of access to care in rural communities. Comments should draw from objective, empirical, and actionable evidence, and, when possible, responses should cite this evidence.

Questions for Public Comment

What are the core health care services needed in rural communities and how can those services be delivered?

A number of researchers and interested stakeholders have proposed sets of core health care services for rural communities. Some of these proposals also discuss various delivery methods, including in-person, locally via virtual technology such as telehealth, or through referrals for services not available locally. While not comprehensive, the following summarizes widely circulated examples on this topic to provide an initial context and starting point for public comments.

  • The Institute of Medicine’s 2005 report Quality through Collaboration: The Future of Rural Health defined core health care services as “primary care in the community, emergency medical services, primary- and secondary-level hospital care, long-term care, mental health and substance abuse services, oral health care, and public health services” (page 36).
  • The Rural Policy Research Institute (RUPRI) has examined this issue from multiple angles. In 2003, the paper Care Across the Continuum: Access to Health Care Services in Rural America (PDF - 80 KB) proposed a continuum of care in which more acute health care services could be provided locally and other services provided at a distance, such as through telemedicine, with seamless linkages between all stages of the continuum. In 2011, The High Performance Rural Health Care System of the Future identified primary care, emergency medical services, and public health as the core rural health services. In 2014, Access to Rural Health Care – A Literature Review and New Synthesis suggested that four dimensions of access (people, place, provider, and payment) could serve as a basis for health care policy assessment. In 2015, the paper Rural Taxonomy of Population and Health-Resource Characteristics (PDF - 539 KB) offered a tool to classify and define rural areas based on both demand and supply sides of the health services market, namely, population and health resources.
  • The National Rural Health Association’s 2013 policy brief The Future of Rural Health concluded that primary care should be the core foundational service in rural areas. As not every rural area can sustain every service, other services that should be reasonably accessible through multiple delivery methods include mental health, substance abuse treatment, oral health, emergent/urgent care, surgery and obstetrics, pharmacy, eye care and audiology, public health, education and cultural competency, inpatient acute care, outpatient care, in-home care and monitoring, long-term institutional care, and transportation services.
  • The American Hospital Association’s 2016 Task Force on Ensuring Access in Vulnerable Communities (PDF - 5 MB) report identified essential health care services for rural and urban communities as primary care services, psychiatric and substance use treatment services, emergency and observation services, prenatal care, transportation, diagnostic services, home care, dentistry services, and a robust referral structure.
  • The Bipartisan Policy Center’s 2018 document Reinventing Rural Health Care: A Case Study of Seven Upper Midwest States identified emergency services as essential, although perhaps not a full-service hospital depending on the community. The case study also highlighted behavioral health, nursing homes, ambulance services, obstetrics, transportation for non-emergent care, and primary and preventive care.

Table 1: Core Health Care Services for Rural Communities Identified by the Examples Above

Source Inpatient Outpatient Emergency Care Primary Care Prenatal Care Mental Health/ Substance Use Disorder Home Care Long Term Care Oral Health Public Health Transportation
Institute of Medicine 2005        
Rural Policy Research Institute (RUPRI) 2011                
National Rural Health Association (NRHA) 2013  
American Hospital Association (AHA) 2016        
Bipartisan Policy Center 2018          

What are the appropriate types, numbers, and/or ratios of health care professionals needed to provide core health care services locally for rural populations of different compositions and sizes?

Below are different methodologies HRSA currently uses to identify community needs related to health workforce and other programs and to target new access points in the Health Center Program. This existing set of standards and methodologies is often used broadly to frame questions of health care access. We include these examples below to illustrate current uses of data in HRSA programs, and we are not requesting feedback on changes to these examples. Rather, we are interested in comments on additional ways to assess community needs, including what data are available.

  • A Health Professional Shortage Area (HPSA) is a geographic area, population, or facility with a shortage of primary care, dental, or mental health providers and services. Under a Cooperative Agreement with HRSA, State Primary Care Offices conduct needs assessments, provide technical assistance to organizations and communities in their states seeking designations, and submit HPSA designation applications to HRSA. HRSA reviews designation applications and designates those that meet established criteria. After a HPSA is designated, it receives a score assessing the HPSA’s overall degree of shortage, with higher scores generally indicating greater need.
  • Medically Underserved Areas (MUAs) and Medically Underserved Populations (MUPs) identify geographic areas and populations with a lack of access to primary care services. MUAs have a shortage of primary care health services for residents within a geographic area. MUPs are specific sub-groups of people living in a defined geographic area with a shortage of primary care health services. These groups may face economic, cultural, or linguistic barriers to health care.
  • The Service Area Needs Assessment Methodology (SANAM) (PDF - 790 KB) calculates an Unmet Need Score (UNS) for each ZIP Code using 24 measures of health determinants and health status, including direct measures of health status and indicators of socioeconomic status. The ZIP Code UNS are population-weighted to produce a service area UNS that is used as part of the needs assessment for applicants for the Health Center Program New Access Points funding opportunity, HRSA-19-080. The service area UNS determined 20 points (20%) of the application scores for this New Access Point competition.

What other factors are important to consider when identifying core health services in different rural communities, such as current and projected population size, distance to the nearest source of care, availability of telehealth, and sustainability of services?

There are efforts in federal and non-federal programs to analyze health care services at various geographic and population units of measure. We include three examples of such analyses below to set an initial context. We are interested in broader comments on how to account for a variety of factors, including but not limited to current and projected population size, population health status, geography, social services, or economy, to appropriately address health care access in rural communities.

  • Network adequacy requirements for insurance plans are one example of how federal and state programs try to account for distance to care. The Centers for Medicare & Medicaid Services (CMS) specify time and distance standards and physician-enrollee ratios for Medicare Advantage plans as part of evaluating that Medicare Advantage plans ensure accessibility and availability of covered services. By regulation, CMS requires states to establish and use network adequacy standards for Medicaid and CHIP managed care plans. Per the CMS 2019 Letter to Issuers (PDF - 260 KB) and the CMS 2020 Letter to Issuers (PDF - 233 KB), CMS defers to states that have a sufficient network adequacy process, with the means and authority to conduct review of network adequacy standards for Health Insurance Marketplace Qualified Health Plans.
  • Another example of a data-driven methodology to define geographic regions connected to where people receive health care services is the Dartmouth Atlas of Health Care, based at The Dartmouth Institute for Health Policy and Clinical Practice . The Atlas uses small area analysis of Medicare data to provide information and analysis about national, regional, and local markets, as well as hospitals and their affiliated physicians. It focuses on current patterns of health care access and utilization by fee-for-service Medicare beneficiaries living in a defined geographic area or using a specific hospital. The Dartmouth Atlas Project defines local markets for health care, hospital service areas, and regional markets for tertiary medical care, hospital referral regions.
  • In the research brief, Access to Care: Populations in Counties with No Federally Qualified Health Center, Rural Health Clinic, or Acute Care Hospital , the North Carolina Rural Health Research and Policy Analysis Center examined availability of safety net facilities, such as community health centers and rural health clinics, by county to illustrate the health care resource landscape in rural counties.

How should we measure access to health care services in rural communities? What are the best ways of measuring quality of care in rural communities?

Researchers often measure access to care using surveys, both nationally representative surveys and others targeted to specific groups of people. We are interested in comments on the use of survey data and other units of measurement that can help inform our understanding of appropriate ways to measure access to care in rural communities. This includes identifying ways to measure how and how much telehealth technologies are part of health care services within a community.

With respect to measuring quality of care, there are challenges due to the smaller volumes of patients served in rural areas. We are interested in comments on appropriate measures to identify high-quality care in rural areas in a variety of settings including pre-hospital, inpatient, outpatient, post-acute, and clinician care. We include examples of access and quality measures below to set an initial context.

  • Multiple national and state health-related surveys measure access across different domains, including usual source of care, use of preventive and wellness care, insurance coverage, delays in and foregone care, financial barriers to care, transportation-related barriers to care, and use of technology to interact with health care providers. The national surveys include, but are not limited to, the Behavioral Risk Factor Surveillance System, National Health Interview Survey, National Health Care Surveys, Medicare Current Beneficiary Survey, Medical Expenditure Panel Survey, Health and Retirement Study, National Health & Aging Trends Study, American Community Survey, Current Population Survey, and National Survey of Children’s Health. Data from these surveys are used in the National Healthcare Quality and Disparities Reports, and a University of Minnesota Rural Health Research Center policy brief, Measuring Access to Care in National Surveys: Implications for Rural Health , discusses these surveys from a rural perspective.
  • Other methods of measuring access examine the receipt and volume of services through claims data and the distribution of known health care delivery sites through administrative data. For example, the Medicare Payment Advisory Commission examines access for Medicare beneficiaries directly through surveys (e.g., beneficiaries’ opinions about access to services) and indirectly by using claims data on utilization, noting that volume data must be interpreted with caution because unrelated factors may influence service volume. For example, see the March 2018 Report to the Congress (PDF - 3 MB).
  • The National Quality Forum (NQF) MAP Rural Health Workgroup outlined in its report A Core Set of Rural-Relevant Measures and Measuring and Improving Access to Care: 2018 Recommendations from the MAP Rural Health Workgroup three rural-relevant domains for measuring access to care – availability, accessibility, and affordability – and presented ways to address the challenges of measurement in rural areas.
  • In the same report, the NQF Workgroup offers 20 quality measures appropriate for rural hospital and ambulatory settings. It also outlines guiding principles in selecting the measures for rural areas, such as addressing low case volumes and facilitating fair comparisons between providers.


HRSA is issuing this RFI in support of the ongoing work of the HHS Rural Task Force to better understand what constitutes health care access in rural communities and how best to measure that access for rural people generally, for people across the life span, and for children and adults with special health care needs. We are interested in comments on the topics raised in this RFI, but especially the four questions presented previously:

  1. What are the core health care services needed in rural communities and how can those services be delivered?
  2. What are the appropriate types, numbers, and/or ratios of health care professionals needed to provide core health care services locally for rural populations of different compositions and sizes?
  3. What other factors are important to consider when identifying core health services in different rural communities, such as current and projected population size, distance to the nearest source of care, availability of telehealth, and sustainability of services?
  4. How should we measure access to health care services in rural communities? What are the best ways of measuring quality of care in rural communities?

Submitting Comments:

Please submit comments via email to, and reference “Rural Access to Health Care Services RFI” in the title. Please also include the specific RFI question to which your comment is directed. If you provide comments to more than one question, please identify the specific RFI question to which each comment is directed. Information obtained as a result of this RFI may be used by HRSA and HHS for program planning and program decision making on a non-attribution basis. Responses to this RFI may be made publicly available; therefore, respondents should not include any information that might be considered proprietary or confidential. HRSA will not respond to any individual comments. Comments will be received through 11:59 p.m. Eastern Time on October 9, 2019.

Special Note to Commenters:

Whenever possible, respondents are asked to draw their responses from objective, empirical, and actionable evidence and to cite this evidence within their responses.

This RFI is issued solely for information and planning purposes; it does not constitute a Request for Proposal, applications, proposal abstracts, or quotations. This RFI does not commit the Government to contract for any supplies or services or make a grant or cooperative agreement award. Further, HRSA is not seeking proposals through this RFI and will not accept unsolicited proposals. Responders are advised that the U.S. Government will not pay for any information or administrative costs incurred in response to this RFI; all costs associated with responding to this RFI will be solely at the interested party’s expense. Not responding to this RFI does not preclude participation in any future procurement or program, if conducted. All submissions become Government property and will not be returned.

Please note that HRSA will not respond to questions about the policy issues raised in this RFI. HRSA may or may not choose to contact individual responders. Such communications would only serve to further clarify written responses.

1 HRSA-funded research by the North Carolina Rural Health Research and Policy Analysis Center. 112 Rural Hospital Closures: January 2010 – Present , accessed August 1, 2019. The researchers track both Prospective Payment System hospitals and Critical Access Hospitals and follow the convention of the HHS Office of the Inspector General to define a closed hospital as “A facility that stopped providing general, short-term, acute inpatient care…”

2 United States Government Accountability Office. GAO-18-634, Rural Hospital Closures: Number and Characteristics of Affected Hospitals and Contributing Factors, August 2018.

3 Hung, P, et al. Closure of Hospital Obstetric Services Disproportionately Affects Less-Populated Rural Counties , Policy Brief, Minnesota Rural Health Research Center, April 2017.

4 RHIhub, Telehealth Use in Rural Healthcare , accessed June 2019.

5 RHIhub, Rural Healthcare Workforce , accessed June 2019.

6 Gale, JA, Hansen AY, and Williamson, ME. Rural Opioid Prevention and Treatment Strategies: The Experience in Four States (PDF - 350 KB), Research & Policy Brief, Maine Rural Health Research Center, April 2017.

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