2020 Census Changes Leave Rural Health Clinics in Legal Grey Area

Nathan Baugh, NARHC Executive Director


Since the inception of the RHC program in 1977, the Rural Health Clinic program has used the Census Bureau’s definition of “urbanized area” to determine if a site met the rurality requirements to establish an RHC. Specifically, the RHC statute says:

For the purposes of this title, such term includes only a facility which (i) is located in an area that is not an urbanized area (as defined by the Bureau of the Census)…

Beginning with the 1950 Census, the term “urbanized area” has been defined as urban areas of 50,000 or more. However, despite our objections, as of the 2020 Census, the Census Bureau is no longer defining the term “urbanized area.” This policy change leaves the RHC program without a clear and explicit location standard.

In order to fully understand this issue, it is important to understand that urban areas and urbanized areas are not the same thing. Urban areas have traditionally been defined as areas with 2,500 or more people, but as of 2020 are now being defined as areas with 5,000 or more people. This change, is why you may have seen articles such as this Wall Street Journal article saying that more of the country is now all of the sudden considered rural.

But again, and I cannot emphasize this enough, the changing “urban area” definition does not impact rural health clinics. What does impact us, is the fact that the Census Bureau is no longer defining the term “urbanized area.”

TABLE: Urban Area vs. Urbanized Area, 2010 and 2020 Census Definitions

 Census  2010  2020 
 Urban Area  Population of 2,500 or more  Population of 5,000 or more
 Urbanized Area  Urban areas of 50,000 or more  N/A


When this Census Bureau change was finalized almost a year ago, NARHC asked CMS how they would evaluate rural health clinic location eligibility. CMS indicated to us that no changes would occur before the 2020 urban area lists and maps were finalized. Therefore, as far as we are aware, there has been no impact on RHC location policy to date. However, the Census Bureau recently released their list of 2020 urban areas and is scheduled to publish the 2020 urban area maps sometime later this month.

Given that these new maps may be released soon, we were hoping CMS would have some sort of policy to clarify how they will evaluate RHC location eligibility. Unfortunately, NARHC recently met with CMS representatives, and they indicated to us that the agency was still in “internal deliberations” regarding publishing a “final disposition” on this matter.

However, CMS staff did indicate that regional offices and surveyors will be “reasonable” when evaluating RHC location eligibility, essentially implying that potential locations for RHCs will still be evaluated on a 50,000 people or less basis. That gives us some comfort, but the fact remains that we need to get a policy in writing on what the location requirements will be given the Census Bureau’s new policy.

No matter what CMS’s final disposition is, NARHC will be working with Congress to fix the underlying statutory definition and preserve the status quo policy of allowing RHCs to be established in towns with a population of 50,000 or less. As such, we are advocating for legislation that revises the statute to the following:

For the purposes of this title, such term includes only a facility which (i) is located in an area that is not an urban area of 50,000 or more (as defined by the Bureau of the Census)...

Such a statutory change would preserve status quo standards and codify the historical RHC location requirements despite the new Census Bureau policy. We expect this to be included as a section in the forthcoming “RHC Burden Reduction Act” legislation which we will be discussing more in the months to come.

If anyone reading this has had their RHC application denied or rejected due to the lack of clarity in this policy, please reach out to Nathan.Baugh@narhc.org and Sarah.Hohman@narhc.org so we can escalate this issue to policymakers as appropriate.