Frontier Frequently Asked Questions
Question: What
is the definition of frontier?
Answer: Frontier areas are sparsely populated
rural areas that are isolated from population centers and services. While frontier
is sometimes defined simplistically as places having a population density of six or
fewer people per square mile this does not take
into account some important factors that may isolate a community.
Therefore, other definitions are more complex and address isolation
by considering distance in miles and travel time in minutes to services.
Definitions
of frontier for specific state and federal programs vary, depending
on the purpose of the project being researched or funded.
Some of the issues that may be considered in classifying an area as frontier
include population density, distance from a population center or specific
service, travel time to reach a population center or service, functional
association with other places, availability of paved roads, and seasonal
changes in access to services. Frontier may be defined at the county
level, by ZIP code or by census tract.
Rural-Urban Commuting
Areas (RUCAs) can be used to identify very remote areas, which
could be considered frontier-like due to their isolation from population
centers. Under the RUCA definition, types of rural and urban are defined
by proximity to urban areas and the portion of the population that
commute for work from place to place. For instance, a RUCA code of
10 is assigned to isolated, small rural census tracts. The WWAMI Rural
Health Research Center publication RUCA
Data: Travel Distance and Time, Remote, Isolated, and Frontier discusses
a method of combining the Rural-Urban Commuting Area (RUCA) codes with
travel distance to urban areas and larger rural towns, in order to
identify areas that are very remote. RUCAs are available by census
tract and by ZIP code area. RUCA Version 1 uses 1990 Census and 1998
ZIP code areas, while Version 2 uses 2000 Census data and 2004 ZIP
code areas. RUCAs were first introduced in a 1999 article by Richard
Morrill, John Cromartie, and Gary Hart - "Metropolitan, Urban, and
Rural Commuting Areas: Toward a Better Depiction of the United States
Settlement System." Urban Geography 20: 727-748.
In 2006, with funding from the
Health Resources and Services Administration's Office for the Advancement
of Telehealth, an expert panel developed a new frontier area definition
that could be applied to telehealth programs. The frontier definition
and the process by which it was developed are described in the report, Defining
the Term “Frontier Area” for
Programs Implemented through the
Office for the Advancement of Telehealth. The recommended frontier
area definition from the panel is: "ZIP
code areas whose calculated population centers are more than 60 minutes
or 60 miles along the fastest paved road trip to a short-term non federal
general hospital of 75 beds or more, and are not part of a large rural
town with a concentration of over 20,000 population."
This report also provides an overview of other currently used frontier
definitions.
The National Center for Frontier Communities, formerly known as the
Frontier Education Center, in 1997-98 brought together a multi-disciplinary
group of experts as a consensus group that developed a matrix for determining
frontier status, based on population density, distance to the closest "market" for
services, and travel time. State Offices of Rural Health participate
in determining the areas considered frontier in each state. For more
detailed description of this frontier definition, please see the Frontier:
A New Definition. A number of other documents analyzing frontier areas and the “consensus” definition are found on the National Center for Frontier Communities website Developing the Consensus Definition.
More information about the challenges of defining non-metropolitan
areas is available on the What is Rural? information
guide.
Question: How much of the U.S. is frontier?
Answer: Frontier is more of a concept than
a specific definition, so the number of people living in the
frontier and the amount of land that is frontier will vary depending
on the definition you select. The North Carolina Rural Health
Research and Policy Analysis Center's map, Frontier
Counties, United States, 2004, identifies 440 counties that meet
the frontier definition of fewer than seven people per square mile, with
a total population for those counties of nearly 2.9 million people. Based on
the USDA
Economic Research Service's Measuring Rurality: Urban Influence Codes, over three million
people live in rural counties that are not adjacent to
a metropolitan or micropolitan county (having an Urban Influence Code
of 11 or 12), and these counties cover an area of over 770,000 square
miles. Using the counties and areas provided to the National Center for Frontier Communities by the State Offices of Rural Health, 56% of the land area of the United States is frontier and more than 9 million people, or less than 4% of the population of the country live in these isolated areas.
Question: How can I find out if my county is a frontier county?
Answer: There are several answers to this
question.
You can determine if your county meets the "six
or fewer people
per square mile" definition
of frontier by using the U.S. Census Bureau's State
and County Quick Facts.
Select your state and then your county. Scroll down to the Geography
Quick Facts section near the bottom of the page and look for "Persons
per square mile."
You can use the National Center for Frontier Communities' List
of Frontier Counties from the 2000 U.S. Census. You may also
want to review their Frontier
Designation Matrix, which describes how frontier status is calculated
by the State Offices of Rural Health and reported to the
National Center for Frontier Communities.
The U.S. Department of Agriculture's Economic Research Service provides
a list of Rural-Urban
Commuting Area (RUCA) codes for each state. A RUCA code of 10 is
assigned to isolated, small rural census tracts. The WWAMI Rural Health
Research Center offers state
and regional maps based on RUCA data.
Question: What are some of the challenges facing frontier areas?
Answer: The isolation and distances that
classify an area as frontier results in long trips to attend school,
shop for groceries, get health care, and reach other basic services.
Public transportation options are often limited or unavailable in frontier
areas, making access to needed services difficult for low-income households, the elderly and disabled.
Frontier areas face seasonal travel barriers that can make travel difficult.
For those living in mountainous areas, some roads and passes may be closed
in winter, leading to longer travel times. Residents may find
that winter driving in the frontier extends travel times because they
need to slow down to adequately account for
road conditions and limited visibility. Flooding caused by melting snow and heavy rains can force the closer of main roads for unexpected and extended periods of time in both mountainous and flatland landscapes. Some island residents and residents
of roadless areas are limited to air access, when airplanes are able
to fly.
The economy in frontier areas is usually based on a
few specific resources or activities and
so are more at risk of downturns and boom-bust cycles. Tourism, farming,
ranching, logging, and mining are some of the businesses that are common
in rural areas. Frontier communities may be more vulnerable to less
desirable sources of business income, such as nuclear waste disposal.
Frontier areas where
much of the land is federally owned may lack an adequate tax base to
pay for needed services.
The USDA's Economic Research Service report, Understanding
Rural Population Loss, notes that counties with low population
density, such as frontier counties, are most at risk for population
loss. Communities with cultural or natural amenities are likely to
fare better than remote communities that have fewer attractions to
offer tourists and retirees.
Question: What are some of the health care challenges in frontier areas?
Answer: The National Center for Frontier Communities' publication Addressing
the Nursing Shortage: Impacts and Innovations in Frontier America notes
that over 30% of frontier counties lack a hospital. Frontier counties
that do have hospitals may face higher costs than non-frontier hospitals,
due to the lower volume of patients served. Frontier counties with
nurse shortages or no hospitals are often clustered together, compounding
the distance residents must travel to reach a hospital.
Frontier areas face the same difficulties as other rural areas in maintaining
their health care workforce. These thinly populated regions cannot easily
compete with the wages and amenities offered to physicians and nurses
by hospitals and clinics in metropolitan areas. Even communities that
do have adequate staffing are often one doctor or nurse away from a shortage. For
more information, please see our guide on Health
Care Workforce.
Some areas must cope with seasonal variations in health care needs,
when the population surges with tourists or retirees. Limited health
resources in frontier areas, including volunteer health services and
costly evacuation services, may be needed to care for people vacationing
in the area, taking away from the resources available for local residents.
For more information, please see the Seasonal
Population Fluctuations in Rural and Frontier Areas: Phase One: The View
from State Offices of Rural Health and Impact of Seasonal Population Variations on Frontier Communities: Maintenance of the Healthcare Infrastructure.
Rural communities are at higher
risk for substance abuse among youth, higher motor vehicle fatalities,
hypertension, cigarette smoking, suicide, and death from serious injuries.
While many studies have identified health disparities for all rural communities,
fewer have focused specifically on the remote rural areas of the frontier.
The National Center for Frontier Communities'
report, Frontier
Youth: Living on the Edge, provides an overview of the behavioral
health issues facing frontier youth, using rural data where frontier-specific
data is not available, but with discussion that focuses on frontier.
According to the December 2003 working paper from the WWAMI Rural Health
Research Center, "Prevalence
and Trends in
Smoking: A National Rural Study,"
24.9 percent of residents in remote rural areas smoke, compared
to 22 percent in urban areas. Obesity in remote, rural areas tends to
be higher than in urban areas, and a college education may have
less impact in these remote areas to reduce levels of obesity (A
National Study of Obesity Prevalence and Trends by Type of Rural County,
Journal of Rural Health, Spring 2005.)
Question: How can telehealth services help frontier areas?
Answer: Telehealth, the provision of health
services over a distance through the use of technology, can help frontier
communities connect with health care services and specialists that would
otherwise be unavailable or require travel. Some of the telehealth applications
that can benefit frontier communities include telemental health and telepharmacy.
The availability and cost of telecommunications access are potential
barriers to the use of telehealth in frontier areas. For more information on this technology,
see the Technology information guide and the Telehealth information
guide.
Question: Are there funding or reimbursement advantages to being considered a frontier area?
Answer: Most of the programs that frontier
areas can access for grants and enhanced reimbursement are available
through shortage designations, including the Health Professional Shortage
Area (HPSA) and Medically Underserved Area (MUA) designations, rather
than through a designation as a frontier area. The Community
Health Center program gives special consideration to sparsely populated
or frontier areas. One program that is specific
to frontier is the Frontier
Extended Stay Clinic (FESC) Cooperative Agreement Program. The Centers
for Medicare and Medicaid Services (CMS) also has a project
for the FESC model, the Frontier
Extended Stay Clinic Demonstration Project.
Frontier communities are rural and so qualify for many rural-specific
funding programs, such as the Office of Rural Health Policy's Rural
Health Care Services Outreach Grant Program and Rural
Health Network Development Grant Program. For additional funding programs available to frontier and other
rural areas, please see our Funding section.
Question: What is a Frontier Extended Stay Clinic (FESC)?
Answer: The Frontier Extended Stay Clinic
(FESC) is being considered as a new provider type to better meet the
needs of remote communities far from a hospital. This program is currently
a cooperative agreement program in Alaska and Washington. The FESC designation
allows a primary care clinic located in a remote area to provide and
be reimbursed for monitoring and observation of patients for a limited
period of time, in cases where patients cannot or should not be transferred.
For more information, please see the Office of Rural Health Policy's
Frontier Extended
Stay Clinic (FESC) Cooperative Agreement Program.
Credits
Last revised 04/16/2009
