Health and Healthcare in Frontier Areas
Frontier areas are the most remote and sparsely populated places along the rural-urban continuum, with residents far from healthcare, schools, grocery stores, and other necessities. Frontier is often thought of in terms of population density and distance in minutes and miles to population centers and other resources, such as hospitals. Frontier areas may be defined at the community level by county, ZIP code or census tract; however, they are often delineated by county.
Many frontier counties are located in the West, a part of the country where individual counties tend to cover a large geographic area. Even counties that have a town with a hospital, grocery store and other services may also encompass areas that are much more rural and isolated, making them frontier counties. Frontier areas face challenges in providing access to health and human services even greater than the challenges faced by other rural communities.
Frequently Asked Questions
- What is the definition of frontier?
- How much of the U.S. is frontier?
- How can I find out if my county is a frontier county?
- What are some of the challenges in frontier areas?
- What are some of the healthcare challenges in frontier areas?
- Are there funding or reimbursement advantages to being considered a frontier area?
- What types of models are being tried to address frontier healthcare issues?
- What types of innovative ideas have been used to address healthcare workforce issues in frontier areas?
What is the definition of frontier?
In general frontier areas are sparsely populated rural areas that are isolated from population centers and services. Unfortunately, there is not a single universally-accepted definition of frontier. Definitions of frontier for specific state and federal programs vary, depending on the purpose of the project being researched or funded.
While frontier is often defined as counties having a population density of six or fewer people per square mile, this simple definition does not take into account other important factors that may isolate a community. Therefore, preferred definitions are more complex and address isolation by considering distance in miles and travel time in minutes to services. 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
- Seasonal changes in access to services
Frontier may be defined at the community level by county, by ZIP code, or by census tract. See the National Center for Frontier Communities' Frontier Definitions List for descriptions of all major definitions.
Rural-Urban Commuting Areas (RUCAs)
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. RUCAs are available by census tract and ZIP code area.
Frontier and Remote (FAR) Codes
Federal legislation to improve access to health services in frontier areas resulted in the USDA's Economic Research Service and the Federal Office or Rural Health Policy developing the Frontier and Remote (FAR) area codes. The FAR codes have not yet been released in final form. A first draft of the FAR methodology based on urban-rural data from the 2000 decennial census was posted in the Federal Register for public comment in November 2012. The draft methodology provides distinct FAR categories, ranging from one that is relatively inclusive (18 million FAR residents) to one that is more restrictive (4.8 million FAR residents).
Four FAR levels were developed because rural areas experience degrees of remoteness depending on the accessibility of different types of goods and services. A relatively large number of people live far from “high-order” goods and services that are usually located in large urban areas, such as advanced medical procedures and regional airport hubs. FAR Level 1 approximates this degree of remoteness by measuring the average travel time within a zip code area to the closest large urban center. A smaller number of people live far from “low-order” goods and services that can usually be found in smaller urban centers, such as grocery stores, gas stations, and primary healthcare services. FAR Level 4 approximates this much higher degree of remoteness by measuring travel time to smaller urban centers. Users of the FAR codes will be able to choose the definition that bests suits their specific application.
FAR codes are being updated based on 2010 data and should be available by the end of this year. Information and maps on the pilot methodology are available at USDA's – Economic Research Service: Frontier and Remote Area Codes
How much of the U.S. is frontier?
The number of people living in the frontier and the amount of land that is frontier will vary depending on the definition of frontier used. In 2011, the National Center for Frontier Communities asked each of the State Offices of Rural Health (SORH) to designate which of their state’s counties were frontier. The SORHs designated 46% of the land area of the United States as frontier, and over 5.6 million people lived in these areas in 2010. For a complete list of these SORH-designated frontier areas by state and county, the National Center for Frontier Communities provides Frontier Areas from 2010 U.S. Census, a tool with downloadable data in both Excel and HTML formats.
According to the most recent RUCA codes, in 2010, 9.9 million people lived in a census tract with a RUCA code of 10, which is assigned to the most isolated, small rural census tracts.
RAC’s map, Frontier Counties, displays the location of frontier counties nationwide with data from the U.S. Census Bureau based on the simple definition of fewer than seven persons per square mile.
How can I find out if my county is a frontier county?
There are several answers to this question depending on which definition you select or are required to use.
You can determine if your county meets the “fewer than seven 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."
The Am I Rural? tool on the RAC website can be used to help determine whether a specific location is considered rural based on various definitions of rural, including definitions that are used as eligibility criteria for federal programs.
The Center for Rural Health at the University of North Dakota and the USDA's Economic Research Service jointly developed Version 3.10 of the 2010 ZIP code Rural-Urban Commuting Areas (RUCA codes) geographic taxonomy (classification). This data set is available from the Center for Rural Health.
A new Frontier and Remote (FAR) taxonomy Version 1.0 classifying the most rural geographic locations in the United States with 2010 U.S. Census data is forthcoming and will be downloadable from the Center for Rural Health and the USDA's Economic Research Service websites.
A complete list of frontier areas by state and county, as designated by the State Offices of Rural Health, based on data from the U.S. Census Bureau, is available from the National Center for Frontier Communities. The Frontier Areas from 2010 U.S. Census is a tool with downloadable data in both Excel and HTML formats.
What are some of the challenges in frontier areas?
The isolation and distances that classify an area as frontier result in long trips to attend school, shop for groceries, get healthcare, and reach other basic services. Public transportation options are often limited or unavailable in frontier areas, making access to needed healthcare services difficult for low-income households, the elderly, and people with disabilities.
Frontier areas often face seasonal travel barriers that make travel difficult. For those living in mountainous areas or the northern regions, some roads and passes may be closed in winter or obstructed by snow and ice, leading to longer travel times. Flooding caused by melting snow and heavy rains can force the closure 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 or boat transport for access to healthcare and are dependent on fair weather conditions. These barriers to travel can be particularly problematic when it comes to emergency medical transport, but also for non-emergency medical transport for routine exams and ongoing care of chronic disease.
What are some of the healthcare challenges in frontier areas?
Access to healthcare
Frontier areas face the same difficulties as other rural areas in maintaining their healthcare 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, see RAC’s Topic Guides: Rural Healthcare Workforce and Recruitment and Retention for Rural Health Facilities.
The National Center for Frontier Communities' map Critical Access Hospitals and Frontier Designated Areas, 2010 notes that only 27% Critical Access Hospitals are located in frontier areas, leaving many frontier areas without a hospital. Frontier counties that do have hospitals may face higher costs than non-frontier hospitals, due to the lower volume of patients served. In addition, frontier counties with no hospitals or with workforce shortages are often clustered together; compounding the distance residents must travel to reach a hospital.
Some areas must cope with seasonal variations in healthcare needs, when the population surges with tourists, seasonal workers or retirees. The limited health resources available in frontier areas, including volunteer health services and costly medical evacuation services, may be required to care for seasonal residents, further restricting the resources available for local residents. For more information, see Impact of Seasonal Population Variations on Frontier Communities: Maintenance of the Healthcare Infrastructure.
Health Risk Factors
Rural communities are at higher risk for substance abuse, suicide, motor vehicle fatalities, obesity, cigarette smoking, and death from unintentional 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' reports that occurrences of domestic violence, child abuse, and suicide are higher in both rural and frontier areas. According to a 2014 article in the Journal of Rural Mental Health, mental and behavioral health providers have recognized problems of substance abuse and domestic violence as significantly more prevalent in frontier areas.
Traffic fatalities are also a risk factor for frontier residents due to poor infrastructure, such as narrower roads with bidirectional traffic. In addition, the increased time to receive emergency services in frontier areas contributes to the fatality rate. Pew Charitable Trust’s Rural States Struggle to Reduce Road Deaths identifies strategies that states can undertake to decrease rural traffic fatalities.
Obesity in remote, rural areas tends to be higher than in urban areas according to A National Study of Obesity Prevalence and Trends by Type of Rural County.
The economy in frontier areas is often based on a few specific industries such as farming, ranching, tourism, logging, and mining. These industries, other than tourism, are associated with higher numbers of unintentional injuries, elevating the need for accessible healthcare, emergency medicine, and emergency medical transportation.
Are there funding or reimbursement advantages to being considered a frontier area?
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. However, the Health Center program gives special consideration to sparsely populated or frontier areas.
The National Center for Frontier Communities has highlighted frontier provisions of the Affordable Care Act (ACA) including a clause that provides enhanced Medicare reimbursement rates to “Frontier States.” These states are defined in the ACA as all states in which at least 50% of counties have an average population density of six people per square mile or fewer. Currently, states that meet these criteria are Montana, Nevada, North Dakota, South Dakota and Wyoming.
Frontier communities are rural and therefore qualify for many rural-specific health related funding programs, such as the Federal 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 RAC's Funding section.
What types of models are being tried to address frontier healthcare issues?
The American frontier is diverse and dynamic, and providing healthcare to residents of the frontier is often challenging. The Critical Access Hospital was one of the first innovations in provider type for rural areas, designed to preserve and sustain essential healthcare services.
The current demonstration entitled “Frontier Community Hospital Integration Project” or FCHIP, is a frontier-specific program which is testing new service delivery and reimbursement models. It is designed to strengthen Critical Access Hospitals in four specific areas: telemedicine, nursing facility care, home health services and ambulance services. It was opened to hospitals located in five frontier states. More information can be found at Frontier Community Health Integration Project Demonstration on the CMS.gov website. Also, RAC’s Testing New Approaches section provides additional information about the Frontier Community Health Integration Program.
Many frontier areas, particularly in Alaska and remote frontier regions, do not have nearby hospitals. The Frontier Extended Stay Clinic (FESC) was a Medicare payment demonstration designed to show that enhanced reimbursement could spur the development of limited observation services (up to 48 hours) in frontier clinics, that such services could be delivered safely, and that they ultimately save payers money, primarily by avoiding costly transportation to a higher level of care. The five demonstration clinics were all isolated, fairly large, and sophisticated outpatient Community Health Centers or Rural Health Clinics. All of the clinics successfully met the Conditions of Participation and demonstrated costs savings, patient safety, and patient satisfaction. However, the start-up cost was a significant factor, particularly in meeting the enhanced life-safety code requirements. A final report on the demonstration, Evaluation of the Medicare Frontier Extended Stay Clinic Demonstration: Report to Congress, provides key findings from the project. The FESC may be a model for communities that are struggling to maintain inpatient services, allowing communities to preserve primary care, emergency services, and observation services. More information on the model is available from the Alaska FESC Consortium and the RAC’s Testing New Approaches: Frontier Extended Stay Clinics.
What types of innovative ideas have been used to address healthcare workforce issues in frontier areas?
Community Health Aides
In Alaska, Community Health Aides (CHAs) provide healthcare in remote areas of Alaska under the supervision of a physician. CHAs work in more isolated locations and rely on telemedicine and other electronic means of communication with physicians to facilitate the care given to patients. CHAs work with a variety of patients and conditions that include mental health, trauma and chronic disease. Some CHAs work as itinerants and travel to several communities to provide healthcare services.
Basic training for Community Health Aides can take 14 months or more, and includes both classroom time and clinical practice. For more information see the Community Health Aide page on the Alaska Center for Rural Health – Area Health Education Center.
Dental Health Aides
A similar model to the CHA is the Alaska Dental Health Aide Therapist (DHAT) program. DHATs train for two years in a post-high school primary care curriculum that incorporates preventive and clinical strategies for providing oral healthcare in Alaska communities where they live.
Recruitment and Retention Strategies
Various types of recruitment and retention strategies have been used to address the significant shortages of health professional often found in frontier areas. The FORWARD NM: New Mexico’s Pathways to Health Careers workforce program seeks to improve the supply and distribution of healthcare professionals through community and academic educational partnerships that include school-based health career clubs, MCAT preparation, and rural clinical internships and rotations.
Some states with large frontier designated areas provide a rural health profession tax credit for healthcare professionals who work in a rural or underserved area. New Mexico offers the Rural Health Care Practitioner Tax Credit and Oregon offers the Rural Practitioner Tax Credit for MDs, DOs, DPMs, NPs, PAs and CRNAs.
Telehealth may be one of the most important developments to positively address healthcare workforce issues in frontier areas. Patients in frontier areas can receive healthcare, including specialty care, more locally, reducing the need to travel long distances to receive healthcare services. With telehealth technology, primary healthcare providers have the opportunity to work with specialists to provide more specialized care. Telehealth has the potential to enhance the quality of care, improve health outcomes, and reduce healthcare costs in both rural and frontier areas. However, telehealth implementation has not been consistent throughout these areas and significant regulatory issues still need to be resolved in many states. In spite of these issues, the practice of telehealth has been increasing and is already improving the availability of services in many frontier regions. For additional information about telehealth see: Telehealth Use in Rural Healthcare.
For additional information regarding new ideas for used to address healthcare workforce issues in frontier areas see RAC’s Rural Health Models and Innovations Hub.