The Balanced Budget Refinement Act of 1999 (BBRA) permitted hospitals located in metropolitan statistical areas that resembled rural facilities to participate in the program; it was referred to as a ³reclassification of certain urban hospitals as rural hospitals.²1 Hence, 59 CAHs are located in metropolitan counties (Map 2). Although these facilities are located in a defined ³urban² area, they are typically located on the border of a rural, sparsely populated area in a metropolitan county.

Map 3 depicts the 173 CAHs that are located in frontier counties, defined here as having no more than seven persons per square mile. Except for one facility in Maine, the remaining hospitals are located in the Midwest and West. The distribution of frontier hospitals along the Canadian border is also quite marked. Compared to the U.S. population, the individuals living in the communities with operating CAHs are older, poorer, more likely to be unemployed, and less diverse in ethnic composition (Table 2).

1Technical Assistance Services Center, 2002. H.R. 3426. Medicare, Medicaid, and SCHIP Balanced Budget Refinement Act of 1999. http://www.ruralresource.org/documents/BBRA.pdf

Map 2

Map 3

Where Can I Get More Information? About this report:     Melissa A. Fruhbeis, MSPH, North Carolina Rural Health Research & Policy Analysis Center, Cecil G. Sheps Center for Health Services Research, UNC-CH, (919) 966-9985 or melissa_fruhbeis@unc.edu About this Project:     Check out our website http://www.rupri.org/rhfp-track Previous Findings From The Field and Tracking Project Reports Report:              Rural Hospital Flexibility Program Tracking Project Year Three Vol. 2, No. 5:     Reauthorizing the Medicare Rural Hospital Flexibility Grant Program:  Lessons from the Field Vol. 2, No. 4:     Critical Access Hospitals and Community Development Vol. 2, No. 3:     Administration in Critical Access Hospitals Vol. 2, No. 2:     Regionalization of Emergency Medical Services:  The Experience of Michiganıs Upper Peninsula Vol. 2, No. 1:     Impact of the Rural Hospital Flexibility Program on Rural Emergency Medical Services:  Evidence From the First Two Years

CAH/FLEX - National Tracking Project FINDINGS FROM THE FIELD Volume 2, Number 6, September 27, 2002 Consortium Members Project HOPE Walsh Center for Rural Health Analysis Rural Policy Research Institute University of Minnesota Rural Health Research Center University of North Carolina Rural Health Research and Policy Analysis Program University of Southern Maine Rural Health Research Center WWAMI Rural Health Research Center