AHA Letter on Proposed Census Bureau Criteria for Defining Urban Areas

May 10, 2021

Vincent Osier
Geographic Standards, Criteria, and Quality Branch
Geography Division
U.S. Census Bureau

RE: Department of Commerce, Bureau of the Census 210212–0021: Urban Areas for the 2020 Census – Proposed Criteria, February 19, 2021.

Dear Mr. Osier:

On behalf of our nearly 5,000 member hospitals, health systems and other health care organizations, our clinician partners – including more than 270,000 affiliated physicians, 2 million nurses and other caregivers – and the 43,000 health care leaders who belong to our professional membership groups, the American Hospital Association (AHA) appreciates the opportunity to comment on the Bureau of the Census’ (Census Bureau’s) proposed criteria for defining urban areas. If finalized, the new definition of urban areas could jeopardize the ability of certain health care providers to participate in programs that expand access to care in vulnerable communities.

The Census Bureau’s current threshold for defining urban areas uses population density areas with at least 2,500 persons. Furthermore, the Census Bureau also uses “urbanized area” and “urban cluster” concepts to distinguish different types of urban areas1:

  • urbanized area describes areas with 50,000 or more persons; and
  • urban cluster describes areas with at least 2,500 persons, but less than 50,000 persons.

The agency is now proposing to change its definition of an urban area to include only those with at least 4,000 housing units or 10,000 persons. It also would cease to distinguish between urbanized areas and urban clusters. The AHA strongly urges the Census Bureau to continue to distinguish between different types of urban areas. Specifically, we urge it to continue to recognize urbanized areas as areas with 50,000 or more persons, and to recognize urban cluster as areas with at least 10,000 persons, but less than 50,000 persons.

The Census Bureau urban delineations directly affect program eligibility and funding formulas. For example, the Centers for Medicare & Medicaid Services (CMS) uses different types of urban areas as the basis for certifying rural health clinics (RHCs). Currently, CMS defines a rural area as an area that is not an “urbanized area;” thus, RHCs can be currently certified in areas with less than 50,000 persons. Under the Census Bureau’s proposal, this may no longer be possible as there would no longer be specific recognition of areas with less than 50,000 persons – only those with less than 10,000 persons.

We recognize the agency’s statement that “[i]n delineating urban areas, the Census Bureau does not take into account or attempt to meet the requirements of any nonstatistical uses of these areas or their associated data.” That said, our recommendation above would not only allow the Census Bureau to use its modified urban threshold of 4,000 housing units or 10,000 persons, but also allow other federal agencies to readily apply different types of urban area delineations to meet their own objectives.

Indeed, urban areas with a population less than 50,000 are very different from urban areas with a population greater than 50,000, and that data reflecting those differences need to be maintained. For example, the Office of Management and Budget currently uses a 50,000-person threshold to qualify for the core of a metropolitan statistical area. Furthermore, the impact of adopting housing unit density as the proposed primary criterion to define an urban area is still to be determined. Thus, continuing to distinguish different types of urban areas per our recommendation above, while also making the Census Bureau’s proposed change to its urban threshold of at least 10,000 persons, would allow for continuity and provide more exact data to users. It is essential that proposed changes be as inclusive and flexible as possible in order to broaden opportunities for providers in various communities.

Furthermore, the programs that rely on these delineations are critical to their communities. The RHC program provides essential health care services for individuals living in vulnerable communities. The program allows individuals to obtain access to high-quality, safe and effective health care services in their own communities, which in turn, improves their health outcomes. Thus, it is vital to maintain access to these RHCs.

We thank you for your consideration of our comments. Please contact me if you have questions, or feel free to have a member of your team contact Shannon Wu, senior associate director of policy, at 202-626-2963 or swu@aha.org.



Ashley Thompson
Senior Vice President
Public Policy Analysis and Development

  1. The Census Bureau identifies two types of urban areas – urbanized areas and urban clusters. “Rural” encompasses areas not included within an urban area.