Where, More or Less, is "The Frontier"?

They are lands of great expanse, of tumbleweed, grand canyons and parks, and yes, national treasures.

But for health program funding and definition purposes, just what is a "Frontier"? How many people must live there to qualify, or sustain a program for funding, licensing, or support?

Should it be defined merely by the great distances between neighbors, the isolation of its people? How about the number of paramedics, the condition of its roads or the challenges of its topography, be it mountains, deserts or tundra? Should weather patterns, economy, or the availability of a licensed health practitioner be considered? What about areas that may not initially have expertise to provide healthcare service, but hopes to get it?

Starting this Friday in Albuquerque, federal officials are holding the first of three meetings to help resolve these questions, followed by meetings May 18 in Seattle and June 26 in Omaha. The task—to better distinguish what is merely "rural" from what is really "out there yonder"—is advocated in part by a patient, but persistent nonprofit group, the National Center for Frontier Communities.

The meetings are entitled "Potential Definitions of the Terms Frontier or Remote Areas."

"We're interested in (defining) frontier because we want to try to identify those areas that are really, really remote," says Steve Hirsch, public health analyst with the Office of Rural Health Policy in Rockville, MD, a division of the federal Health Resources and Services Administration. They have special needs, and may not be as easily or simply categorized, Hirsch acknowledged.

Initially, he says, federal officials are not looking to define frontier for funding purposes, but that is a logical consequence down the line.

"These are areas that lack access to healthcare services or population, and when we define these, we can think about what sort of healthcare services they can support," he says.

Areas are often excluded from "rural" program designation because they don't have the required number of providers or people, or perhaps just a few too many. These might qualify for funding under "frontier" status. There might be a telemedicine project, or grants for a van or helicopter service that can transport patients to the doctor or a hospital 150 miles away. Now, there's no shades of gray in the way such areas are defined, he says.

Carol Miller, former director of a community clinic in Tierra Amarilla, NM, is executive director of the National Center for Frontier Communities, as well as a former Health Resources and Services Administration official. She insists that government officials should not be too exact with whatever definition they eventually write. What she wants, she says, is "geographic democracy," so even people in frontier lands get the care they need.

Whatever definition comes out, it must be flexible because the area is extremely diverse, she says. Lands now loosely called frontier make up 56% of the land area of the U.S., but hold about 3% of the nation's population (fewer than 9 million people).

One way to deal with that diversity, advocated by her organization, is to use a weighted formula that gives "frontier" points to regions of the country based on three elements: population density, travel distance to whatever health service services might exist, and the time it takes to get there. A region with more than 12 people per square mile might lose points because it has more people, but if its distances or travel times are greater, it will gain points.

But such a proposal, Miller says "was not uniformly appreciated by federal policy makers," at least initially.

"It really gets down to one thing: how isolated are you?" she says. "I spend a lot of time explaining to people who may need emergency care one day: we hope to reach you with a paramedic within an hour, and get you to a hospital in another hour."

For city folks, it's easy to lose perspective, Miller said. Frontier areas are not just ultra rural. Urban areas are home to 80% of the U.S. population, but just 4% of America's geography.

Today's definitions of urban and rural have evolved, more or less by default, Hirsch says. First, it was agreed in general what areas would be called "urban." Everything else was classified as "rural," including that which was truly frontier.

Today, however, the term frontier is all too frequently lumped in with rural, which is 96% of the nation's real estate, but only 20% of its population. What is rural is usually much more urban than what is frontier. Rural and frontier, she said, are two different worlds.

"The frontier is not empty," Miller says. "These are places from which much of our national wealth is derived, from mining, agriculture, ranching, and many Native Lands. There is someone there, maybe a ranger station, a fire watcher or a national park that gets 12 million visitors a year driving through."

Miller explains the problem by describing the challenges of providing healthcare in Lordsburg, a 4,000 population town in New Mexico 50 miles from the Mexican border in Hidalgo County, an area with only 1.7 people per square mile and about as remote as anyone can be in the U.S.

A few years ago, Miller says, Charlie Alfero, CEO of HMS Health System, was trying to start a two-bed extended care service in his clinic so patients who don't need to go to the hospital 50 miles away in Silver City, or 150 miles away to El Paso, can get appropriate care closer to home. The project had been planned for years and was ready to go, or so he thought, Miller said.

But the day before his pilot project was to be approved as part of federal legislation, someone changed the rules, eliminating him from opening his service because his clinic was less than 75 miles away from the nearest hospital.

That was unfair, Miller said, because in an area this rural, many patients live in towns like Rodeo or Playas that are already at least 25 miles farther away.

"That structural barrier left out many other facilities that had worked for the legislation," she says.

Miller enumerates dozens of ways in which very rural areas are discriminated against. Bigger areas, for example, get more money per capita than smaller ones and tend to fund projects in pieces rather than taking a holistic approach to healthcare.

Frontier areas have extreme difficulties recruiting health professionals. They may be lumped in with multiple county groups, partners who may not always like to share.

Miller sums up the issue this way. "Do people throughout the entire country have access to a minimum amount of services, and if they don't, how do we create a system that allows them to get them?"