The Critical Access Hospital (CAH) Program has offered Medicare cost-based reimbursement to small hospitals that meet certain eligibility criteria to improve their financial viability and quality of care. However, cost-based reimbursement has been associated with inefficiency in hospital operations. This study uses a two-stage approach and bootstrap procedures to examine the effects of environmental variables on the technical efficiency of CAHs. The two-stage approach with quality controls significantly improved statistical efficiency of parameter estimates in the second stage bootstrapped truncated regression relative to a similar model without quality controls. Overall, our results suggest that enhanced Medicare reimbursement may not have had detrimental effects on the technical efficiency of CAHs.

We analyze county-level social, demographic, and economic data in U.S. counties to explore how economic mobility in the United States varies across the geography of the rural-urban interface. We reveal that micropolitan areas—small and medium urban centers—appear to play a unique role in the geography of intergenerational economic mobility. Micropolitan areas help to define the blurred boundaries of the new rural-urban interface, and play a unique and potentially powerful role in supporting the upward mobility of low-income youth. In some geographic areas, micropolitan counties serve as cores of nonmetropolitan America, supporting upward mobility in ways that take advantage of their density and scale. In other domains, they are relatively low-density transition zones between remote noncore rural counties and metropolitan America, supporting upward mobility of low-income youth in ways that exploit the opportunities and reveal weaknesses associated with nonmetropolitan small size, lack of density, and limited technological capacity.

Average absolute upward mobility is greater for youth in non‐metropolitan counties than in metropolitan counties. What may be more important for upward mobility of low‐income youth, however, is not whether their county is metro or non‐metro but rather how far their county is from metropolitan centres. We test this hypothesis and find support for the conclusion that distance is a significant predictor of upward mobility, that remoteness from central metro counties is associated with higher upward mobility. We also find that the association of other factors with upward mobility differs between metro and non‐metro counties. The shares of single‐mother families and income inequality have a smaller negative association with upward mobility in metro than non‐metro counties. The high school dropout rate, on the other hand, has a much larger negative association with upward mobility in metro than in non‐metro areas, suggesting that the quality of the school system matters more in urban areas. Better spatial job matching and higher social capital, by contrast, are more positively correlated with mobility in non‐metro counties than in metro counties, suggesting that specific place‐based rural policies may have more potential to increase upward mobility in rural areas.

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