Two thirds of rural residents who lack health insurance live in states that have not expanded Medicaid, putting rural Americans at a greater risk of falling into the health-care coverage gap.
Rural residents who don’t have medical insurance are disproportionately affected by state decisions not to expand Medicaid under the Affordable Care Act, reports a Kaiser Family Foundation research brief.
About two-thirds of uninsured rural residents currently reside in states that have not implemented Medicaid expansion. Nationally, 52% of uninsured Americans live in states that didn’t expand Medicaid.
That means rural residents are more likely than average to live in a state that didn’t expand Medicaid.
Across the nation, 47.3 million residents lacked medical insurance in 2013, the study found. The percentage of the population that lacked insurance was about the same in both rural and urban areas, 18%.
But because uninsured rural residents are more likely to live in states that didn’t expand Medicaid coverage, they face special challenges, the study says. They are more likely to fall in the “coverage gap” – where they earn too much to qualify for Medicaid but too little to qualify for tax credits to purchase private insurance.
The study shows 15% of nonelderly rural uninsured fall in the coverage gap, while only 9% of their urban counterparts do.
The gap in coverage is related to a 2012 Supreme Court decision that allowed states to decide individually whether to expand Medicaid to cover residents who earn up to 138% of the poverty level.
The original healthcare-reform legislation mandated the expansion of Medicaid to all qualified residents who earned up to the 138% of poverty threshold. Residents who earn more can qualify for tax credits to help with private insurance. But in states that didn’t expand Medicaid and maintain a lower eligibility threshold, uninsured residents can earn too much for public assistance and too little for tax credits.
As of June, 24 states have chosen not to expand Medicaid. The states not expanding Medicaid include some with high percentages of rural residents, such as Alabama (41% rural), Mississippi (50%), Maine (60%) and South Dakota (43%).
While some states with high percentage of rural residents have opted to expand Medicaid, such as Arkansas (44%) and West Virginia (51%), that list also includes big states with large numbers of urban residents like California and New York. (Here’s a complete list of where states stand on Medicaid expansion.)
The study also found the following:
Rural residents are less likely than urban residents to be ineligible for health insurance due to citizenship status. (6% vs. 14%)
Rural residents are less likely to receive employer-sponsored health insurance (ESI) than residents of urban regions. (51% vs. 57%)
Rural residents are more likely to receive health insurance via Medicaid than urban residents. (21% vs. 16%)
Uninsured rural residents are less likely to qualify for government aid (Medicaid or tax credits) than uninsured urban residents. (77% vs. 79%).