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RURAL ACCESS TO QUALITY HEALTH INSURANCE
By Jane N. Bolin, PhD, JD, BSN; Gail Bellamy, PhD; Alva O. Ferdinand, DrPH, JD; and Chinedum
Ojinnaka, MBBS, MPH
SCOPE OF THE PROBLEM
• The Healthy People 2010 target for insurance coverage was not met by any state. 1
• Nearly 48 million people in the United States were uninsured in 2012; 2 this is an increase of 6.7
million in uninsured compared to a 2001 study. 3 However, a recent study released by the Kaiser
Family Foundation shows that the rate of uninsured has decreased by between 2.5 percent and 4.7
percent with a gain of 5.4 million to 9.3 million. 4 The numbers of uninsured are expected to continue
to decline under the Affordable Care Act.
• A larger proportion of the rural population is uninsured and poor (below 138 percent federal poverty
level) compared to the urban population (9.9 percent versus 8.5 percent). 5
• Rural residents under age 65 are more likely than urban residents to be uninsured. Estimates range
from ten percent to 49 percent depending on region of the country. 6
• Disparities in insurance coverage increased significantly for those residents in remote and frontier
areas. 7
• Hispanics and Blacks continue to be less likely to have health insurance coverage compared to non-
Hispanic whites. 2
• Among rural residents, all minority races combined are less likely to have insurance coverage than
whites. 7
• Rural populations would benefit disproportionately from the expansion of Medicaid nationwide (43.5
percent rural compared to 38.5 percent urban). 5
• Only 25 states expanded Medicaid coverage under the Affordable Care Act. 8
• It is estimated that in states that do not expand coverage, about five million individuals will have
income higher than Medicaid eligibility criteria but lower than required to qualify for market place
premium tax credits. 8
1
Prior to the Affordable Care Act (ACA) enrollment million previously uninsured individuals 8 including
deadline, the number and proportion of uninsured 7.8 million rural residents below age 65. 11 New
individuals had continued to climb steadily since ACA coverage will include 600,000 young adults
2000 9 (Fig. 1) with a modest decline reported in between ages 19 and 26 who will have insurance
2011 and 2012. 10 With the ACA enrollment period coverage through their parents’ insurance plans. 11
implemented and Medicaid expansion occurring in Approximately eight million individuals enrolled in
27 states, including D.C. (three states undecided, the health insurance marketplace for the 2013/2014
21 states refusing to expand), rates of uninsured enrollment period. 12
declined from 2.5 percent to 4.7 percent. 4 While
most attribute the recent decline to the ACA Several other provisions of the ACA should assist
enrollment deadline, others point out that allowing rural healthcare providers in providing care in
children to remain on their parents’ health plan difficult, rural and remote markets and individuals
until age 26 has also contributed. 4, 8 It is also are going to find insurance where previously
estimated that after the ACA is fully implemented, consumer choices were either nonexistent or
insurance coverage will be expanded to about 17 controlled by one insurer or plan, often at costprohibitive
Rural Access to Quality Health Insurance
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rate levels.