Medicaid’s Role in Small Towns and Rural Areas
In analyzing the Medicaid cuts under consideration by House Republicans for inclusion in budget reconciliation legislation, it is often easier to examine each specific proposal in isolation. But singular reviews does not paint a complete picture
It is important to take a step back and look at how these proposals would interact with each other and the impact on various portions of the country. In doing so, it is certain the Medicaid cuts being discussed would result in 40 states and the District of Columbia ending the Medicaid expansion over time. The end result would be taking away coverage from nearly 21 million low-income people including parents, people with disabilities, near-elderly adults, and adults with chronic conditions.
This particular piece by Georgetown discusses the importance of Medicaid for rural communities. However, it does miss one key element and that is the support it renders to rural hospitals and clinics. I will have to find a piece to highlight those issues.
Medicaid’s Role in Small Towns and Rural Areas, Center For Children and Families
Key Findings
- Non-elderly adults and children in small towns and rural areas are more likely than those living in metro areas to rely on Medicaid/CHIP for their health insurance. As a consequence, reductions in federal Medicaid funding being contemplated in Congress are more likely to cause greater harm to rural areas and small towns than metro areas.
- For children this is especially true in Arizona, Florida, North Carolina, Virginia, South Carolina, California, Minnesota, Georgia, South Dakota, and Alaska.
- For adults this is especially true in Arizona, New York, Washington, Texas, Kentucky, Virginia, Louisiana, Oregon, South Carolina and Montana.
- For people over age 65, the rate of Medicaid coverage is slightly lower in rural areas than metro ones.
- In six states, at least half of children living in small towns and rural areas are covered by Medicaid/CHIP. These include New Mexico (59.9%), Louisiana (57.7%), Arizona (55.9%), Florida (51.9%), South Carolina (51.1%), and Arkansas (50.5%).
- In fifteen states, at least one-fifth of non-elderly adults living in small towns and rural areas are covered by Medicaid. These include Arizona (35.9%), New York (33.9%), New Mexico (31.6%), Louisiana (30.2%), Kentucky (28.5%), West Virginia (25.5%), Oregon (24.9%), Washington (24.4%), Montana (22.2%), Arkansas (22.0%), Maine (21.9%), Vermont (21.7%), Massachusetts (21.5%), Michigan (21.2%), and Alaska (20.4%).
- Residents of rural counties with a large share of American Indian or Alaska Native residents and tribal lands are more likely to rely on Medicaid for coverage for all age groups, including seniors.
- Large reductions in federal Medicaid funding would put the residents of small towns and rural communities and their health care systems at serious risk.
One-fifth of people in the United States live in areas that are classified as non-urban. Residents of rural areas and small towns face additional challenges accessing needed health services compared to residents of metro areas for a variety of reasons including acute provider shortages, limited connectivity, and long distances to travel to access care, often without reliable public transportation options. Residents of rural areas also have worse health outcomes including: higher maternal and infant mortality rates; higher mortality rates from heart disease, cancer, and stroke; and higher rates of mental illness and overdose deaths. States with the largest number of rural residents include Texas, North Carolina, Ohio, Georgia and Pennsylvania and states with the largest share of population in rural areas include Wyoming, Vermont, Mississippi, South Dakota, and Montana
The residents of rural areas and small towns have lower incomes on average than people living in metro areas and less access to employer-sponsored health insurance. Public coverage such as Medicaid and the Children’s Health Insurance Program (CHIP) fill an even more critical role in these areas than in other areas of the country. Uninsured rates have come down significantly since passage of the Affordable Care Act (ACA). They do remain higher in small towns and rural areas than in metro areas. Moreso found in states not expanding Medicaid for adults.
In the past ten years, 120 rural hospitals have either closed or ceased offering inpatient services. Hospitals operating in rural areas have lower operating margins. This occurs in states that have not taken up the Affordable Care Act Medicaid expansion for adults. In a struggle to keep their doors open, many rural hospitals opt to close less lucrative units such as maternity wards. In 2022, a slight majority of rural hospitals (52%) no longer had maternity wards compared to 36% of urban hospitals. Rural hospital closures have adverse economic effects on rural communities and limit access to care.
Findings
As shown in Figure 1, in 2023 40.6% of children living in small towns and rural areas were enrolled in Medicaid/CHIP as compared to 38.2% in metro areas. This is the largest differential in the examined populations. The vast majority of states (38 of 48) have similar or larger shares of children in small towns/rural areas covered by Medicaid/CHIP than in Metro areas. See Appendix Table 1 for state-by-state analysis.
Similarly, non-elderly adults are covered by Medicaid at higher rates in rural areas as compared to metro areas (18.3% v. 16.3%), with 40 states out of 48 showing similar or higher rates of Medicaid enrollment in rural areas/small towns. See Appendix Table 2.
Seniors in rural areas and small towns do not disproportionately rely on Medicaid (15.8% v. 17.0%).2 It is unclear why seniors would have a different pattern overall. However, looking at state-specific patterns, in the majority of states — 29 states — larger shares of seniors in small towns and rural areas were enrolled in Medicaid than in metro counties, including in Arizona where 46.1% of seniors in small towns and rural areas were enrolled in Medicaid as compared to 13.1% in metro counties. See Appendix Table 3.
A Closer Look at Where Children’s Medicaid Coverage in Rural Areas and Small Towns is Especially High
As Table 1 shows, in six states (NM, LA, AZ, FL, SC, AR) half or more of the children living in small towns and rural areas are covered by Medicaid/CHIP. A closer look at the counties nationwide with the highest share of children covered by Medicaid/CHIP finds that the top 20 rural counties in the country have between 62 and 73 percent of children enrolled. These counties are primarily found in the six states listed above along with Humphreys County in Mississippi and Wolfe County, Kentucky.
Table 2 depicts the states with the largest differential in coverage rates for children in rural areas as opposed to metro counties with Arizona and Florida leading the way. For states in Table 2, cuts in Medicaid funding will likely have an outsized impact on families living in rural communities and small towns.
Finally, Table 3 shows the states with the largest number of children in small towns and rural areas enrolled in Medicaid/CHIP, with Texas, North Carolina, Georgia, Kentucky, and Mississippi leading the way.
A Closer Look at Where Adult Medicaid Coverage in Rural Areas and Small Towns is Especially High
As Table 4 shows, there are 15 states where at least one fifth or more of non-elderly adults in small towns/rural areas are covered by Medicaid. Arizona and New York have more than one-third of rural adults covered by Medicaid. A look at the top 20 rural counties nationwide for adult enrollment in Medicaid is available in Appendix Table 5; all of these counties are in the 15 states shown in Table 3.
Table 5 illustrates the states where the importance of Medicaid/CHIP to adults in small towns/rural areas is even more pronounced as compared to metro areas and includes states that have expanded Medicaid coverage for adults under the Affordable Care Act as well as some that have not (TX, SC). Arizona again leads the way with New York, Washington, Texas, and Kentucky following. For states in Table 5, cuts to federal Medicaid funding will likely have an outsized impact on rural communities.
Impact on Native People
American Indian and Alaska Native (AI/AN) people are much more likely to live in non-metro areas (40%). Native peoples face significant challenges to accessing health care and have higher rates of chronic conditions, such as diabetes, as well as higher mortality rates. The Indian Health Service has been historically underfunded and importantly is not a health insurer but rather a provider of health care services in accordance with the federal trust responsibility.
Medicaid plays a very important role as an insurer for Native peoples – protecting them from high out-of-pocket costs. American Indian/Alaska Native children have historically had much higher rates of Medicaid enrollment than other children. Three quarters of AI/AN people live in the Southern and Western regions.
Our analysis finds that Medicaid continues to play an outsize role as a coverage source for people living in counties with large American Indian and Alaska Native populations – especially in rural areas and small towns. As Figure 3 shows, half of children living in rural AI/AN areas (including tribal lands) are covered by Medicaid/CHIP. Non-elderly adults and seniors in rural areas are also more likely to be covered by Medicaid in AI/AN areas.
A closer look at the top twenty rural counties where seniors have the highest Medicaid coverage rates underscores the critical role that Medicaid plays for indigenous elders, with two-thirds of seniors covered by Medicaid in Oglala Lakota County in South Dakota, which consists entirely of the Pine Ridge Reservation, and Apache County in Arizona (which includes primarily tribal lands) – far exceeding the national rate of under one in five. Seven of the top 20 rural counties for seniors enrolled in Medicaid are in South Dakota and all of these counties are in Indian Country, seniors in these counties have Medicaid enrollment rates ranging from 39 to 66 percent. See Appendix 6 for the full list of counties with high shares of seniors covered by Medicaid.
Conclusion
Rural communities face greater challenges than metro areas in keeping their health care infrastructure strong enough to support rural residents’ health needs. American Indian and Alaska Native people are also at grave risk; Medicaid is a key insurer protecting these families from medical debt.
Large cuts to Medicaid currently being contemplated by Congress pose very severe threats to rural communities. Hospitals and other providers in rural communities are already operating on tighter margins and disproportionately rely on Medicaid for their patient revenues. Families and non-elderly adults in rural areas rely on Medicaid for their health insurance at higher rates than those living in metro areas, underscoring that large cuts will have dire consequences for communities that are already struggling.
More Reading
“Medicaid Plays Key Role for Maternal and Infant Health in Rural Communities,“ Georgetown University
If you look at the big picture, it seems obvious that this is how the Republicans plan to save Social Security, by shortening American lifespans.
@Kaleberg,
Since a larger proportion of Republican voters live in small towns and rural areas, this does pose problems for them in the long term.
Kaleberg:
I believe there is to be an increase in age for collecting SS. This would be from 67 to 70 years of age. Is this what you are discussing right now?
The Northwest Plan proposed by Dale and Bruce would be successful if it was implemented ~ 2 years ago. It could “still” work if implemented now with an increase slightly greater than 1 tenth of 1% for both companies and individuals.
To “maybe” offset some of the increase (if not all) above 1 tenth of 1% could be accomplished by implementing “some” of the recommendations by Brookings.
Brooking is calling for an increase of 1 tenth of 1% in SS withholding. Why not follow it through for more years. Definitely, whatever is collected would offset the funding shortcomings. Add to it, increased income becoming subject to SS with no increase in benefits.
To your point of shortening the life of us commoners. Cutting Medicaid, healthcare in general, increasing age to receiving SS, and raising costs is other ways of saving SS also.
Where are you reading on this plan to shorten life for Americans?