QuickTake: Substantial Gains in Health Insurance Coverage Occurring for Adults in Both Rural and Urban Areas


Michael Karpman, Stephen Zuckerman, Genevieve M. Kenney, and Yvette Odu

April 16, 2015


The Urban Institute has been using the Health Reform Monitoring Survey (HRMS) to examine trends in health insurance coverage since the first quarter of 2013. Recent HRMS data show an estimated 15.0 million (95% CI [11.9 million, 18.1 million]) adults ages 18 to 64 gained coverage between September 2013, just before the first open enrollment period for the Affordable Care Act’s (ACA) health insurance Marketplaces, and March 2015, just after the close of the second open enrollment period (Long et al. 2015).


This QuickTake explores how coverage changed between June/September 2013 and December 2014/March 20151 for adults in rural and urban areas,2 overall and by family income and state Medicaid expansion status.3 An earlier HRMS analysis suggested that the uninsurance rate gap between adults in rural and urban areas was narrowing between September 2013 and September 2014 (Karpman 2015). In this analysis, which is based on more recent HRMS data collected in December 2014 and March 2015, we find coverage increases between June/September 2013 and December 2014/March 2015 of 7.2 percentage points (95% CI [3.9, 10.5]; figure 1) in rural areas and 6.3 percentage points (95% CI [4.7, 7.9]) in urban areas, but less evidence that the rural/urban coverage gap has shrunk.4


The share of adults in rural areas with coverage increased from 78.4 percent in June/September 2013 to 85.6 percent in December 2014/March 2015 (data not shown), and the share of adults in urban areas with coverage increased from 82.8 percent to 89.1 percent during the same period (data not shown).


In both rural and urban areas, the largest coverage gains were among low-income adults targeted by the ACA’s Medicaid expansion (i.e., those with family income at or below 138 percent of the federal poverty level [FPL]). The share of low-income adults with coverage increased 13.9 percentage points (95% CI [10.8, 17.0]) in urban areas and 12.7 percentage points (95% CI [4.9, 20.4]) in rural areas. Coverage gains for middle-income adults targeted by the ACA’s Marketplace subsidies (i.e., those with family income between 139 and 399 percent of FPL) were 6.6 percentage points (95% CI [4.3, 9.0]) in urban areas and 7.9 percentage points (95% CI [3.3, 12.5]) in rural areas.


Coverage increased 7.2 percentage points (95% CI [5.3, 9.0]) for adults in urban areas and 9.1 percentage points (95% CI [4.9, 13.3]) for adults in rural areas in states that expanded Medicaid. In states that did not expand Medicaid, coverage increased 4.8 percentage points (95% CI [2.7, 6.9]) for adults in urban areas and 5.7 percentage points (95% CI [0.7, 10.8]) for adults in rural areas.


A large majority of uninsured individuals in nonmetropolitan areas live in states that do not operate their own health insurance Marketplace, which have thus far received less federal funding for outreach and enrollment assistance compared with states that operate their own Marketplace (National Advisory Committee on Rural Health and Human Services 2014). Therefore, different outreach and enrollment strategies may be needed in rural and urban areas to overcome barriers to obtaining coverage.



Methods: Each round of the HRMS is weighted to be nationally representative. We use these weights and regression adjustment to control for differences in the demographic and socioeconomic characteristics of the respondents across the different rounds of the survey. This allows us to remove changes in insurance coverage caused by changes in the types of people responding to the survey over time rather than by changes in the health insurance landscape. The basic patterns shown for the regression-adjusted measures are similar to those based solely on simple weighted estimates. In presenting the regression-adjusted estimates, we use the predicted rate of coverage in each quarter for the same nationally representative population. For this analysis, we base the nationally representative sample on survey respondents from the most recent 12-month period from the HRMS (i.e., quarter 1 of 2015 and quarters 2–4 of 2014). We focus on statistically significant changes in insurance coverage over time (defined as differences that are significantly different from zero at the 5 percent level or lower) and highlight changes relative to September 2013, just before the open enrollment period for the Marketplaces began. We provide a 95 percent confidence interval for key estimates.


Limitations to the analysis: The HRMS is designed to provide early feedback on ACA implementation to complement the more robust assessments that will be possible as more federal survey data become available. Though HRMS estimates capture the changes in insurance coverage from the first open enrollment period under the ACA, the estimates understate the full effects of the ACA because the estimates do not reflect the effects of some important ACA provisions (such as the ability to keep dependents on health plans until age 26 and early state Medicaid expansions) that were implemented before 2013. In addition, these change estimates might not reflect only the effects of the ACA, because they do not control for long-term trends in health insurance coverage that predate the ACA nor do they control for changes in the business cycle. Further, the difference in coverage gains between the states that did and did not expand Medicaid should not be entirely attributed to the ACA; there were other policy choices that likely affected enrollment. For example, many of the nonexpansion states did not set up their own Marketplaces and therefore did not get the same access to outreach and enrollment assistance funding.




Karpman, Michael. 2015. QuickTake: Thirty-Six Percent Drop in Uninsurance Rate for Adults in Rural Areas Narrows Rural-Urban Coverage Gap. Washington, DC: Urban Institute.


Long, Sharon K., Michael Karpman, Genevieve M. Kenney, Stephen Zuckerman, Douglas Wissoker, Adele Shartzer, Nathaniel Anderson, and Katherine Hempstead. 2015. Taking Stock: Gains in Health Insurance Coverage under the ACA as of March 2015. Washington, DC: Urban Institute.


National Advisory Committee on Rural Health and Human Services. 2014. Rural Implications of the Affordable Care Act Outreach, Education, and Enrollment. Rockville, MD: Health Resources and Services Administration Office of Rural Health Policy.


About the Series


This QuickTake is part of a series drawing on the HRMS, a quarterly survey of the nonelderly population that explores the value of cutting-edge Internet-based survey methods to monitor the Affordable Care Act before data from federal government surveys are available. The QuickTakes provide information on health insurance coverage, access to and use of health care, health care affordability, and self-reported health status, as well as timely data on important implementation issues under the ACA. Funding for the core HRMS is provided by the Robert Wood Johnson Foundation and the Urban Institute.


For more information on the HRMS and for other QuickTakes in this series, visit www.urban.org/hrms.



1 Given the small sample size for the rural population in a single round of the HRMS, we pool data across quarters to increase the sample size and the precision of our estimates.

2 We define urban areas as those that are part of a metropolitan statistical area and rural areas as those that are not part of a metropolitan statistical area.

3 For this analysis, we focus on state decisions to expand Medicaid by March 1, 2015. The states that had expanded Medicaid by this date are AZ, AR, CA, CO, CT, DE, DC, HI, IL, IN, IA, KY, MD, MA, MI, MN, NH, NV, NJ, NM, NY, ND, OH, OR, PA, RI, VT, WA, and WV. Several of those states, including CA, CT, DC, and MN, expanded Medicaid under the ACA before 2013.

4 In an earlier analysis of HRMS data, we estimated a decline in the uninsurance rate of 7.6 percentage points for adults in rural areas and 5.0 percentage points for nonelderly adults in urban areas between September 2013 and September 2014 (Karpman 2015). Civis Analytics and Enroll America, using a different methodology from that of the HRMS, showed similar patterns of change in the uninsurance rate among nonelderly adults between 2013 and 2014, with declines of 6.7 percentage points in rural areas, 4.9 percentage points in cities, and 6.3 percentage points in small cities (see Kevin Quealy and Margot Sanger-Katz, “Obamacare: Who Was Helped Most?” New York Times, October 29, 2014). Though we are not aware of any other recent estimates of the change in uninsurance for rural and urban areas, ongoing assessments using multiple data sources will be needed to monitor uninsurance trends in rural and urban communities.



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