QuickTake: Thirty-Six Percent Drop in Uninsurance Rate for Adults in Rural Areas Narrows Rural-Urban Coverage Gap


Michael Karpman

February 4, 2015


The Urban Institute is using the Health Reform Monitoring Survey (HRMS) to examine trends in health insurance coverage and other health and economic outcomes for adults and their families under the Affordable Care Act (ACA). Recent HRMS data show an estimated 10.6 million adults ages 18 to 64 gained coverage between September 2013, just before the first open enrollment period for the ACA’s health insurance Marketplaces, and September 2014, just before the second open enrollment period (Long et al. 2014). This QuickTake extends that work to compare coverage changes for adults living in rural and urban areas1 overall and by family income, state Medicaid expansion status, and gender. We find the largest coverage gains for adults in rural areas, particularly among those with low family income, those in states that expanded Medicaid, and women.


The uninsurance rate fell 36.0 percent among adults in rural areas and 28.9 percent among adults in urban areas. The share of uninsured nonelderly adults in rural areas fell 7.6 percentage points (95% CI [4.6, 10.6]) from 21.1 percent in September 2013 to 13.5 percent in September 2014, a 36.0 percent reduction (figure 1). Among adults in urban areas, the uninsurance rate fell 5.0 percentage points (95% CI [3.7, 6.2]) from 17.1 percent to 12.2 percent, a 28.9 percent reduction. These changes narrowed the urban-rural gap in insurance coverage from 4.0 percentage points to 1.3 percentage points. The estimated changes in the uninsurance rate show similar patterns to those reported by Civis Analytics and Enroll America, which rely on a different methodology from that of the HRMS. Civis Analytics and Enroll America estimate declines in the uninsurance rate among nonelderly adults between 2013 and 2014 of 6.7 percentage points in rural areas, 4.9 percentage points in cities, and 6.3 percentage points in small cities.2



Coverage gains in rural areas were most pronounced among low-income adults, adults in Medicaid expansion states, and women. The uninsurance rate fell most sharply among low-income adults targeted by the ACA’s Medicaid expansion (those with family income at or below 138 percent of the federal poverty level; figure 2). The uninsurance rate declined 14.8 percentage points (95% CI [7.2, 22.4]) among low-income adults in rural areas and 11.3 percentage points (95% CI [8.1, 14.5]) among low-income adults in urban areas. Middle-income adults (i.e., those with family income between 139 and 399 percent of the federal poverty level), targeted by the ACA’s coverage subsidies through the health insurance Marketplaces, experienced an uninsurance rate reduction of 5.3 percentage points (95% CI [3.6, 7.0]) for those in urban areas and 4.9 percentage points (95% CI [0.0, 9.9]) for those in rural areas. Estimated changes for high-income adults in rural and urban areas were not statistically significant.



In states that expanded Medicaid, the share of adults without health insurance in rural areas fell from 17.4 percent to 8.5 percent, a change of 9.0 percentage points (95% CI [5.5, 12.4]) and a decline in this group’s uninsurance rate of more than 50 percent. Adults in urban areas living in Medicaid expansion states saw their uninsurance rate fall 5.4 percentage points (95% CI [4.0, 6.8]). In states that did not expand Medicaid, the uninsurance rate fell 6.8 percentage points (95% CI [2.3, 11.3]) for adults in rural areas and 4.4 percentage points (95% CI [2.2, 6.5]) for adults in urban areas.


Women in rural areas experienced larger coverage gains than men: the share of rural women with coverage rose 8.2 percentage points (95% CI [3.9, 12.6]). The uninsurance rate for women in rural areas declined 40.9 percent. For men in rural areas, the estimated decline in uninsurance was 6.7 percentage points (95% CI [1.7, 11.6]), or 30.3 percent. Coverage gains were small but significant among men and women in urban areas.


Methods: Each round of the HRMS is weighted to be nationally representative. We use these weights and a 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 any variation 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 each coverage type 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 4 of 2013 and quarters 1–3 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.




Long, Sharon K., Michael Karpman, Adele Shartzer, Douglas Wissoker, Genevieve M. Kenney, Stephen Zuckerman, Nathaniel Anderson, and Katherine Hempstead. 2014. “Taking Stock: Health Insurance Coverage under the ACA as of September 2014.” Washington, DC: Urban Institute.


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. Funding for the core HRMS is provided by the Robert Wood Johnson Foundation and the Urban Institute, and this analysis was also supported by funding from the Ford Foundation.


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



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

2 Kevin Quealy and Margot Sanger-Katz, “Obamacare: Who Was Helped Most?New York Times, October 29, 2014.


Urban Institute Robert Wood Johnson Foundation