The Role of Medicaid in Rural America Julia Foutz, Samantha Artiga, and Rachel Garfield This brief describes Medicaid’s role for 52 million nonelderly children and adults living in the most rural areas in the United States and discusses how expansions or reductions in Medicaid could affect rural areas. It shows:  Rural populations face significant challenges to their health care coverage and access. People who live in the most rural counties of America are spread across almost 2,500 counties that are heavily concentrated in the South and Midwest. Individuals living in rural areas are less likely to be employed and more likely to be low-income than individuals living in other areas. Individuals in rural areas also face significant barriers to accessing care, including provider shortages, recent closures of rural hospitals, and long travel distances to providers.  Medicaid plays a central role in helping to fill gaps in private coverage in rural areas. Although private insurance accounts for the largest share of health coverage in rural areas, nonelderly individuals in rural areas are less likely to have private coverage compared to those in urban and other areas (61% vs. 64% and 66%, respectively). Medicaid helps fill this gap in private coverage, covering nearly one in four (24%) nonelderly individuals in rural areas. Further, in many states, Medicaid coverage rates are higher in rural areas than in urban or other areas of the state. In some cases, these differences are large. For example, in California, the Medicaid coverage rate in rural areas is 16 percentage points higher than in urban areas, and Hawaii has a 13 percentage point difference between Medicaid coverage rates in rural and other areas. Similarly, rural areas in Arizona, Arkansas, and Florida have a Medicaid coverage rate that is about ten percentage points higher than the rate in urban or other areas.  The Affordable Care Act (ACA) Medicaid expansion led to coverage gains in rural areas. Prior to the ACA Medicaid expansion to low-income adults, rural areas in Medicaid expansion and non- expansion states had similar rates of Medicaid coverage. However, in rural areas that expanded Medicaid, the Medicaid coverage rate increased from 21% to 26% between 2013 and 2015, while it increased by just one percentage point, from 20% to 21%, in rural areas of non-expansion states. As a result, as of 2015, nonelderly individuals in rural areas within non-expansion states were nearly twice as likely to be uninsured as those living in expansion states (15% vs. 9%). Additional action to expand Medicaid within the 19 states that have not yet adopted the Medicaid expansion would likely lead to further increases in coverage among individuals living in rural areas. These non-expansion states are home to 59% of nonelderly uninsured individuals living in rural areas. Conversely, cuts to Medicaid could disproportionately affect people living in rural areas given the large role of the program in these areas. People in rural areas face unique challenges in health care coverage and access, including low density of providers and longer travel times to care, limited access to employer-sponsored coverage, and greater health care needs due to older age and lower income. Medicaid plays an important role in helping to address these challenges. This brief provides insight into the role of Medicaid in rural areas and discusses how expansions or reductions in Medicaid such as those currently under debate could affect rural areas. The analysis is based on data from the 2013-2015 American Community Survey and classifies counties as “rural” based on an Index of Relative Rurality (IRR). We group counties into quintiles of rurality and define those with the highest degree of rurality as “rural,” those with the lowest degree as “urban,” and those in the middle as “other.” While Medicaid provides assistance to many low-income elderly individuals, primarily as a wrap-around benefit to Medicare, this analysis focuses on its role in covering nonelderly children and adults. The analysis shows that Medicaid plays a particularly important role providing coverage in rural areas and that gains in Medicaid coverage have helped reduce the uninsured rate in rural areas. More detail on the methods underlying the analysis is available in the “methods” box at the end of the brief. The nearly 20% of the nonelderly population, or 52 million people, who live in the most rural counties of America are spread across almost 2,500 counties that are heavily concentrated in the South and Midwest (Click here for a county level map). In contrast, the 20% of the nonelderly population (or 55 million people) who live in the most urban counties of America are spread across fewer than 70 counties that are heavily concentrated in the Northeast. Rurality varies widely by state (Figure 1 and Appendix Table 1). By the definition used in this brief, states such as Montana, North Dakota, and Wyoming are entirely rural, whereas states such as Connecticut, New York, and the District of Columbia have little to no rural area. In 11 states, more than half of the nonelderly population resides in a rural area (Montana, North Dakota, Wyoming, South Dakota, Vermont, New Mexico, Mississippi, Alaska, Iowa, Idaho, and Arkansas). Figure 1 Share of Nonelderly Population in Rural Area by State, 2015 WA VT ME MT ND NH MN OR WI NY MA ID SD MI RI WY CT PA NJ IA NE OH DE NV IL IN MD UT WV VA CO KS MO DC CA KY NC TN OK AR SC AZ NM MS AL GA LA TX AK FL HI < 25% (25 states, including DC) United States = 19% 25% - 49% (15 states) 50% - 74% (7 states) ≥ 75% (4 states) NOTE: Includes nonelderly individuals ages 0-64. SOURCE: KFF analysis of 2015 American Community Survey, 1-Year Estimates. The Role of Medicaid in Rural America 2 People living in rural areas are more likely to be older, White, and have lower levels of education compared to people living in other areas. A greater share of people living in rural areas are ages 65 and older than in urban and other areas (data not shown);1 however, there are not large differences in the age distribution of nonelderly individuals living in rural areas compared to those in urban and other areas (Appendix Table 2). Fewer than one quarter of individuals living in rural areas are people of color, compared to over half of people living in urban areas and four in ten people living in other areas (Figure 2). Similar to other areas of the US, nearly nine in ten people living in rural areas have at least a high school diploma or GED. However, fewer than two in ten people in rural areas have a Bachelor’s degree or higher, compared to nearly four in ten people in urban areas and three and ten people living in other areas of the US (Figure 3). Figure 2 Figure 3 Race/Ethnicity Among the Nonelderly by Geographic Area, Education Among Nonelderly Adults by Geographic Area, 2015 2015 5% 9%* 12%* 10% 19% 30%* 8% 21%* 37%* 22%* Bachelor's Degree Other Race 11%* 36% Some College 21%* Hispanic 34%* HS Diploma/GED Black 28%* <High School 76% White 58%* 34% 45%* 23%* 25%* 11% 12%* 11%* Rural Urban Other Rural Urban Other NOTE: Includes nonelderly individuals ages 0-64. Totals may not sum to 100% due to rounding. People of Hispanic origin may be of any race but are categorized as Hispanic for this analysis; other racial groups are non-Hispanic. * Indicates statistically significant NOTE: Includes nonelderly individuals ages 19-64. Totals may not sum to 100% due to rounding. * Indicates statistically significant difference from the rural population at the p < 0.05 level. difference from the rural population at the p < 0.05 level. SOURCE: KFF analysis of 2015 American Community Survey, 1-Year Estimates. SOURCE: KFF analysis of 2015 American Community Survey, 1-Year Estimates. People living in rural areas are less likely to be in the labor force, more likely to have a disability, and more likely to be low-income than people living in other areas (Figure 4). A smaller share of nonelderly adults in rural areas are working than in urban and other areas (70% vs. 74% and 73%, respectively). Further, nonelderly adults living in rural areas are significantly more likely to have a disability (14%) than those in urban and other areas (9% and 10%, respectively; Figure 4). Reflecting their lower employment rate, nonelderly individuals living in rural areas are more likely than those in other areas to be low-income (below 200% of the federal poverty level or $40,320 per year for a family of three in 2017). Figure 4 Employment Status, Income, and Disability by Geographic Area, 2015 Rural Urban Other 74%* 73%* 70% 38% 33%* 32%* 14% 9%* 10%* Employed With Disability Low-Income (<200% FPL) NOTE: Employment status and disability includes nonelderly adults ages 19-64. Income includes nonelderly individuals ages 0-64. * Indicates statistically significant difference from the rural population at the p < 0.05 level. SOURCE: KFF analysis of 2015 American Community Survey, 1-Year Estimates. The Role of Medicaid in Rural America 3 Rural populations face longstanding and significant disparities in their health and access to health care. Previous research has shown that rural residents are more likely to report poorer physical and mental health and have higher rates of cigarette smoking, obesity, and physical inactivity compared to their urban counterparts.2 In addition, people living in rural areas face significant barriers to accessing care, including provider shortages, recent closures of rural hospitals, and high travel distances to providers.3 Medicaid plays a central role helping to fill gaps in private coverage in rural areas. Private insurance accounts for the largest share of health coverage among individuals in rural areas. However, nonelderly individuals in rural areas have a lower Figure 5 rate of private coverage compared to those in Health Coverage Among the Nonelderly by Geographic urban and other areas, reflecting greater Area, 2015 employment in jobs that do not offer employer- sponsored health insurance4 and the lower labor 12% 11%* 10%* 3%* 4% 2%* force participation rate in rural areas (Figure 5). 22%* 21%* 24% Medicaid helps fill this gap in private coverage, Uninsured Other Public covering nearly one in four (24%) nonelderly Medicaid individuals in rural areas, compared to 22% in 64%* 66%* Private 61% urban areas and 21% in other areas. However, Medicaid coverage does not fully offset the gap in private coverage. As such, rural areas have a Rural Urban Other NOTES: Includes nonelderly individuals ages 0-64. Totals may not sum to 100% due to rounding. Other Public includes Medicare, slightly higher nonelderly uninsured rate (12%) military, and Veterans Administration coverage. * Indicates statistically significant difference from the rural population at the p < 0.05 level. SOURCE: KFF analysis of 2015 American Community Survey, 1-Year Estimates. compared to urban (11%) and other areas (10%). Within states, Medicaid generally plays a larger role in rural areas of the state compared to other areas. Medicaid coverage rates are higher in rural areas than in urban areas in 12 of the 19 states with both rural and urban areas (Appendix Table 3). Similarly, rural areas have a higher Medicaid coverage rate than other areas in 41 of the 43 states with both Figure 6 rural and other areas. In some states, the Medicaid Coverage Rates Among the Nonelderly by Medicaid coverage rate in rural areas is much Geographic Area, Selected States, 2015 higher than other areas. Figure 6 shows the six Rural Urban Other states with the largest differences in Medicaid coverage rates between rural and urban or other areas. For example, in California, the Medicaid 37% 32% 32% 33% coverage rate in rural areas is 16 percentage 28% 28% 24%23% 27% 21% 22% 23% 20% points higher compared to urban areas and in 15% 17% Hawaii there is a 13 percentage point difference N/A N/A N/A between Medicaid coverage in rural and other California Hawaii Kentucky Arizona Arkansas Florida areas. Similarly, in Arizona, Arkansas, and Florida, rural areas have a Medicaid coverage NOTE: Includes nonelderly individuals ages 0-64. N/A indicates lack of geographic area in state. rate that is about ten percentage points higher SOURCE: KFF analysis of 2015 American Community Survey, 1-Year Estimates. than urban or other areas or the state. The Role of Medicaid in Rural America 4 The share of people living in rural areas Figure 7 who are covered by Medicaid has grown Health Coverage Among the Nonelderly by Geographic under the ACA, corresponding with Area, 2013-2015 reductions in the uninsured rate. Rural areas experienced growth in Medicaid and 12% 11% 16% 10% 17% 17% private coverage that was similar to urban and 4% 4% 2% 2% 3% 3% 22% 21% other areas. In rural areas, the share of people 21% 24% 20% 17% Uninsured with Medicaid and private coverage increased Other Public from 21% to 24% and 58% to 61% between 2013 58% 61% 61% 64% 63% 66% Medicaid Private and 2015, resulting in a decrease in the uninsured rate from 17% to 12%. Similarly, in 2013 2015 2013 2015 2013 2015 urban and other areas, Medicaid and private Rural Urban Other coverage rates increased by 3 percentage points NOTES: Includes nonelderly individuals ages 0-64. Totals may not sum to 100% due to rounding. Other Public includes Medicare, military, and Veterans Administration coverage. and uninsured rates decreased by 5 and 6 SOURCE: KFF analysis of 2013 & 2015 American Community Survey, 1-Year Estimates. percentage points, respectively (Figure 7). Rural areas in states that implemented the ACA Medicaid expansion to low-income adults experienced larger gains in coverage than those in non-expansion states. Prior to the ACA coverage expansion, which was implemented in 2014, rural areas in Medicaid expansion and non-expansion states had similar rates of Medicaid coverage. However, rural areas in non-expansion states had a lower rate of private coverage, which contributed to a higher uninsured rate for rural areas in non-expansion Figure 8 Health Coverage Among the Nonelderly in Rural Areas by states (Figure 8). In rural areas, the Medicaid State Medicaid Expansion Status, 2013-2015 coverage rate in expansion states increased from 21% to 26% between 2013 and 2015, while it rose 9% just one percentage point, from 20% to 21%, in 16% 4% 3% 19% 15% 5% 5% non-expansion states. Reflecting the larger gains 21% 26% 20% 21% Uninsured in Medicaid coverage in expansion states, the Other Public uninsured rate in rural areas within expansion Medicaid 59% 61% 57% 60% Private states fell by nearly half from 16% to 9%. This reduction was nearly twice as large as the 2013 2015 2013 2015 reduction in rural areas of non-expansion states. Expansion States Non-Expansion States As a result, as of 2015, nonelderly individuals in NOTES: Includes nonelderly individuals ages 0-64. Totals may not sum to 100% due to rounding. Other Public includes Medicare, rural areas within non-expansion states were military, and Veterans Administration coverage. SOURCE: KFF analysis of 2013 & 2015 American Community Survey, 1-Year Estimates. nearly twice as likely to be uninsured as those within expansion states (15% vs. 9%). The Role of Medicaid in Rural America 5 These data illustrate that Medicaid plays a particularly important role in the most rural communities within our nation. This analysis shows that Medicaid helps fill gaps in private coverage within rural areas, helping to reduce disparities in coverage between rural areas and the rest of the nation. Medicaid coverage has grown in rural areas under the ACA, helping to reduce uninsured rates. However, states that expanded Medicaid experienced larger coverage gains than non-expansion states, leaving individuals in rural areas in non-expansion states nearly twice as likely to be uninsured as those in expansion states. Further action among states to implement the ACA Medicaid expansion to low-income adults could lead to additional coverage gains in rural areas. As of April 2017, 19 states have not yet adopted the Medicaid expansion to low-income adults. These non-expansion states are home to 59% of nonelderly uninsured individuals living in rural areas. Additional action to expand Medicaid within these states would likely lead to increased coverage among individuals living in rural areas. In the four states (Kansas, Maine, North Carolina, and Virginia) that have had recent legislative activity related to implementing the expansion,5 nearly a quarter or more nonelderly individuals live in rural areas. Reductions in Medicaid could disproportionately affect individuals living in rural America. If federal funding for Medicaid is reduced through elimination of enhanced funding for the ACA Medicaid expansion or limits on funding for the broader program, states would likely need to increase state spending to maintain coverage or make program cutbacks that would reduce eligibility, benefits, or provider payments. Given the larger role Medicaid plays for individuals in rural areas compared to other areas, individuals in these areas would likely be disproportionately impacted by coverage losses as well as reduced benefits and increased premiums and cost sharing. Further, analysis shows that high poverty states and states in the South, which include many rural areas, would be disproportionately impacted by reductions in federal Medicaid funds and face the highest increases in state spending to maintain coverage amid federal reductions. Reductions in Medicaid coverage would also increase demands on safety net providers, including community health centers and public hospitals. At the same time, the loss of federal Medicaid revenues would increase fiscal strains on these providers who already face a range of challenges that have contributed to increases in closures among rural hospitals in recent years. 6 The Role of Medicaid in Rural America 6 This brief is based on analysis of American Community Survey (ACS) data from 2013-2015. In this brief, rural areas are defined using the 2010 Index of Relative Rurality (IRR) measure, which is a continuous measure of a county’s degree of rurality based on population size, population density, extent of urbanized area, and distance to the nearest metro area.1 For this analysis the IRR is divided into five equally weighted population quintiles based off ACS weighted data. County level data for ACS was obtained by using a public use microdata area (PUMA) code to county crosswalk based on the 2010 Census definition.2 Although the IRR determines the degree of a county’s rurality and not if a county is rural or urban, throughout this brief, the population quintile with the highest degree of rurality is referred to as “rural,” and the population quintile with the lowest degree of rurality is referred to as “urban.” The remaining three population quintiles are referred to as “other.” While the elderly population is included in the assignment of rurality, they are excluded from the remainder of the analysis, as our focus is Medicaid’s role as a health insurer for children and non-elderly adults. 1 Brigitte Waldorf and Ayoung Kim, Defining and Measuring Rurality in the US: From Typologies to Continuous Indices, (West Lafayette, IN: Purdue University, Department of Agricultural Economics, April 2015), http://sites.nationalacademies.org/cs/groups/dbassesite/documents/webpage/dbasse_168031.pdf. 2 Missouri Census Data Center Geographic Correspondence Engine, http://mcdc.missouri.edu/websas/geocorr12.html. The Role of Medicaid in Rural America 7 Alabama 34% 0% 66% Alaska 59% 0% 41% Arizona 17% 0% 83% Arkansas 51% 0% 49% California 3% 10% 86% Colorado 19% 13% 68% Connecticut 0% 51% 49% Delaware 0% 0% 100% DC 0% 100% 0% Florida 5% 4% 91% Georgia 22% 37% 40% Hawaii 18% 0% 70% Idaho 52% 0% 48% Illinois 15% 54% 31% Indiana 30% 15% 56% Iowa 52% 0% 48% Kansas 46% 0% 54% Kentucky 49% 17% 34% Louisiana 33% 0% 67% Maine 45% 0% 55% Maryland 4% 11% 85% Massachusetts 1% 46% 53% Michigan 21% 18% 61% Minnesota 34% 33% 33% Mississippi 60% 0% 40% Missouri 35% 22% 43% Montana 100% 0% 0% Nebraska 44% 0% 56% Nevada 9% 0% 91% New Hampshire 25% 0% 75% New Jersey 0% 43% 57% New Mexico 67% 0% 33% New York 10% 51% 39% North Carolina 22% 11% 67% North Dakota 100% 0% 0% Ohio 20% 29% 51% Oklahoma 47% 0% 53% Oregon 32% 0% 68% Pennsylvania 12% 33% 55% Rhode Island 0% 0% 100% South Carolina 24% 0% 76% South Dakota 78% 0% 22% Tennessee 30% 0% 70% Texas 15% 34% 51% Utah 24% 0% 76% Vermont 73% 0% 27% Virginia 23% 34% 43% Washington 16% 0% 84% West Virginia 46% 0% 54% Wisconsin 33% 17% 49% Wyoming 100% 0% 0% NOTES: Includes nonelderly individuals ages 0-64. Totals may not sum to 100% due to rounding. Totals for Hawaii do not sum to 100% because FIPS county codes 15005 and 15009 are not assigned an IRR; population in geographic area is N/A. SOURCE: Kaiser Family Foundation analysis based on the 2015 American Community Survey 1-Year Estimates. The Role of Medicaid in Rural America 8 Appendix Figure 1 Share of Nonelderly Population in Rural Area by State, 2015 Wyoming 100% North Dakota 100% Montana 100% South Dakota 78% Vermont 73% New Mexico 67% Mississippi 60% Alaska 59% Iowa 52% Idaho 52% Arkansas 51% Kentucky 49% Oklahoma 47% West Virginia 46% Kansas 46% Maine 45% Nebraska 44% Missouri 35% Minnesota 34% Alabama 34% Wisconsin 33% Louisiana 33% Oregon 32% Tennessee 30% Indiana 30% New Hampshire 25% Utah 24% South Carolina 24% Virginia 23% North Carolina 22% Georgia 22% Michigan 21% Ohio 20% US Total 19% Colorado 19% Hawaii 18% Arizona 17% Washington 16% Texas 15% Illinois 15% Pennsylvania 12% New York 10% Nevada 9% Florida 5% Maryland 4% California 3% Massachusetts 1% Rhode Island 0% New Jersey 0% DC 0% Delaware 0% Connecticut 0% NOTE: Includes nonelderly individuals ages 0-64. SOURCE: Kaiser Family Foundation analysis based on the 2015 American Community Survey 1-Year Estimates. The Role of Medicaid in Rural America 9 0.51 0.13 0.34 Age 0-18 30% 28% 29% 19-34 24% 28% 26% 35-54 30% 31% 31% 55-64 17% 14% 15% Sex Male 50% 49% 50% Female 50% 51% 50% Race/Ethnicity Non-Hispanic White 76% 45% 58% Non-Hispanic Black 8% 21% 11% Hispanic 10% 22% 21% Non-Hispanic Other Race 5% 12% 9% Citizenship Citizen 96% 79% 86% Naturalized Citizen 1% 9% 6% Non-Citizen 3% 12% 8% Poverty <100% FPL 18% 16% 15% 100-199% FPL 20% 17% 17% 200-399% FPL 32% 26% 29% 400% FPL 28% 40% 38% Census Region Northeast 8% 35% 14% Midwest 31% 26% 16% South 42% 31% 38% West 19% 7% 31% Education Less than High School 11% 12% 11% High School Diploma or GED 34% 23% 25% Some College 36% 28% 34% Bachelor's Degree or Higher 19% 37% 30% Work Status Working 70% 74% 73% Unemployed 4% 5% 5% Not in Labor Force 26% 21% 22% Disability With Disability 14% 9% 10% Without Disability 86% 91% 90% NOTES: People of Hispanic origin may be of any race but are categorized as Hispanic for this analysis; all other racial groups are non- Hispanic. Disability includes limitation in vision, hearing, mobility, cognitive functioning, self-care, and/or independent living. SOURCE: Kaiser Family Foundation analysis of the 2015 American Community Survey 1-Year Estimates. The Role of Medicaid in Rural America 10 California 37% 21% 28% 3% 1% 3% 49% 69% 60% 11% 9% 10% Colorado 26% 23% 18% 4% 2% 5% 57% 62% 70% 12% 13% 8% Connecticut N/A 21% 20% N/A 1% 2% N/A 69% 73% N/A 9% 5% Delaware N/A N/A 23% N/A N/A 3% N/A N/A 67% N/A N/A 6% DC N/A 26% N/A N/A 2% N/A N/A 68% N/A N/A 4% N/A Hawaii 28% N/A 15% 3% N/A 12% 64% N/A 69% 5% N/A 4% Louisiana 25% N/A 23% 4% N/A 4% 55% N/A 60% 16% N/A 13% Minnesota 22% 21% 15% 2% 1% 1% 70% 72% 79% 5% 6% 4% Montana 17% N/A N/A 4% N/A N/A 66% N/A N/A 14% N/A N/A New York 26% 31% 21% 4% 1% 2% 63% 58% 71% 7% 10% 6% Oregon 31% N/A 24% 3% N/A 2% 56% N/A 66% 9% N/A 8% Pennsylvania 22% 22% 18% 3% 2% 2% 67% 69% 73% 8% 8% 7% Rhode Island N/A N/A 24% N/A N/A 2% N/A N/A 68% N/A N/A 6% Washington 30% N/A 21% 4% N/A 4% 56% N/A 68% 10% N/A 7% West Virginia 32% N/A 28% 4% N/A 4% 57% N/A 62% 7% N/A 6% Alaska 19% N/A 20% 8% N/A 9% 55% N/A 60% 19% N/A 11% Arizona 32% N/A 22% 5% N/A 3% 48% N/A 62% 15% N/A 13% Arkansas 33% N/A 23% 4% N/A 4% 52% N/A 62% 11% N/A 11% Illinois 25% 22% 20% 2% 2% 2% 67% 67% 71% 6% 10% 6% Indiana 17% 26% 17% 3% 3% 3% 69% 58% 70% 11% 14% 11% Iowa 20% N/A 18% 2% N/A 2% 72% N/A 74% 6% N/A 6% Kentucky 32% 24% 23% 6% 2% 4% 54% 67% 67% 8% 6% 7% Maryland 25% 34% 16% 3% 3% 4% 66% 53% 73% 6% 9% 7% Massachusetts 24% 21% 28% 1% 1% 2% 71% 75% 67% 4% 3% 3% Michigan 25% 37% 21% 3% 2% 2% 64% 53% 71% 8% 8% 6% Nevada 21% N/A 20% 3% N/A 4% 65% N/A 62% 11% N/A 14% New Hampshire 17% N/A 12% 3% N/A 3% 69% N/A 78% 11% N/A 7% New Jersey N/A 19% 18% N/A 1% 2% N/A 68% 72% N/A 13% 8% New Mexico 36% N/A 32% 4% N/A 5% 47% N/A 52% 13% N/A 11% North Dakota 11% N/A N/A 4% N/A N/A 76% N/A N/A 9% N/A N/A Ohio 24% 24% 22% 3% 2% 3% 65% 66% 68% 8% 8% 7% Vermont 29% N/A 21% 2% N/A 2% 63% N/A 74% 6% N/A 4% North Carolina 24% 16% 19% 5% 2% 6% 56% 69% 63% 15% 13% 12% Virginia 17% 12% 11% 5% 8% 9% 66% 69% 71% 12% 11% 9% Alabama 24% N/A 20% 5% N/A 4% 58% N/A 64% 13% N/A 12% Florida 27% 17% 20% 5% 4% 4% 50% 64% 60% 18% 14% 16% Georgia 24% 16% 17% 5% 2% 6% 53% 66% 62% 18% 16% 14% Idaho 19% N/A 17% 3% N/A 3% 64% N/A 68% 14% N/A 12% Kansas 14% N/A 14% 6% N/A 2% 69% N/A 73% 10% N/A 11% Maine 25% N/A 16% 4% N/A 3% 59% N/A 71% 12% N/A 9% Mississippi 29% N/A 23% 4% N/A 6% 52% N/A 57% 15% N/A 14% Missouri 19% 15% 13% 7% 2% 3% 60% 74% 73% 14% 9% 10% Nebraska 13% N/A 13% 2% N/A 4% 74% N/A 75% 10% N/A 8% Oklahoma 21% N/A 17% 5% N/A 5% 57% N/A 63% 17% N/A 15% South Carolina 27% N/A 19% 5% N/A 5% 55% N/A 64% 13% N/A 12% South Dakota 15% N/A 12% 5% N/A 2% 66% N/A 75% 14% N/A 11% Tennessee 26% N/A 19% 5% N/A 4% 57% N/A 64% 12% N/A 12% Texas 19% 20% 16% 4% 2% 4% 57% 58% 62% 21% 21% 17% Utah 13% N/A 11% 2% N/A 2% 71% N/A 76% 14% N/A 11% Wisconsin 18% 30% 14% 2% 2% 2% 73% 60% 78% 7% 9% 6% Wyoming 12% N/A N/A 4% N/A N/A 71% N/A N/A 12% N/A N/A NOTES: Includes nonelderly individuals ages 0-64. Totals may not sum to 100% due to rounding. Other Public includes Medicare, military, and Veterans Administration coverage. MT and LA adopted Medicaid expansion in 2016. N/A indicates lack of geographic area in state. SOURCE: Kaiser Family Foundation analysis based on the 2015 American Community Survey 1-Year Estimates. The Role of Medicaid in Rural America 11 1 Kaiser Family Foundation analysis of 2015 American Community Survey 1-Year Estimates. 2 Michael Meit et al., The 2014 Update of the Rural-Urban Chartbook, (Bethesda, MD: The North Dakota and NORC Rural Health Reform Policy Research Center, October 2014), https://ruralhealth.und.edu/projects/health-reform-policy-research-center/pdf/2014- rural-urban-chartbook-update.pdf. 3 Jane Wishner et al., A look at Rural Hospital Closures and Implications for Access to Care: Three Case Studies, (Washington, DC: Kaiser Commission on Medicaid and the Uninsured, July 2016), http://kff.org/medicaid/issue-brief/a-look-at-rural-hospital-closures- and-implications-for-access-to-care/. 4 Kaiser Family Foundation analysis of 2015 American Community Survey 1-Year Estimates. 5 http://kff.org/medicaid/slide/state-medicaid-expansion-approaches/ 6 Jane Wishner et al., A look at Rural Hospital Closures and Implications for Access to Care: Three Case Studies, (Washington, DC: Kaiser Commission on Medicaid and the Uninsured, July 2016), http://kff.org/medicaid/issue-brief/a-look-at-rural-hospital-closures- and-implications-for-access-to-care/. The Henry J. Kaiser Family Foundation Headquarters: 2400 Sand Hill Road, Menlo Park, CA 94025 | Phone 650-854-9400 Washington Offices and Barbara Jordan Conference Center: 1330 G Street, NW, Washington, DC 20005 | Phone 202-347-5270 www.kff.org | Email Alerts: kff.org/email | facebook.com/KaiserFamilyFoundation | twitter.com/KaiserFamFound Filling the need for trusted information on national health issues, the Kaiser Family Foundation is a nonprofit organization based in Menlo Park, California.