Health Insurance Coverage
and Access in Rural America
Timothy D. McBride, PhD
September 20, 2004
The Uninsured in the United
States
Type of Health Insurance Coverage for
the U.S. Non-Elderly Population, 2003
Public only
16%
Private
68%
Uninsured
16%
45.0 million people without health insurance
Source: U.S. Census Bureau (2004).
Rise in the Uninsured
Millions of Persons and Percentage of Population, 1987-2002
20%
43.6
41.2
39.3
39.8
43.4
41.7
40.6
15%
15%
17%
16%
16%
16%
15%
15%
15%
13%
14%
14%
14%
14%
14%
13%
13%
Year
Number uninsured, and uninsurance rate, constantly rising
Source: U.S. Bureau of the Census (2004), based on Current Population Survey (CPS).
Note: CPS questions redesigned in 1999, 1997, and in the 1992-94 period.
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
12%
1987
25
Percentage of population
15%
15%
14%
30
39.7
38.6
34.7
33.4
32.7
35
19%
18%
16%
16%
35.4
40
31.0
Millions of persons
39.7
Percent of Population
45
44.3
Uninsured population
45.0
50
Health Insurance Coverage
in Rural America
Results by:
Erika Ziller, Andy Coburn, Cathy Hoffman, Sharon
Loux, Timothy McBride
Kaiser Family Foundation (2003)
Data Source:
Medical Expenditure Panel Survey (MEPS), 1996-1998
Urban-Rural County Comparison
Nonelderly, 1998
Urban Counties
192 million
Rural - Adjacent to
Urban Counties
22 million
Rural – Not Adjacent to
Urban Counties (Remote)
22 million
Trends in Insurance Coverage
Sources of Health Insurance Coverage
(Age 0 – 64, December 1998)
Medicaid/Other Public
Private
Uninsured
100%
24%
19%
18%
61%
71%
72%
16%
10%
11%
Rural Not Adjacent
Rural Adjacent
Urban
80%
60%
40%
20%
0%
Rural Non Adjacent (RNA) residents are far less likely to have private
coverage, and more likely to have Medicaid or other public coverage.
Nearly one-fourth are uninsured.
Trend: Percent of Nonelderly Uninsured,
December 1996-1998
Rural Not Adjacent
Rural Adjacent
Urban
30%
25%
25.5%
23.9%
23.5%
23.7%
21.7%
20%
19.3%
18.7%
18.5%
17.9%
15%
10%
1996
1997
1998
The uninsured rate for those living in RNA remained unchanged from
1996 to 1998 in contrast to declines for urban and RA residents.
Figure 2
Children’s Health Insurance Coverage
by County Type, December 1998
21%
16%
14%
Uninsured
Private
Medicaid/Other
52%
27%
Rural, Not Adjacent
67%
67%
17%
19%
Rural, Adjacent
Urban
SOURCE: KCMU/Muskie School, Health Insurance
Coverage in Rural America, 2003
Figure 3
Percent of Nonelderly Population Uninsured
for Full Year by County Type, 1998
30%
20%
20%
15%
14%
Rural, Adjacent
Urban
10%
0%
Rural, Not Adjacent
SOURCE: KCMU/Muskie School, Health Insurance
Coverage in Rural America, 2003
Trend: Percent of Nonelderly Uninsured
All Year, December 1996-1998
Rural Not Adjacent
Rural Adjacent
Urban
30%
25%
20%
19.8%
18.6%
18.5%
15.8%
15%
13.6%
14.3%
20.4%
14.7%
13.6%
10%
1996
1997
1998
RNA residents were one-third more likely to be uninsured all of 1998.
From 1996-98, RA and Urban rates decreased or stayed the same while
the rate for RNA residents increased.
Characteristics of the
Rural Uninsured
Figure 14
Family Income of the Nonelderly Uninsured
by County Type, 1998
200% or more of FPL*
100-199% FPL*
<100% FPL*
100%
80%
53%
60%
40%
69%
73%
20%
15%
12%
12%
25%
20%
22%
0%
Rural, Non-adjacent
Rural, Adjacent
*In 1998, the federal poverty level (FPL) for a family of three was $13,650
SOURCE: KCMU/Muskie School, Health Insurance
Coverage in Rural America, 2003
Urban
Figure 15
Percent Uninsured by Family Income and
County Type, Nonelderly, 1998
Rural, Not Adjacent
32%
35%
32%
32%
29%
Rural, Adjacent
Urban
32%
16%
13% 12%
< 100% of FPL*
100 - 199% of FPL*
* In 1998, the federal poverty level (FPL) for a family of three was $13,650
SOURCE: KCMU/Muskie School, Health Insurance
Coverage in Rural America, 2003
200% of FPL* or more
Employment Characteristics
& the Uninsured
Key Employment Factors Driving Health
Insurance Gaps in Rural Counties
• Size of Rural Businesses
• Wage-Scale of Rural Workers
A Profile of the Rural and Urban Uninsured
• Among the uninsured in rural non-adjacent
counties:
– 68% come from families where there is at least one
full-time worker;
– almost two-thirds come from low-income families
(less than 200% of the federal poverty level)
compared to half of the urban uninsured (almost half
of the population in rural, non-adjacent counties are
low-income families);
– 30% are children;
A Profile of the Rural and Urban
Uninsured
–
–
–
The rural uninsured are more likely to be white, nonHispanics, in part reflecting the higher concentration
of whites in rural America (83% vs. 67% in urban
counties);
Self-reported health status is generally poorer than
for the urban uninsured; and,
Families with two full-time workers and married
couples are at higher risk of being uninsured if they
live in a rural, non-adjacent area—where job-based
health benefits are less available and incomes are
lower.
Percent of Adults Uninsured, by
Employment Status and Residence, 1998
Rural
30%
Urban
27%
27%
25%
21%
20%
18%
15%
10%
5%
0%
Employed
Unemployed
There is no rural-urban difference in the uninsured rate for adults who
are unemployed or OLF. The rate is higher for rural than urban workers.
Employer-Sponsored Health Insurance among
Workers: Offer, Enrollment, and Coverage, 1998
Rural Not Adjacent
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
83%
66%
Rural Adjacent
86%
Urban
84%
69%
59%
56%
58%
49%
ESI Offered
Enrolled, If Offered
Covered by ESI
The lower rate of ESI among RNA workers stems from lower employer
offers; take up rates are the same for all three residence types.
Percent Uninsured among Self-Employed
Workers by Residence, 1998
40%
35%
33%
30%
24%
25%
20%
15%
10%
5%
0%
Rural
Urban
Self-employed rural workers living in rural counties are far more likely to
be uninsured than those living in urban counties.
Key Characteristics of Uninsured Workers
• Regardless of where a worker lives, working for a
business with fewer than 20 employees more than
doubles the risk of being uninsured
• This is pronounced for RNA, where ⅓ of small business
workers are uninsured compared to ¼ of urban workers
with small employers.
• Low-wage workers (< $7 per hour) are about 3 times
more likely to be uninsured no matter where they live.
Firm Size among Uninsured Workers and Total
Working Population by Residence, 1998
<20 Employees
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
32%
54%
68%
20 Employees or More
43%
61%
58%
46%
Uninsured
44%
Total
Rural Not Adjacent
63%
56%
40%
Uninsured
Total
Rural Adjacent
37%
Uninsured
Total
Urban
RNA workers are the most likely to work for small business. More than
2/3 of uninsured RNA workers work for firms with < 20 employees.
Wages of Uninsured Workers and Total Working
Population by Residence, 1998
< $7 per hour
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
40%
$7 per hour or more
47%
60%
67%
60%
74%
53%
40%
33%
Uninsured
81%
Total
Rural Not Adjacent
26%
Uninsured
Total
Rural Adjacent
19%
Uninsured
Total
Urban
One-third of RNA workers earn less than $7 per hour. 60% of uninsured
workers in RNA areas earn low wages compared to 40% in urban areas.
“Underinsurance”
Dental and Prescription Drug Coverage
among Privately Insured, MEPS, 2000
40%
35%
35%
30%
29%
25%
Rural
Urban
20%
14%
15%
9%
10%
5%
0%
No Dental Insurance
No Drug Coverage
Rural residents with private health insurance are less likely to have
dental or prescription drug coverage.
Privately Insured Individuals Who “Never”
Go to the Dentist, MEPS, 2000
20%
15%
15%
10%
10%
5%
0%
Never Go to Dentist
Rural residents are 50% more likely to report they never go to the
dentist.
Rural
Urban
Mean Out-of-Pocket Expenditures among
Privately Insured, MEPS, 2000
$500.00
$400.00
$462
$416
$391
$354
$300.00
Rural
Urban
$200.00
$100.00
$0.00
OOP Expenditures (All)
OOP Expenditures
(Service Users)
Rural residents with private coverage have higher OOP expenses,
suggesting their benefits are less comprehensive than in urban areas.
Mean Out-of-Pocket Dental Expenditures
among Privately Insured, MEPS, 2000
$300.00
$258
$250.00
$218
$200.00
Rural
Urban
$150.00
$100.00
$50.00
$0.00
OOP Dental Expenditures (Users)
Rural residents have higher OOP expenses for dental care, reflecting
lower rates of dental coverage and potentially poorer benefits.
Access to Care: Preventive
Services
Time Since Last Physical Exam
(Adults 18-64), MEPS, 1998
In Past Year
Past 2-5 Years
More Than 5 Years/Never
100
80
60
22
21
31
34
38
47
45
Rural, Not Adjacent
Rural, Adjacent
Urban
27
35
40
20
0
Adults in RNA areas have routine physical exams with less frequency
than those in other areas.
Time Since Last Cholesterol Test
(Adults 18-64), MEPS, 1998
In Past Year
Past 2-5 Years
More Than 5 Years/Never
100
80
39
33
21
23
35
41
44
Rural, Not Adjacent
Rural, Adjacent
Urban
45
60
40
20
20
0
Almost half of adults did not have a cholesterol test in the past 5 years,
compared to only one-third of urban adults.
Time Since Last Pap Smear
(Females 18-64), MEPS, 1998
In Past Year
100
Past 2-5 Years
More Than 5 Years/Never
13
11
24
24
55
63
66
Rural, Not Adjacent
Rural, Adjacent
Urban
16
80
30
60
40
20
0
Women in RNA areas were 50% more likely to have gone without a pap
smear in the last five years than urban women were.
Time Since Last Mammogram
(Females 39-64), MEPS, 1998
In Past 2 Years
Not in Past 2 Years
100
80
36
34
25
64
66
75
Rural, Not Adjacent
Rural, Adjacent
Urban
60
40
20
0
More than one-third of RNA women aged 39-64 had not had a
mammogram in the prior two years, compared to only one-fourth of
urban women.
Policy Implications
Not All Rural Places & People Are the Same
• National surveys and reports overlook
sometimes dramatic differences between rural,
non-adjacent, other rural, and urban residents.
– Policy-makers need to understand that not all rural
areas are the same in order to design and implement
effective reform strategies.
Differences in Characteristics Have
Important Policy Implications
• Strategies to increase health insurance among
rural residents should have a long-term focus
– Many of the rural uninsured, particularly those in
counties not adjacent to an urban area, lack
insurance for long periods of time.
– These strategies would contrast with past federal
reforms, such as COBRA or HIPAA, which provide
transitional insurance coverage.
Rural Residents Depend on the
Medicaid & SCHIP Program for Coverage
•
The Medicaid and SCHIP programs are a vital
coverage option for many rural residents
because:
1. They are less likely to be offered employer-based
coverage, and
2. They have lower wages and incomes that allow
them to qualify for Medicaid/SCHIP.
•
Any erosion in Medicaid/SCHIP eligibility or
benefits would adversely affect rural areas
Rural Economic Realities Are Critical to
Expanding Insurance Coverage
• Efforts to increase enrollment in private health
insurance, either through employer or individual
plans, would require generous subsidies:
– Financial fragility of small rural employers
– Lower wages and incomes of rural workers