An Insurance Profile of Rural America: A Chartbook

Research center:
Lead researcher:
Project funded:
September 2020
Anticipated completion date:
November 2022

The Center will create a chartbook that illustrates health insurance coverage data for the entire U.S. as well as breakouts by insurance type, region, and the following demographics: age, race/ethnicity, income, employment status, and family structure. In all cases, the chartbook will assess these characteristics within rural and urban subgroups.

The Center will analyze these data using the American Community Survey, which is the preferred source for subnational data estimates of insurance coverage in the U.S. In analyses using both samples, the Center will account for persons/households with multiple sources of coverage, using methods that are standard in the literature. This is an opportunity to examine pre/post-Patient Protection and Affordable Care Act of 2010 trends at the county level with updated data, so that the Center can assess the policy impact on rural people and places.

The insurance market analysis will focus on Health Insurance Marketplace data (from the federal platform, supplemented by rating-area-level data from Robert Wood Johnson's HIX Compare project for the state-based marketplaces, which the Center will further refine manually to be sure all issuers are participating in all counties throughout a rating area) and Medicare Advantage data. In both cases, the Center will provide counts of unique issuers participating in each county's market and will compare current figures to historic trends.

The Center will also capture the dynamics of participation over time, i.e. it will calculate for each county and each year whether its participating issuers are the same as in the prior year or whether entry and exit has occurred over time. This will be summarized by county rurality.

The description of the "underinsured" will come from a simple simulation exercise in which county-level enrollment data from, which are available by metal tier and cost-sharing level, are aggregated according to out-of-pocket maximum limits. Using the Medical Expenditure Panel Survey, the Center will estimate likely total medical expenses by income group, which will then determine out-of-pocket exposure. Calculating out-of-pocket exposure as a percent of income yields a measure of the underinsured, because it is commonly held that expenses in excess of 10% of income are unlikely to be manageable by most households.