Changes in Rural Health Insurance Coverage, 2019-2024

This project builds on the September 2025 Rural Policy Research Institute (RUPRI) policy brief covering changes to insurance coverage in rural areas in broad age groups (age <19, age 19-64, age 65+), and the 2019 RUPRI product “Rural Health Insurance Chartbook”.

This project explores the following questions:

1. How have changes in rural economies and rural employment impacted insurance coverage?
2. How are changes in the demographics of rural areas impacting coverage over time?
3. How have average out-of-pocket costs changed for rural people, relative to urban people, during the 2019-24 period?

County-level insurance status and demographics will be obtained from American Community Survey 5-year estimates. The Medical Expenditure Panel Survey will provide estimates of out-of-pocket expenses. Monthly Bureau of Labor Statistics data will be used to capture unemployment rates by sector and industry. The 2023 Rural-Urban Continuum Codes from the Economic Research Service, US Department of Agriculture, will be used to classify counties as rural and urban.

Descriptive analysis will characterize rural insurance coverage, and changes in out-of-pocket costs, as it relates to employment. Changes over time will include testing for differences between rural and urban measures across characteristics of interest. Analysis of the impact of policy change will be incorporated as needed.