An Insurance Profile of Rural America: A Chartbook

Research center:
Lead researcher:
Project funded:
September 2020
Project completed:
October 2022

The Center created 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 assessed these characteristics within rural and urban subgroups.

The Center analyzed 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 accounted for persons/households with multiple sources of coverage, using methods that are standard in the literature. This was 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 could assess the policy impact on rural people and places.

The insurance market analysis focused 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 further refined manually to be sure all issuers are participating in all counties throughout a rating area) and Medicare Advantage data. In both cases, the Center provided counts of unique issuers participating in each county's market and compared current figures to historic trends.

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

The description of the "underinsured" came from a simple simulation exercise in which county-level enrollment data from, which are available by metal tier and cost-sharing level, were aggregated according to out-of-pocket maximum limits. Using the Medical Expenditure Panel Survey, the Center estimated likely total medical expenses by income group, which then determined 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.


  • An Insurance Profile of Rural America: Chartbook
    RUPRI Center for Rural Health Policy Analysis
    Date: 11/2022
    Over the past decade, health insurance coverage has changed in major ways in rural areas with shifts towards public and publicly subsidized coverage among the nonelderly – Medicaid, Marketplace plans – and a shift towards Medicare Advantage among those eligible for Medicare. This chartbook describes these trends in detail.