Knowledge of Health Insurance Concepts and the Affordable Care Act Among Rural Residents


Health insurance literacy is central to identifying eligibility for coverage and subsidies, choosing a plan, and using optimal healthcare services under the Affordable Care Act (ACA) or other insurance reform initiatives. To fully benefit from policy efforts to improve health insurance access, rural residents must have the ability to select the plan that best meets their healthcare needs. However, a higher proportion of rural residents possess characteristics that may put them at risk of lower health insurance literacy, including lower incomes and educational attainment, less experience with private insurance, and historically higher uninsured rates.

Using Health Reform Monitoring Survey data from 2013 and 2014, this study examined whether rural and urban residents demonstrated different knowledge and/or use of the ACA Marketplace and subsidies; enrollment information sources (e.g.,, the Marketplace); the health insurance mandate; and health insurance terms and concepts.

Additionally, we examined whether knowledge and use changed between the fourth quarters of 2013 and 2014. Findings indicate that familiarity with and the Marketplace increased dramatically among both rural and urban residents between 2013 and 2014. However, knowledge in rural areas lagged somewhat behind that of urban residents. Rural and urban residents appear to have comparable levels of health insurance literacy. While this study focuses on some concepts that are specific to ACA policy changes, its results have implications for alternative reforms under consideration by Congress that may require consumer awareness and input.

Maine Rural Health Research Center
Erika Ziller, Jennifer Lenardson, Amanda Burgess