Assuring Health Coverage for Rural
People through Health Reform
Prepared by the
RUPRI Health Panel
Andrew F. Coburn, Ph.D.
A. Clinton MacKinney, M.D., M.S.
Timothy D. McBride, Ph.D.
Keith J. Mueller, Ph.D.
Rebecca T. Slifkin, Ph.D.
Erika Ziller, M.S., Guest Author
October 30, 2009
Rural residents of the United States have a higher uninsured rate than their urban counterparts,
and therefore have the most to gain from efforts to reform the U.S. health care system.
Currently, the challenges that rural people face in obtaining health insurance are partly due to the
structure of the rural economy: 64 percent of adults working in rural areas that are not adjacent to
urban centers are employed in jobs where health insurance is provided, compared to 71 percent
of their urban counterparts (adults working in urban areas). Self-employed workers in rural areas
not adjacent to urban areas are more likely to be uninsured (40% vs. 32%). Rural workers also pay
higher costs than do urban workers for similar health insurance plans. Seven in 10 firms in non-
urban areas (69.2 percent) are more likely to offer plans that include deductibles, compared to
42.9 percent of firms in urban areas.
Effects of Reform:
Health reform proposals that include (i) a subsidy for individual purchase, (ii) availability of
insurance plans to individuals and small groups through exchanges, and (iii) expansion of Medicaid
would significantly improve coverage of rural populations.
The total number of uninsured people in rural (nonmetropolitan) areas would decrease to
1.9 million from the current 8.1 million – leaving only 4.2 percent of rural Americans
without insurance, less than the 5.9 percent projected in urban areas.
Rural residents would be more likely than urban residents to take advantage of subsidies or
tax credits (30.6 percent of those obtaining coverage, as compared to 25.4 percent in
urban areas) and Medicaid expansions (28 percent