US Health Care Reform and Rural America: Results From the ACA's Medicaid Expansions

Purpose: Medicaid expansions, prompted by the Affordable Care Act, generated generally positive effects on coverage and alleviated much of the financial burden associated with seeking health care. We do not know if these shifts also extend to the nation's rural populations. Methods: Using 2011-2015 Behavioral Risk Factor Surveillance System data, this study compares trend changes for coverage, access to care, and health care utilization in response to Medicaid expansion among urban and rural residents using a difference-in-differences regression approach. Findings: Following Medicaid expansion, low-income rural and urban residents both experienced reductions in uninsurance; however, the coverage uptake in rural settings (8.5 percentage points [pp], P <.01) was much larger than the uptake in coverage in more urban settings (4.1 pp, P >.10). In spite of larger uptakes in coverage among rural residents, reductions in cost-related barriers to medical care were slightly larger among urban residents, and access to a regular source of medical care (5.2 pp, P <.05) and doctor visitation (4.5 pp, P <.01) were only statistically significant among urban residents. Conclusions: The ACA Medicaid expansions produced larger gains in coverage for rural residents than urban residents; however, it appears there remain opportunities to improve access to care among potentially vulnerable rural residents.