Changing Rural and Urban Enrollment in State Medicaid Programs

Area of Science:

• Health Policy
• Public Health
• Rural Health Disparities

Background:

• The Affordable Care Act (ACA) significantly impacted Medicaid enrollment nationwide.
• Understanding geographic variations in Medicaid enrollment changes is crucial for policy evaluation.

Purpose of the Study:

• To analyze changes in Medicaid enrollment across the rural-urban continuum in states that did and did not expand Medicaid coverage under the ACA.
• To identify factors influencing enrollment growth disparities.

Main Methods:

• Comparative analysis of Medicaid enrollment data from October 2013 to November 2016.
• Stratification of enrollment changes by geographic classification (metropolitan, micropolitan, rural) and state Medicaid expansion status.

Main Results:

• Medicaid enrollment growth was lower in rural counties compared to metropolitan counties, particularly in nonexpansion states (7% vs. 14%).
• Expansion states exhibited more uniform growth rates across metropolitan, micropolitan, and rural areas (43%, 38%, 38%).
• State-level variability was observed, with some rural states showing significant increases while others experienced decreases, influenced by pre-ACA eligibility levels.

Conclusions:

• Medicaid enrollment growth post-ACA was geographically uneven, with rural areas lagging, especially in nonexpansion states.
• State Medicaid expansion decisions and pre-ACA eligibility policies significantly moderated enrollment trends across the rural-urban spectrum.