Rural America and the Medicaid Gap

By John Crabtree,, Center for Rural Affairs

A recently released Center for Rural Affairs report ( examines differences between rural and urban states regarding the decision of whether they would expand their Medicaid program as provided in the Affordable Care Act.
The healthcare law extends Medicaid eligibility to nearly everyone under age 65, earning up to 138 percent of the 2013 federal poverty income level – $15,856, or $32,499 for a family of four. As a result of the U.S. Supreme Court ruling on June 28, 2012, however, each state has the option of whether or not to expand. So far, 25 states and the District of Columbia have expanded Medicaid with 25 states declining or delaying.
Whatever the reasons, rural states appear less likely to expand Medicaid, leaving nearly 1.8 million rural Americans in a “coverage gap,” earning too much to qualify for Medicaid but not enough for premium subsidies through health insurance marketplaces. This represents about four percent of the total rural and small town population in the 24 non-expansion states for which data is available, comparable to the number of people nationally informed their policies from the individual health insurance market were not compliant with the healthcare law.

In non-expansion states, rural health care provider networks will be stretched, possibly to the breaking point. Small towns may be left without crucial pieces of healthcare infrastructure, rural residents may be left without institutions to attend to their healthcare needs, and rural communities may be denied jobs and economic activity.