Research Update: What Does Persistent Poverty Mean for Medicaid?

A recent report from the U.S. Census Bureau has identified 341 counties nationwide that are in persistent poverty, which is defined as having a poverty rate of 20% or higher during the past 30 years from 1989 through the 2015-2019 data period (for context, the national poverty rate in 2015-2019 was 13.4%). While persistent poverty focuses on geographic areas instead of people, individuals in persistent poverty communities likely face greater challenges like lower access to high-quality education and jobs, healthy food, and health care regardless of whether they or their family are actually living below the federal poverty level.

Looking at this county data alongside CCF’s new interactive rural data, more than 80% of these persistently poor counties identified by the Census Bureau are also rural or small town areas and many had some of the highest Medicaid coverage rates in the country in 2020-2021. Fifteen out of the top 20 rural counties with the highest Medicaid coverage rates for children in 2020-2021 are in persistent poverty; for adults, all of the top 20 were. But as states begin unwinding Medicaid’s pandemic-era continuous coverage protections, many people are being disenrolled for procedural reasons rather than because they were determined to be no longer eligible for Medicaid. Rural areas like these counties with a long history of high poverty—and high reliance on Medicaid for their health coverage — could be even more at risk for inappropriate coverage losses as individuals who are likely still eligible may have to contend with problems like connectivity issues or transportation difficulties to faraway eligibility offices that could keep them from being able to complete their renewal.

Additionally, nearly half of these persistently poor counties (46%) are located in states that have still not adopted the Medicaid expansion. Because Medicaid eligibility for parents is so low in these states (median income eligibility is just 37% of poverty for parents), many who are still far below the poverty level but who are no longer eligible would likely end up in the coverage gap.

In any event, effective outreach and communication are essential to making sure that Medicaid can continue serving as a vital lifeline to health care access in counties with persistent poverty and rural areas.

Here are some additional highlights from the report:

  • About 11% of all counties nationwide are in persistent poverty (341 out of 3,142). However, they tend to be smaller counties and represent a lower share of the total population living in these areas (19.4 million people, or about 6%)
  • More than 10% of the population in Texas, Arkansas, Maryland, and Pennsylvania and more than 15% in New Mexico, Louisiana, Mississippi, Kentucky, West Virginia, and New York lived in a persistently poor county
  • More than 80% of counties in persistent poverty are in the South (278 out of 341), clustered around the Southwest border, the Mississippi Delta, the Southeast, Appalachia, and some counties that overlap with American Indian and Alaska Native tribal lands. More than half (54.9%) of everyone who lives in a persistently poor county lives in the South
  • In the Northeast, just 3 counties are in persistent poverty (Kings and Bronx counties in New York and Philadelphia County in Pennsylvania), but they’re so heavily populated that they account for more than one-quarter of the region’s entire population (28.4%)
  • Census tracts are smaller geographic levels that offer a more localized view of high-poverty areas. A similar share of tracts nationwide are in persistent poverty (8,238 out of 73,060, or 11.3%), but they represent a larger share of the total population (28.5 million people, or about 9%). Most persistently poor tracts are located within counties that are not overall in persistent poverty—for example, DC, Wayne County, MI (home to Detroit), and Los Angeles County, CA, are not persistently poor at the county level, but more than 15% of DC residents live in a persistent poverty tract, and hundreds of tracts within Wayne and Los Angeles counties are in persistent poverty
Aubrianna Osorio is a Research Manager at the Georgetown University McCourt School of Public Policy’s Center for Children and Families.