Last week, my colleague Joan Alker announced the publication of our latest report on the importance of Medicaid in rural areas and small towns around the country. She covered how as states “unwind” pandemic-era Medicaid continuous coverage protections, the reach of Medicaid in rural areas means negative effects there can be quite significant if states don’t take special care as greater health coverage losses can result.

Our updated report on Medicaid’s rural reach also shows how the last ten states that haven’t expanded Medicaid to more lower-income, largely working adults also have a special responsibility to consider the effect of their decisions on small towns and rural areas.

In states that have yet to expand Medicaid, our report found the median income eligibility level for parents was about 35% of the federal poverty level (or about $8,700 annually for a single adult in 2023.) Across the county, more than 1 in 5 rural adults living in a Medicaid expansion state were covered by Medicaid, but just 13% of rural adults in non-expansion states had Medicaid coverage.

The higher enrollment in Medicaid in rural areas and small towns in Medicaid expansion states shows how states that expand Medicaid have helped rural areas – where jobs often pay less, private health coverage is less available, and there are transportation and other barriers to health care access – increase health care coverage. While increasing Medicaid coverage is obviously not going to solve every rural health care issue, it is an important building block to begin to address many problems in health access faced by rural areas and small towns.

The largest numbers of adults who would get coverage through their state deciding to join the vast majority of states who have expanded Medicaid now live in Texas, Florida and Georgia. Not coincidentally, Texas has the largest rural population of any state, with over 4.7 million residents living in rural areas and small towns. Florida and Georgia also have large rural populations.

As more states move to consider expansion following North Carolina’s decision this year, rural communities in these states stand to benefit significantly.