Click on a state below to view rates of Medicaid coverage in Metro and Small Town/Rural counties.
Methodology
Data Sources and Model
This report from the Georgetown University Center for Children and Families (CCF) uses 2023 American Community Survey (ACS) Public Use Microdata Sample (PUMS) data to model the estimated share of children (under age 19), non-elderly adults (ages 19-64), and seniors (age 65 and over) covered by Medicaid/CHIP in counties classified as either “Metro” or “Small Town/Rural Area.” Data from 2022 ACS were used to augment model performance. County estimates were developed with the assistance of Mark Holmes, PhD at the Rural Health Research Center, University of North Carolina-Chapel Hill and follow the general approach used previously in J. Hoadley, J. Alker, and M. Holmes, "Health Insurance Coverage in Small Towns and Rural America: The Role of Medicaid Expansion" (Georgetown University Center for Children and Families, September 2018).
In the first step of the estimation, a predictive model is developed that relates social, demographic, and economic factors to individual Medicaid coverage (the 2023 model has been updated to include Supplemental Security Income (SSI) and poverty flags specific to seniors). ACS PUMS data are used to identify demographic characteristics associated with the likelihood that an individual is covered by Medicaid. In the second step, these individual-level relationships are applied to area-level values from corresponding county-level ACS summary data. These are used to estimate the number and share of individuals with Medicaid coverage in each county; county estimates are further adjusted to match state-level targets.
CCF suppresses estimates in counties with fewer than 50 individuals overall or 50 individuals covered by Medicaid/CHIP, including for children, adults, and seniors.
Geography
Counties are classified as either “Metro” or “Small Town/Rural Area” using the Missouri Census Data Center’s Master Area Block Level Equivalency (MABLE) Geocorr 2022 data engine. Rural areas and small towns are defined as counties with no urban areas of at least 50,000 residents. Three states (DC, NJ, RI) have no counties classified as a “Small Town/Rural Area.”
Health Insurance Coverage and Medicaid Undercount
ACS data represent a “point-in-time” estimate of an individual’s insurance coverage, meaning that the survey collects information on the respondent’s coverage only at the moment they complete the form, not at another point during the year. (The ACS is conducted over the course of the year.)
The ACS reports Medicaid and Children’s Health Insurance Program (CHIP) coverage as a single category of health insurance. CCF uses “Medicaid/CHIP” when describing children’s coverage, although it is important to note that the majority (67%) of children enrolled in CHIP are covered through CHIP-funded Medicaid coverage. CCF uses “Medicaid” when describing non-elderly adults’ and seniors’ coverage as very few adults are covered through CHIP.
Please note that ACS estimates are not adjusted by the Census Bureau (or by CCF) to address the “Medicaid undercount” often observed when comparing surveys to the reported numbers of individuals enrolled in Medicaid and CHIP using federal and state administrative data. This undercount occurs in the majority of surveys and is not unique to the ACS, though the extent of the undercount varies among federal surveys. Additionally, recent research on the decennial Census shows that young children are consistently and significantly undercounted, likely worsening the Medicaid undercount among children. In 2023, the Medicaid unwinding may have affected individuals’ reported coverage sources as states began recertification processes at different times and individuals may have transitioned between coverage sources.
North Carolina adopted the ACA Medicaid expansion on December 1, 2023. State administrative data indicate that Medicaid enrollment rose considerably in 2024 but is not reflected in this report.
