Medicaid is the backbone of many aspects of our health care system including paying for the majority of nursing home residents, covering 40 to 50 percent of children and births depending on where you live, people with disabilities and other low-income people. Medicaid covers almost 80 million people in total – roughly four times as many people as covered by the Affordable Care Act Marketplaces and considerably more than the roughly 48 million seniors covered by Medicare. This is particularly true in rural areas where a higher share of residents are covered by Medicaid. Rural areas face greater challenges in their health ecosystems as their residents have higher rates of chronic diseases, hospitals are operating on tighter margins, and provider shortages are more acute.

As we release our new report “Medicaid’s Role in Small Towns and Rural Areas”, Congressional leaders are making highly consequential decisions about the future of Medicaid — and in particular whether or not to impose crippling and draconian cuts. Medicaid’s future has quickly become one of the most consequential issues that members of Congress will soon decide upon. Documents leaked last week made clear that key House Republicans are considering $2.3 trillion (with a T!!) in Medicaid cuts – that equates to almost one-third of Medicaid spending.

Medicaid – our nation’s health care insurer for the most vulnerable people in society — is at the top of the list for cuts to generate revenue that Republicans are looking for to finance among other things, extending tax cuts which will disproportionately benefit the wealthy.  As the report findings make clear, rural communities are at grave risk if substantial federal cuts are enacted.

Medicaid is a health insurance program that protects families and people from exposure to high medical costs. Medicaid is very good at this! Cuts to Medicaid, which is already a very lean payer in the health care system, will result in transferring cutting services and shifting costs to families and providers – in rural communities as our guest speakers will discuss – health care systems are already under enormous pressure and can ill afford any loss of resources.

So let’s turn to the new report’s findings. A few words about the data first:

1. The underlying data is from the Census Bureau’s American Community Survey which we and others commonly use especially when we want to make comparisons across states as we are doing today. But this data tends to undercount Medicaid so these estimates are conservative and may be lower than other estimates you encounter in your state based on administrative enrollment data.
2. There are quite a few definitions of rurality that exist; the definition of rural used in this report is the following: counties that have no urban areas with a population of greater than 50,000. Using this definition New Jersey, Rhode Island and the District of Columbia have no rural counties and are excluded from the report’s findings.
3. Finally, a special note about North Carolina, because the state implemented the Medicaid ACA expansion relatively recently this data most definitely undercounts the number of non-elderly adults in NC’ rural counties. The state has easily accessible administrative data on its website.

Now some key findings from the report:

• Non-elderly adults and children in small towns and rural areas are more likely than those living in metro areas to rely on Medicaid/CHIP for their health insurance. As a consequence, reductions in federal Medicaid funding being contemplated in Congress are more likely to cause greater harm to rural areas and small towns than metro areas.
  • For children this is especially true in Arizona, Florida, North Carolina, Virginia, South Carolina, California, Minnesota, Georgia, South Dakota, and Alaska.
  • For adults this is especially true in Arizona, New York, Washington, Texas, Kentucky, Virginia, Louisiana, Oregon, South Carolina and Montana.
  • For people over age 65, the rate of Medicaid coverage is slightly lower in rural areas than metro ones.
• In six states, at least half of children living in small towns and rural areas are covered by Medicaid/CHIP. These include New Mexico (59.9%), Louisiana (57.7%), Arizona (55.9%), Florida (51.9%), South Carolina (51.1%), and Arkansas (50.5%).
• In fifteen states, at least one-fifth of non-elderly adults living in small towns and rural areas are covered by Medicaid. These include Arizona (35.9%), New York (33.9%), New Mexico (31.6%), Louisiana (30.2%), Kentucky (28.5%), West Virginia (25.5%), Oregon (24.9%), Washington (24.4%), Montana (22.2%), Arkansas (22.0%), Maine (21.9%), Vermont (21.7%), Massachusetts (21.5%), Michigan (21.2%), and Alaska (20.4%).
• Residents of rural counties with a large share of American Indian or Alaska Native residents and tribal lands are more likely to rely on Medicaid for coverage for all age groups, including seniors.
• Large reductions in federal Medicaid funding would put the residents of small towns and rural communities and their health care systems at serious risk.

Our county level data included in Appendix 6 of the report finds that the top 20 counties with the highest proportion of seniors with Medicaid coverage in rural areas far exceed the national averages and is heavily populated by American Indian elders. An astonishing two-thirds of seniors are covered by Medicaid in the counties that include the Pine Ridge Reservation in South Dakota and Apache County in Arizona which consists primarily of tribal lands. Seven of the top 20 counties are in Indian Country in South Dakota with coverage rates for seniors ranging from 39 to 66 percent.

Please visit our interactive maps and see what the data shows for your state.