Last year, working with our partners at the University of North Carolina’s Rural Health Project, we released a report that underscored the critical role that Medicaid plays in rural areas and small towns with populations below 50,000. This year Jack Hoadley, Mark Holmes and I took a look at how Medicaid expansion has impacted these same rural areas.

It is well established now that Medicaid expansion has been incredibly important in reducing uninsured rates in general for states that have chosen to do so. As our new report illustrates, state decisions to expand Medicaid have been and will continue to be enormously consequential for residents of small towns and rural areas.

States that expanded Medicaid saw more than three times as large a decline in the uninsured rates for low-income citizen nonelderly adults living in rural areas and small towns than non-expansion states experienced for the period between 2008/09 and 2015/16. The uninsured rate for this population dropped sharply from 35 percent to 16 percent in rural areas and small towns in states that expanded Medicaid compared to a much smaller decline from 38 percent to 32 percent for states that have not expanded.

Improved coverage rates typically translate to a more stable health care system anywhere, but this is especially critical for rural areas and small towns where shortages of health care providers and hospital closures are all too common. Access to rural health providers is especially important to women of child-bearing age, the elderly, and those with chronic conditions such as asthma. Because Medicaid expansion is so important for providers in these communities, everyone there has a stake in the expansion question – even if they have other coverage.

Here are some of our other key findings:

• The states that experienced the biggest drop in uninsured rates for low-income adults living in small towns and rural areas are Arkansas, Colorado, Connecticut, Hawaii, Kentucky, Michigan, Nevada, New Mexico, Oregon, and West Virginia.
• Non-expansion states with the highest rate of uninsured low-income adults in small towns and rural areas are South Dakota, Georgia, Oklahoma, Florida, Texas, Alabama, Missouri, and Mississippi. Two states that more recently made decisions to expand Medicaid—Alaska and Louisiana—are also among the states with the highest uninsured rates for low-income adults in non-metro areas.
• The non-expansion states with the biggest coverage disparities between rural areas and small towns and metro areas are Virginia (which recently decided to expand Medicaid), Utah (which will vote this fall on a Medicaid ballot initiative), Florida, and Missouri.

Check out the report to see how low-income rural residents in your state are faring with or without Medicaid expansion.