2015-16 Health Insurance Marketplace enrollment rates as a percent of the potential market, by metropolitan and expansion status. (RUPRI Center for Rural Health Policy Analysis)

As Congress voted to make it easier to eliminate the Affordable Care Act, a report shows that the number of rural Americans who purchased insurance through the federally managed marketplace increased to 1.4 million, a gain of more than 10 percent, in the last year.

The study compared 2015 and 2016 data from the 36 states with nonmetropolitan counties whose individual insurance marketplace is managed through the federal system. (The states that weren’t part of the study either managed their own marketplaces or had no nonmetropolitan counties.)

The report showed that the percentage of the potential market in nonmetropolitan counties who purchased individual insurance through the federal system had grown from 36 to 40 percent from 2015 to 2016.

Metropolitan counties had a higher estimated rate of enrollment (48 percent), but the gap between rural and urban enrollment narrowed slightly over the study period.

The study created an enrollment percentage estimate for each American county by using statewide uninsured figures and county-level Census data. Data for states that managed their own insurance marketplaces were not available, the report said.

Whether states chose to expand Medicaid appeared to have some impact on rural and urban enrollment rates. Rural residents’ estimated enrollment was generally lower in states that didn’t expand:

Six of the eight states with the highest differentials (states in which metropolitan enrollment substantially outpaced non-metropolitan enrollment) were non-expansion states: Florida, Georgia, Kansas, Mississippi, Oklahoma, and Texas all showed large enrollment differences, as did Pennsylvania and Arizona in the Medicaid expansion group.

The study said a number of factors could contribute to the overall better performance of states that expanded Medicaid:

This finding could be a result of greater outreach, more positive attitudes towards the ACA, political leanings, and/or demographic differences in non-metropolitan areas between expansion and non-expansion states. Differences in prices and other market characteristics could also play a role. Reaching extremely low-income populations and convincing them of the value of private health insurance (even when heavily subsidized) may pose special challenges.

Though a lower percentage of potential market purchased insurance in states that didn’t expand Medicaid, those states had a greater year-to-year increase in enrollment. That may be because private insurance was the only option for more residents in those states that didn’t expand Medicaid.

The study noted that counties that had a concentration of residents who lived at 100 to 200 percent of the poverty income (defined as $24,300 for a family of four and $11,880 for individuals) had better enrollment rates than other counties. The scholars theorized that was because lower-income residents are eligible for greater subsidies to help them pay for their insurance, so the insurance was a better deal.

One of the study’s authors said it’s important for policymakers to study how market-driven insurance systems will affect rural areas. Smaller populations often mean less competition, she said. “”You just have to be careful in the design of it that you are picturing how that’s going to look in a rural place,” she said.

At present, however, there are no new policies to study. The Senate and House last week voted mostly along party lines to approve separate budget resolutions that eliminate Affordable Care Act provisions but create nothing to replace it. Proponents say replacement legislation will come later. The budget-resolutions votes will protect ACA repeal from a Democratic filibuster.

The report was produced by the RUPRI Center for Rural Health Policy Analysis and was written by Abigail R. Barker, Ph.D.; Kelsey A. Huntzberry, MPH; Timothy D. McBride, Ph.D.; Leah M. Kemper, MPH; Keith J. Mueller, Ph.D.

State data is included below, broken out into states that expanded Medicaid and those that didn’t. Please note that the list does not include states that manage their own health insurance marketplace instead of using the federal system.

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