Rural America carried President Donald Trump to his election win in November. Trump Country it might be, but rural areas and small towns also make up Medicaid Country, those parts of the United States where low-income children and families are most dependent on the federal-state health insurance program, according to a report released Wednesday (June 7).

Medicaid’s enrollment has swollen to more than 72 million in recent years, and the ranks of uninsured residents fell to 9 percent in 2015 from 13 percent in 2013. That’s largely due to the Affordable Care Act, which let states expand Medicaid eligibility with federal funds. Thirty-one states, including Louisiana, and the District of Columbia did so.

Those gains might be in jeopardy under a GOP- and White House-backed health care measure called the American Health Care Act. It would replace major parts of the Affordable Care Act, known as Obamacare, and dramatically cut federal funding for Medicaid. The House approved the the bill in May.

“There is no doubt that children and families in small towns would be disproportionately harmed by cuts to Medicaid,” said Joan Alker, executive director of the Georgetown University Center for Children and Families.


According to the center’s new report, Medicaid covered 45 percent of children and 16 percent of adults in small towns and rural areas in 2015. Those figures are lower in metropolitan areas: 38 percent of children and 15 percent of adults. Rural areas have larger Medicaid populations because more people with disabilities live there, household incomes tend to be lower, unemployment rates higher and jobs with employer-paid insurance less common, the Georgetown report said.

In states that expanded Medicaid under Obamacare, the rate of uninsured people in small towns and rural areas fell by 11 percentage points between 2008-09 and 2014-15, from 22 percent to 11 percent, the report said. That was slightly larger than the decrease in metro areas of expansion states.

If the House-passed bill became law, Medicaid would be cut by more than $800 billion over 10 years. Alker said that would lead to higher uninsured rates and reduce Americans’ access to health care.

The Republican-controlled Senate is expected to circulate a preliminary proposal of its repeal-and-replace legislation to members as early as this week. Compared with House members, senators are typically more sensitive to issues facing rural residents because they represent entire states rather than districts often dominated by urban areas.

With the Senate edging closer to creating its own bill, disability and health advocates and Medicaid enrollees on Tuesday held “Don’t Cap My Care” rallies in nine cities. They implored Congress to reject efforts to cut Medicaid funding. About 400 people gathered outside the U.S. Capitol in Washington — blind, disabled, elderly people among them — with many holding signs reading “Don’t Mess With Medicaid” and “No Cuts, No Caps to Medicaid.”

Ten million people with disabilities rely on Medicaid to help them live, work, attend school and participate in their communities.

Cindy Jennings, 53, of Lititz, Pa., who attended the rally, said she fears the loss of Medicaid coverage under the Republican plan or reduced coverage for her son, Matthew. He is disabled and unable to speak because he was born with a chromosome abnormality.

“It’s frustrating and scary,” she said. “I need to stay healthy to care for him.”

Steven Powe, a Medicaid recipient from Washington, fears losing Medicaid benefits under the GOP’s Obamacare replacement, the American Health Care Act. (Photo by Phil Galewitz, Kaiser Health News) 

Erickia Bartee, 31, of Owings Mills, Md., said Medicaid enables her to live in a group home and get drugs and other health services to live with cerebral palsy. “I will struggle to survive if my Medicaid benefits are cut,” she said.

Other findings from the Georgetown report:

  • Thirteen states have at least 20 percent of adults in rural areas enrolled in Medicaid
  • Arizona leads the country with 34 percent in the program
  • Rural Oregon saw the biggest gain in adults with insurance over the study’s period. Its uninsurance rate dropped 19 percentage points, while adults in the state covered by Medicaid increased 17 percentage points
  • In 14 states, more than half of children in rural areas are covered by Medicaid. Of those, Arkansas and Mississippi were the only states with 60 percent or more of children in rural areas on Medicaid.

The report defined rural areas and small towns as non-metropolitan counties or parishes with main urban areas of no more than 50,000 people.

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Story by Phil Galewitz for Kaiser Health News, a national health policy news service that is part of the Henry J. Kaiser Family Foundation.

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GOP Medicaid cuts hit rural U.S. hardest, report finds