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Health Care Coverage, Affordability, and Access Among Rural and Urban Adults Ages 50 to 64

Rural/Urban Healthcare

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The Patient Protection and Affordable Care Act of 2010 (ACA) helped increase access to health insurance coverage by expanding Medicaid eligibility, establishing health insurance marketplaces where people can shop for and purchase individual coverage, and providing financial assistance to help enrollees afford health coverage, among other provisions. As a result, more older Americans have gained health insurance coverage and fewer report having unmet health care needs due to cost or difficulty paying medical bills.

Both rural and urban areas saw health coverage gains after ACA implementation, but older adults living in rural areas have consistently been more likely than older adults living in urban areas to be uninsured. This analysis examines rural–urban differences in health care coverage, affordability, and access over time from 2012, two years prior to implementation of the ACA, through 2019, the sixth full year of ACA Marketplace operations.

Key Takeaways

  • The Affordable Care Act reduced the uninsured rate among adults ages 50 to 64 in both urban and rural areas, though rural areas continue to have higher uninsured rates.
  •  Coverage gains among this age group were driven primarily by increased Medicaid enrollment in both urban and rural areas.
  • Nongroup (i.e., individual) health insurance enrollment expanded more among older urban residents than it did among older rural residents.
  • Household income, coverage options, and health insurance premiums likely factor into differences in rural and urban coverage rates.
  • Rural residents ages 50 to 64 are more likely than their urban counterparts to delay or cancel care due to cost.

Possible factors behind rural–urban coverage differences include that rural older adults have lower average incomes and are less likely to be offered health insurance through their employers. Nongroup premiums are also less affordable in rural areas.

The Role of Medicaid

With the ACA giving states the option to expand Medicaid, by 2019 Medicaid became the second largest source of health coverage for adults ages 50 to 64 in both urban and rural areas, behind employer insurance. In 2012, the share of older adults enrolled in Medicaid was the same in urban and rural areas. With Medicaid expansion, Medicaid enrollment among adults ages 50 to 64 outpaced enrollment among all other forms of coverage between 2012 and 2019—and this was the case in both rural and urban areas. Medicaid enrollment rose even more among rural older adults, increasing 5.3 percentage points compared with 4.6 percentage points among urban older adults. However, older adults in rural areas continued to have higher uninsured rates in 2019, even in Medicaid expansion states. In Medicaid expansion states, 7.6 percent of rural adults ages 50 to 64 were uninsured in 2019, compared with 6.7 percent of adults in urban areas.


Health insurance is important for healthy aging, and improving access to equitable, affordable, comprehensive coverage and care can help reduce rural–urban health disparities. The ACA improved coverage rates among adults ages 50 to 64 in both rural and urban areas, but our analysis found that small coverage differences and larger gaps in access to care remain. Older adults living in rural areas also continue to face disproportionate barriers to health care and coverage—including higher premiums and fewer coverage options and providers—that can result in forgoing or delaying care and lead to worse health outcomes.  These factors also play a role in higher rates of chronic disease and mortality among older adults living in rural areas.  Policymakers may consider a wide range of proposals to improve access to coverage and affordable health care among older adults, especially those living in rural areas, including expanding Medicaid and increasing outreach and enrollment efforts for Medicaid and state marketplaces.


Suggested Citation:
Dean, Olivia, and Beth Carter. Health Care Coverage, Affordability, and Access Among Rural and Urban Adults Ages 50 to 64. Washington, DC: AARP Public Policy Institute, March 31, 2023.