Medicaid enrollment growth higher in urban areas, new study finds

Enrollment in Medicaid grew more rapidly in metropolitan areas than in rural areas in states that did not expand the program under the Affordable Care Act, according to new research from the Brown School at Washington University in St. Louis.

Researchers compared urban/rural Medicaid growth rates from October 2013, before the ACA went into effect, to November 2016, during which time Medicaid enrollment grew by 27 percent. They found the growth rates varied widely among states that did not expand the program under the ACA, as well as among those that did.

The findings include:

• In non-expansion states, growth rates from 2012-2015 were 14 percent in metropolitan areas, but just 7 percent in rural areas.
• That difference was much less pronounced in states that did expand Medicaid.
• Some states with above-average rural populations, such as Tennessee, had higher-than-average enrollment increases, while other, similarly rural states, like Nebraska, experienced enrollment decreases.

More research is needed to examine the causes of these variations, said lead author Abigail Barker, manager for data and methods at Brown's Center for Health Economics and Policy (CHEP).

She said potential reasons for the disparities include differing outreach efforts, fewer ACA navigators in rural areas, as well as broader political and social factors. In addition, the wide variation in pre-ACA eligibility levels for parents and children is likely a factor.

"At the policy level, best practices gleaned from states with higher enrollment rates could be implemented in states with lower enrollment rates," Barker said.

The brief was published this month by the Center for Rural Health Policy Analysis at the Rural Health Policy Research Institute. Other authors include: Tim McBride, professor at the Brown School and co-direct of CHEP; Kelsey Huntzberry, statistical data analyst at the Brown School; and Keith Mueller, professor at the University of Iowa.