Exploring Health Insurance Coverage in the North Central Region at the Intersection of Location, Employment, Gender, Race, and Ethnicity
By Renee D. Wiatt
The 2022 NCR-Stat: Baseline Survey measured whether individuals had health insurance along with other variables such as employment status, gender, race, ethnicity, and location. A recent study by Dobis and Todd (2022) found that health insurance rates varied more widely among age categories and employment status than rural/urban status; our analysis concurred. Analysis of the dataset found that percentage of populations with health insurance varied by state in the North Central Region, employment status, and race/ethnicity. There are minimal differences in health insurance coverage between genders or by rural/urban location. Research by Turrini et al. (2021) found that the American Rescue Plan (ARP) made healthcare insurance more affordable to Marketplace consumers in rural locations in the United States. Even with the affordability issue somewhat mediated by the ARP, many rural residents still struggle with lack of providers in their area, the distance that they must travel to a provider (Turrini et al., 2021), and also face telehealth limitations due to broadband cost and availability.
Analysis of the American Community Survey (2019) found that one in every six rural adults (ages 19-64) was uninsured. Exploring health insurance status in general (e.g., whether an individual is insured or uninsured), Figure 1 shows the rates of insurance by state were relatively high. For example, all 12 states in the North Central Region (NCR) had a rate of health insurance among respondents that was 87% or higher, with the lowest rate occurring in Kansas at 87% and the highest rate occurring in Iowa at 98%. Respondents with insurance could have private insurance through an employer or purchased directly from an insurance company (through themselves or a family member), Medicare, Medicaid or other government coverage, TRICARE or other military health care, Veteran Affair health care, Indian Health Service, or other health insurance.
Figure 1. Percentage of Respondents with Health Insurance by State in the North Central Region
Further analysis of state-level data shows that there are differences among states between the percentage of rural and urban respondents who were insured. Some rates of insured respondents were higher within rural populations (7 states) while there were also cases with higher rates of insurance among urban respondents (5 states). The largest gap between insured rural respondents and insured urban respondents was found in Illinois, where 100% of rural respondents were insured and 92% of urban respondents were insured. Almost no difference (1%) was found in terms of percentage of individuals with health insurance between insured urban and rural populations in Iowa, Nebraska, and Wisconsin.
Table 1. Percentage of respondents per rural or urban category who have health insurance
Source: NCR-Stat: Baseline Survey, 2022
We compared the percentage of each category that was insured among rural and urban employment types, (Figure 2). The employment statuses analyzed were wage employed, self-employed (with sub-categories of home-based businesses and family businesses), unemployed, and retired. Rural respondents had higher or the same rates of being insured in three of the four categories, with unemployed individuals being the outlier. Among the wage employed respondents, 94% of rural respondents were insured and 93% of urban respondents were insured. Eighty-eight percent of unemployed workers were insured among rural respondents and 91% among urban respondents. Among retired individuals, 99% of rural and urban respondents were insured.
Figure 2. Percentage of Rural and Urban Respondents with Health Insurance by Employment Type
For self-employed workers, 88% of rural respondents and 82% of urban respondents were insured (Figure 2). According to Dobis and Todd (2022), 4.1% of adults (aged 26 years and older) in the U.S. were self-employed in 2019. Dobis and Todd also found that roughly 80% of nonmetro (rural) self-employed working adults had health insurance and only 78.5% of metro (urban) self-employed adults were insured.
Among rural and urban self-employed respondents, a higher percentage of family business owners were insured than home-based and family business owners (Figure 3). From our NCR-Stat data, 95% of rural family business owners had insurance, compared to 90% of urban family business owners. Furthermore, 86% of rural home-based business owners had health insurance, slightly higher than the 83% of urban home-based business owners with health insurance.
Figure 3. Percentage of Rural/Urban Respondents with Health Insurance by Home-Based and Family Businesses
Health insurance coverage was also explored at the intersection of rural and urban location and demographic characteristics such as gender, race, and ethnicity. Rural and urban men and women had similar rates of health insurance status, with 94% of rural women and 93% of urban women having coverage (Figure 4). Among men, 96% of the rural men and 94% of the urban men had insurance coverage.
Figure 4. Percentage of Respondents with Health Insurance by Gender and Rural/Urban Designation
Roughly 94% of rural Hispanic residents had health insurance, but only 91% of urban Hispanic residents were insured. Among American Indians and Alaska Natives, a lower percentage of rural residents had health insurance than urban residents, 85% and 93%, respectively. A larger percentage of rural Asian residents (95%) were insured when compared to urban Asian residents (93%). Among Black/African American respondents in rural communities 91% had insurance coverage compared to 89% of urban respondents.
Figure 5. Percentage of Respondents with Health Insurance by Race, Ethnicity, and Rural/Urban Designation
Bednarikova, Z., Marshall, M. I., Wiatt, R. D., and Wilcox, Jr, M. D. (2022). North Central Region Household Data (NCR-Stat): Baseline Survey. Purdue University Research Repository. doi:10.4231/2DEM-Z333
Census Bureau, 2016; analysis of American Community Survey (ACS), 1-year estimates, 2019.
Dobis, E.A. and Todd, J.E., 2022. Health care access among self-employed workers in nonmetropolitan counties. Economic Research Service (U.S. Department of Agriculture), Administrative Publication Number 099.
Turrini, G., Branham, D.K., Chen, L., Conmy, A.B., Chappel, A.R., De Lew, N., and Sommers, B.D. (2021) Access to affordable care in rural America: Current trends and key challenges. Assistant Secretary for Planning and Evaluation Office of Health Policy: Research Report.
Renee D. Wiatt, Research and Extension Specialist, North Central Regional Center for Rural Development