Missourians living in rural communities are more likely to lack health insurance than those in urban areas, according to a new policy brief from researchers at Washington University in St. Louis.
Missouri's overall uninsured rate closely mirrors the national average. In 2024, 7.6% of Missourians were uninsured, slightly lower than the 8.2% national rate.
Yet that statewide figure masks a sharper divide between rural and urban communities. In rural Missouri, 9.9% of residents lacked health insurance, compared with 6.9% of people living in urban areas.
The resulting 3-percentage-point rural-urban gap is far wider than the national difference of about 0.6 percentage points, indicating that Missouri's rural communities face a larger coverage disparity than those elsewhere in the country. The policy brief analyzes U.S. Census data, providing the first comprehensive look since the end of pandemic-era Medicaid enrollment protections.
Researchers say the gap reflects structural differences in the types of jobs available in rural areas. Residents are more likely to work for smaller employers or in sectors such as agriculture, retail and service industries where coverage is less common. Rural workers also are more likely to work part time and earn lower incomes, making private coverage harder to obtain. Health insurance premiums tend to be higher in rural areas, and disability rates are higher, creating additional barriers to consistent coverage.
"These jobs are less likely to offer health insurance," said Timothy D. McBride, the Bernard Becker Professor in the School of Public Health and co-director of the Center for Advancing Health Services, Policy & Economics Research.
"That difference in employer-sponsored coverage is one of the key factors behind the rural-urban gap we see in Missouri," he added, noting the disparity merits further study.
Public programs fill rural gaps
Uninsured rates are lowest among adults ages 65 and older because most people in that group qualify for Medicare. Residents under age 65 in rural Missouri are significantly less likely to have private health insurance - typically obtained through employers or purchased individually - than those in urban areas.
In 2024, 60.6% of rural residents had private insurance, roughly 10 percentage points lower than the 70.8% rate in urban areas. Employer-sponsored coverage accounted for much of the difference: 46.1% of rural Missourians had job-based coverage, compared with 59% of urban residents.
Urban Missourians are also more likely to have private coverage than urban residents nationally, reflecting a higher concentration of jobs that offer employer-sponsored insurance, including positions in health care, finance, legal services and education.
With fewer rural workers covered through employers, public programs fill a larger share of the gap. In 2024, 21.9% of rural residents were covered by Medicaid, compared with 16% of urban residents. Overall, 43.2% of rural Missourians were covered by public programs such as Medicare, Medicaid and veterans benefits, compared with 33.7% of urban residents.
"Employer-sponsored insurance is still the main pathway to coverage for most Americans," McBride said. "When fewer rural residents have access to those jobs, public programs like Medicaid become an even more important source of coverage."
Medicaid unwinding shifts rural coverage
Medicaid coverage declined in rural Missouri between 2023 and 2024 as states completed the unwinding of pandemic-era policies that had allowed people to remain continuously enrolled.
The share of rural residents covered by Medicaid fell by 1.9 percentage points, contributing to a broader 1-percentage-point drop in public program coverage overall. Coverage changes in urban areas were minimal over the same time period.
Some residents shifted to other forms of coverage, including employer-sponsored insurance, but the changes still led to a small increase in the uninsured rate. In rural Missouri, the share of residents without coverage rose by 0.4 percentage points from the previous year.
Children experienced the largest coverage declines. Public insurance coverage for children in rural Missouri fell by about 4.4 percentage points, compared with a 1.6-point decline in urban areas.
Researchers said it will be important to monitor how insurance coverage changes in the coming years, particularly as Medicaid enrollment continues to adjust following the end of pandemic-era eligibility protections.
The policy brief, written by Sarah A. Eisenstein, statistical data analyst, and McBride, draws on data from the American Community Survey conducted by the U.S. Census Bureau.
The research was supported by the Missouri Foundation for Health.
