During the last decade, health insurance coverage trends show an increased reliance on public sources of coverage, in part due to the Patient Protection and Affordable Care Act (PPACA). However, little is known regarding the relative importance of the different sources of coverage in nonmetropolitan areas compared to metropolitan areas.

This brief uses the American Community Survey five-year estimates from 2009 to 2013 and 2013 to 2017 to compare types of health insurance coverage for the nonelderly in metropolitan and nonmetropolitan areas. Post-PPACA implementation, nonelderly individuals living in Medicaid expansion states experienced significant growth in public insurance rates compared to those living in nonexpansion states. This increase was larger for those living in nonmetropolitan areas compared to metropolitan areas. Pre- and post-PPACA, uninsured rates were higher in nonmetropolitan areas than in metropolitan areas and remained the highest in nonexpansion states. The overall differential in uninsured rates between metropolitan and nonmetropolitan areas grew between 2009 and 2017 and was driven by expansion status.