Key Findings:
- Medicaid is a vital source of health coverage for women of childbearing age across the U.S. but is even more important to those living in small towns and rural communities than metro areas. Nationally 23.3% of women of childbearing age in rural areas are covered by Medicaid as compared to 20.5% of women in metro areas. The top ten states with the highest share of women of childbearing age covered by Medicaid in rural areas are New Mexico, Louisiana, Kentucky, West Virginia, Arizona, Oregon, Montana, Maine, New York, and Arkansas. These are all states that have taken up the Affordable Care Act’s Medicaid expansion.
- Twenty counties nationwide have approximately half of women of childbearing age covered by Medicaid. Six of these counties are in Louisiana, five are in New Mexico, and three are in Montana. Two are in Colorado and Kentucky, and Arkansas and Idaho have one county each.
- Rural communities have been suffering hospital closures, and multiple studies have shown declines in the provision of obstetrical services at rural hospitals that remain open. Labor and delivery is the top reason for a hospital stay nationwide. A lack of access to obstetrical services puts at risk the health of mothers and babies in rural communities and small towns irrespective of the family’s coverage source. Medicaid covers almost half (47%) of births in rural areas and 40% in metro areas.
Introduction
This paper examines the role of Medicaid in covering women of childbearing age (19 through 44 years old) living in small towns and rural areas. Previous research in this series found a higher reliance on Medicaid as a coverage source for children and all non-elderly adults living in small towns and rural areas as opposed to metro areas.1 Americans living in rural communities and small towns face serious problems accessing needed health care. In particular, the ability of families to grow and thrive in rural communities and small towns is threatened by declining access to obstetric services which puts the health of both mothers and babies at risk.2 For example, rates of low-birthweight births in rural counties tend to be higher than births in urban areas.3
More broadly, the closure of rural hospitals nationwide is well-documented.4 In recent years, numerous studies have also shown that rural areas across the country have faced a pernicious loss of labor and delivery units and/or provision of obstetrical services. By 2022, the majority of rural hospitals (52.2%) did not offer obstetric care.5 Another study found that from 2011 to 2023, 293 rural hospitals stopped providing obstetric care.6 Rural counties are much more likely than metro areas to have inadequate access to maternity care—nearly two-thirds of counties without a birthing facility or obstetrician are in rural areas.7
In general, women of childbearing age are more likely to live in metropolitan areas. But a higher share of women living in rural communities and small towns are covered by Medicaid. See Figure 1. For state data see Appendix Table 1.
Medicaid covered 41% of births nationwide,8 but nearly half (47%) of all births in rural areas in 2023. The vast majority of those rural births (96%) occurred in hospitals.9 Severe Medicaid cuts that lead to substantial losses in Medicaid revenue and higher uncompensated care would likely result in an accelerated loss of obstetric services already facing rural communities. Continued loss of hospital obstetric services would adversely impact the ability of all women living in rural communities to give birth safely – not only women who are covered by Medicaid.
Which States Have the Highest Share of Women Covered by Medicaid in Rural Areas?
Across the United States, 23.3% of women of childbearing age living in small towns and rural areas have Medicaid as their source of coverage10. Twenty-three states have higher shares of women of childbearing age in rural communities covered by Medicaid than the national rate. With the exception of South Carolina, all of these states have expanded Medicaid to adults up to 138 percent of the poverty line under the Affordable Care Act’s Medicaid expansion. Medicaid expansion helps women maintain continuous health coverage to meet their health needs before, during and after pregnancy.
New Mexico and Louisiana top the list with 40 percent of women of childbearing age in rural areas covered by Medicaid. Kentucky, West Virginia, Arizona, Oregon and Montana all have 30 percent or more. These are all states that have expanded Medicaid under the Affordable Care Act.11
States that have the largest differentials in Medicaid coverage in rural areas versus metro areas for women of childbearing age (greater than five percent higher in rural areas) are: Arizona, Kentucky, Louisiana, Maine, Montana, Oregon, South Carolina, Virginia and Washington. See Appendix Table 1 for the full list of states.
Which Counties Have the Highest Share of Women Covered by Medicaid in Rural Areas?
A look at county-level data for Medicaid coverage of women of childbearing age finds that approximately half are covered by Medicaid in twenty counties, primarily in Louisiana and New Mexico. These counties are all in states that have adopted the Affordable Care Act Medicaid expansion.
In states that have not expanded Medicaid, women of childbearing age make up a larger proportion of the non-elderly adults covered by Medicaid. These states are primarily in the South. (See figure 2.)
Conclusion
Medicaid is a vital source of coverage for women of childbearing age across the U.S., but especially in rural communities and small towns. Financial pressures have resulted in a severe decline in the availability of obstetric services in these communities, putting the health of mothers and babies at risk. Medicaid coverage, including the Affordable Care Act’s Medicaid expansion, helps to ensure that women are healthy before, during and after pregnancy. Severe cuts to Medicaid would result in declining Medicaid revenues and increase uncompensated care costs for rural hospitals. This would result in further deterioration of an already precarious situation for pregnant women and infants living in rural areas and threaten the ability of rural communities to grow and thrive.
Methodology
Data Sources and Model
This report from the Georgetown University Center for Children and Families (CCF) uses 2023 American Community Survey (ACS) Public Use Microdata Sample (PUMS) data to model the estimated share of women of childbearing age (ages 19 through 44) covered by Medicaid in counties classified as either “Metro” or “Small Town/Rural Area.” Data from 2022 ACS were used to augment model performance. Estimates follow the general approach used previously in Medicaid’s Role in Small Towns and Rural Areas.
In the first step of the estimation, a predictive model is developed that relates social, demographic, and economic factors to individual Medicaid coverage. ACS PUMS data are used to identify demographic characteristics associated with the likelihood that an individual is covered by Medicaid. In the second step, these individual-level relationships are applied to area-level values from corresponding county-level ACS summary data. These are used to estimate the number and share of individuals with Medicaid coverage in each county; county estimates are further adjusted to match state-level targets.
Geography
Counties are classified as either “Metro” or “Small Town/Rural Area” using the Missouri Census Data Center’s Master Area Block Level Equivalency (MABLE) Geocorr 2022 data engine. “Small Town/Rural Area” combines the “micropolitan” and “noncore” designations into a single category representing non-metropolitan counties with central urban areas of fewer than 50,000 people. Three states (DC, NJ, RI) have no counties classified as a “Small Town/Rural Area.”
Health Insurance Coverage and Medicaid Undercount
ACS data represent a “point-in-time” estimate of an individual’s insurance coverage, meaning that the survey collects information on the respondent’s coverage only at the moment they complete the form, not at another point during the year. (The ACS is conducted over the course of the year.)
The ACS reports Medicaid and Children’s Health Insurance Program (CHIP) coverage as a single category of health insurance. CCF uses “Medicaid” when describing coverage for women of childbearing age as very few adults are covered through CHIP.
Please note that ACS estimates are not adjusted by the Census Bureau (or by CCF) to address the “Medicaid undercount” often observed when comparing surveys to the reported numbers of individuals enrolled in Medicaid and CHIP using federal and state administrative data. In 2023, the Medicaid unwinding may have affected individuals’ reported coverage sources as states began recertification processes at different times and individuals may have transitioned between coverage sources.
North Carolina adopted the ACA Medicaid expansion on December 1, 2023. State administrative data indicate that Medicaid enrollment rose considerably in 2024 but is not reflected in this report.
