Medicaid's Critical Role in Covering Women of Childbearing Age in Rural America

Medicaid plays a crucial role in providing health coverage to women of childbearing age (19-44 years) residing in small towns and rural areas across the United States. Research indicates a higher Medicaid reliance in rural and small-town populations compared to metropolitan regions. Rural communities face significant challenges in accessing obstetric services, which affects maternal and infant health outcomes, including higher rates of low-birthweight births in these areas.

The closure of rural hospitals and labor and delivery units is a well-documented national issue. As of 2022, over half of rural hospitals did not offer obstetric care, with nearly 300 rural hospitals ceasing these services between 2011 and 2023. The lack of obstetric facilities is particularly acute in rural counties where nearly two-thirds lack birthing facilities or obstetricians, exacerbating healthcare access disparities.

While women of childbearing age predominantly reside in metro areas, a larger proportion of those in rural areas depend on Medicaid for coverage. In 2023, Medicaid covered 41% of births nationally and nearly 47% of births in rural areas, with the majority occurring in hospitals. Reductions in Medicaid funding could accelerate the loss of obstetric services in rural regions, adversely impacting maternal and infant health beyond just Medicaid recipients.

Approximately 23.3% of rural women of childbearing age rely on Medicaid, with 23 states exhibiting higher coverage rates in rural communities compared to the national average. Most of these states have expanded Medicaid under the Affordable Care Act (ACA), facilitating continuous healthcare coverage before, during, and after pregnancy. States like New Mexico and Louisiana report up to 40% coverage, with others such as Kentucky, West Virginia, and Arizona exceeding 30%.

The differential in Medicaid coverage between rural and metro areas exceeds five percentage points in several states including Arizona, Kentucky, and Louisiana. County-level data highlight clusters where Medicaid coverage reaches about 50%, predominantly in states that adopted Medicaid expansion. In contrast, states that have not expanded Medicaid, mainly in the South, show higher proportions of women of childbearing age comprising Medicaid beneficiaries.

The ongoing decline in rural obstetric services, coupled with Medicaid’s vital role, underscores the importance of sustained Medicaid funding and expansion policies. Major Medicaid cuts could reduce hospital revenues and raise uncompensated care costs, further eroding obstetric care availability and impacting rural health outcomes and community vitality.

This analysis utilized 2023 American Community Survey (ACS) and 2022 ACS data, modeling Medicaid coverage based on demographic, social, and economic variables. Counties were classified as metro or small town/rural using the Missouri Census Data Center’s geocoding. The ACS data provides point-in-time insurance coverage snapshots but does not adjust for Medicaid undercounts common in survey data versus administrative counts.

Recent Medicaid policy changes, such as North Carolina's Medicaid expansion in late 2023, reflect evolving coverage landscapes but were not fully captured in this report's data. The Center for Children & Families at Georgetown University conducted this research to inform policy and healthcare strategies addressing rural health disparities and Medicaid’s role in maternal care coverage.

The findings highlight the intersection of Medicaid policy, rural healthcare infrastructure, and maternal health outcomes, emphasizing the need for targeted support to maintain and improve obstetric service availability in rural America. Policymakers and healthcare stakeholders should consider sustaining Medicaid funding and expansion to mitigate growing service gaps and support rural families' health needs.