Document Type

Working Paper

Publication Date



Access, health insurance, rural, employment, MRHRC, USM Aging Initiative, Economics, Health and Wellness, Policy


Numerous studies have found that rural residents are more likely to be uninsured than urban residents. This coverage difference is generally due to more limited access for rural workers to employer-sponsored health insurance. Lower wages, and the tendency for rural residents to work for small employers, account for this reduced access. While we have substantial information on static insurance coverage rates for rural residents, our knowledge about how coverage changes with employment transitions is limited. Prior research indicates that loss of a job puts workers at greater risk of becoming uninsured, and there is some evidence that this risk is even greater for rural workers. Other studies suggest that access to health insurance plays an important role in determining whether a worker decides to change. Whether this relationship is any different for urban versus rural workers has not been well-studied.

In the past 20 years, much of the federal-level policy attention related to health insurance coverage has emphasized ensuring continuity of coverage for individuals that experience an employment transition. For example, the Consolidated Omnibus Budget Reconciliation Act (COBRA), passed in 1985, ensured that those with employer-sponsored coverage could retain that coverage even if that employment ceased. Similarly, the 1996 Health Insurance Portability and Accountability Act (HIPAA) guaranteed individual coverage for those who leave a group plan. However, both of these key policy interventions are inapplicable to the smaller employers that are the backbone of rural economies. Thus, rural workers may be more likely than urban workers to experience disruptions in health insurance coverage following an employment transition.

The Patient Protection and Affordable Care Act (ACA) provides a new background against which to consider the issues of job change, job loss, health insurance portability and coverage of rural residents. Understanding how changes in employment status impact insurance coverage for rural workers can help to identify potential challenges and opportunities for implementing ACA in rural areas.

Funding Organization

This study was funded under a Cooperative Agreement with the federal Office of Rural Health Policy, Health Resources and Services Administration, DHHS. The conclusions and opinions expressed in the paper are the authors' and no endorsement by the University of Southern Maine or the sponsor is intended or should be inferred.

Grant Number




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