Rural-Urban Uninsured Gap Persists, but More North Carolinians Have Insurance

News | November 26, 2018


Kaitlin Ugolik Phillips, MS



Media Release


Morrisville, NC (November 26, 2018) – Rural residents are less likely to have private insurance than their urban counterparts, and many are not insured at all. But a new analysis published in the latest issue of the North Carolina Medical Journal shows that the rural-urban coverage gap may be more nuanced than it may seem. While rural counties in North Carolina tend to have more residents without health insurance, not all rural demographics are less insured than their urban counterparts, and the state is seeing an increase in coverage overall.


Rural residents who are preschool children, over the age of 65, have no college coursework or live below 200% of the federal poverty line are all less likely to be uninsured than their urban equivalents, according to a paper by Randy Randolph, MRP, and Mark Holmes, PhD, of the Cecil G. Sheps Center for Health Services Research at the University of North Carolina at Chapel Hill.


Randolph and Holmes analyzed data on more than 2 million residents gathered by the American Community Survey (ACS) and the Census Bureau’s Small Area Health Insurance Estimates program for the time periods 2009-2013 and 2012-2016. They found that North Carolina’s rural counties, which account for 54% of the counties in the state, include 20 of the 22 counties with the highest percentage of residents with no health insurance. The mountains and southern coastal plain have the highest numbers of uninsured. But there was some good news for rural counties to be found in the data as well.


Two of the demographic groups where an upset of the traditional vulnerability to lack of insurance was most stark were people with less than a high school education and Native Hawaiian and other Pacific Islander residents. According to data from ACS for the period 2012-2016, residents with less than a high school education had a statewide uninsurance rate of 30.2%. In rural areas, the percentage was 26.6%, while in urban areas 31.8% of people in this demographic had no insurance. Native Hawaiian and other Pacific Islander residents had an uninsurance rate of 23.8% statewide, 19.8% in rural counties, and 24.6% in urban counties.


“Overall, rural areas of North Carolina have a smaller share of residents with health insurance coverage, with sizable gaps in some populations. For example, among 45-to-54-year-olds, rural residents are about a third more likely to be uninsured than urban residents,” said Holmes. “A deep understanding of factors leading to higher uninsured rates is important if we want to narrow the rural-urban gap.”


Even with these gaps, however, North Carolina residents’ rates of insurance have improved as a whole. Both rural and urban areas had more insured residents across demographic categories in the 2012-2016 study period than in 2009-2013, and both had comparable reductions in the percentage of residents without insurance.


“One of the most impressive findings in this report is the large increase in the rates of insurance coverage from rural to urban areas when looking before and after the Affordable Care Act, even though our rural communities continue to lag behind, speaking to the success of the Affordable Care Act in improving access to health insurance,” said Adam Zolotor, co-publisher of the NCMJ.


To read “Health Insurance Coverage in North Carolina: The Rural-Urban Uninsured Gap” by Randy Randolph and Mark Holmes, visit



The North Carolina Medical Journal is a journal of health policy analysis and debate co-published by the North Carolina Institute of Medicine and The Duke Endowment. The NCMJ publishes six issues per year. This issue is co-sponsored by Medical Advocates for Healthy Air. To learn and read more, visit