Double vulnerability? Examining the effect of living in nonmetropolitan areas within non-expansion Medicaid states on health status among working-age adults in the United States, 2022-2024.

Objective: To examine whether living in nonmetropolitan areas within a state that has not expanded Medicaid is associated with poor/fair self-reported health status among working-age adults in the United States. Methods: We analyzed data from the 2022-2024 Current Population Survey (n = 220, 601, ages 25-64). Self-reported health was dichotomized as having reported poor/fair or good/very good/excellent health status. We produced a four-level measure of the overlap between residential and policy contexts indicating whether the respondent lived in a metropolitan or nonmetropolitan area within a state that had or had not expanded Medicaid coverage by 2023. Multilevel logistic regression models were fit to examine the association between our measure of residence-policy overlaps and poor/fair self-reported health status while accounting for individual and state-level characteristics. Results: About 3.7 % of respondents resided in nonmetropolitan areas within non-expansion states. Approximately 11.4 % of respondents reported poor/fair self-reported health, with respondents living in nonmetropolitan areas within non-expansion states having the highest rates of poor/fair self-reported health status (18.1 %). Living in a nonmetropolitan area within non-expansion states was associated with higher odds of poor/fair self-reported health status for the overall population and by sex. Conclusion: In this nationally representative and racially diverse sample, we found that individuals residing in nonmetropolitan areas in non-expansion Medicaid states were more likely to report poor/fair self-reported health status. This effect was present for the majority of the population subgroups. Our findings underscore the double vulnerability faced by populations living in these residence-policy overlaps and the need for targeted interventions.