Most People in the Most Rural Counties Get Medicare Coverage from Traditional Medicare

Enrollment in Medicare Advantage, the private plan alternative to traditional Medicare, has grown steadily over the past decade, and since 2023, more than half of all eligible Medicare beneficiaries have been enrolled in Medicare Advantage. The rapid transformation of the Medicare program to a system that is largely administered by private companies has been less pronounced in places where Medicare Advantage has a smaller presence, such as in rural counties, especially those that are far from metropolitan areas.

This data note examines the share of eligible Medicare beneficiaries (those with both Part A and Part B) with coverage under traditional Medicare and Medicare Advantage across counties that are part of either urban or rural areas, defined using Urban Influence Codes published by the U.S. Department of Agriculture. To focus on rural areas that have less access to the goods and services of urban areas, including for the delivery of health care services, rural counties are further classified as adjacent or not adjacent (most rural) to an urban area.

In the most rural areas, nearly six in ten (58%) Medicare beneficiaries are covered by traditional Medicare.

The share of Medicare beneficiaries who receive their coverage through traditional Medicare is higher in the most rural counties (58%) than in rural counties that border an urban area (48%) or counties that are within an urban area (44%) (Figure 1). Among the just over 61 million Medicare beneficiaries with both Part A and Part B in 2024, 3.4 million lived in a rural county that is outside an urban area, 7.3 million lived in a county that borders an urban area, and 50.4 million lived in a county that is in an urban area.

In 44% of the most rural counties, at least 70% of Medicare beneficiaries are in traditional Medicare.

In 44% of the most rural counties, at least 70% of Medicare beneficiaries are in traditional Medicare, which is substantially larger than the 13% of counties in rural counties adjacent to urban areas, and 6% of counties in urban areas where at least 70% of Medicare beneficiaries are in traditional Medicare (Figure 2). Across all 3,144 counties in the United States (excluding territories), 912 are in a rural area not adjacent to an urban area, 1,046 are in a rural area adjacent to an urban area, and 1,186 are in an urban area.

Half as many Medicare Advantage plans are available to people living in the most rural areas compared with those living in urban areas

Medicare Advantage plans are offered at the county level and the number of plans available varies considerably across counties. Counties with larger populations tend to have more plans available. In 2024, the average Medicare beneficiary living in one of the most rural counties had 22 plans to choose from, compared with 30 for those living in rural counties adjacent to urban areas, and 46 for those in urban areas (Figure 3) (note, plan counts include those with and without Part D prescription drug coverage).

The share of Medicare beneficiaries in traditional Medicare varies substantially in both rural and urban counties.

Among the most rural counties, the share of beneficiaries in traditional Medicare ranges from 26% in Clay County, Kentucky to 100% in Lake and Peninsula Borough, Alaska (Figure 4, Tab 1). Among rural counties adjacent to urban areas, the share of beneficiaries in traditional Medicare ranges from 16% in Starr County, Texas to 99% in Yukon-Koyukuk Census Area, outside of Fairbanks, Alaska (Figure 4 Tab 2). Similarly, among counties in urban counties, the share of eligible beneficiaries in traditional Medicare ranges from 17% in Monroe County, New York to 98% in Fairbanks, AK (Figure 4, Tab 3).