ABSTRACT: Context: Rural residents are disproportionately represented among the uninsured in the United States. Purpose: We compared nonelderly adult residents in 3 types of nonmetropolitan areas with metropolitan workers to evaluate which characteristics contribute to lack of employment-related insurance. Research Design and Analysis: Data were obtained from the Medical Expenditure Panel Survey, pooled across 3 panels (1996–1998) to enhance the rural sample size. Econometric decomposition was used to quantify the contribution of employment structure to differences in the probability of being offered employment-related health insurance. Findings: The most rural workers are 10.4 percentage points less likely to be offered insurance compared with urban workers; the difference is smaller for residents of other rural areas. In rural counties not adjacent to urban areas, lower wages and smaller employers each account for about one-third of the total difference. Conclusions: Health insurance disparities associated with rural residence are related to the structure of employment. Major factors include smaller employers, lower wages, greater prevalence of self-employment, and sociodemographic characteristics.