Purpose <p>The objective of this study was to examine reasons for uninsurance among rural working-age adults with and without a history of cancer in the U.S.</p> Methods <p>We used nationally representative weighted data from the 2020–2024 National Health Interview Survey waves on uninsured rural U.S. individuals ages 18–64 (<i>N</i> = 1,930). Outcomes of interest were 5 reasons for uninsurance. We conducted bivariate and multivariate regressions to determine adjusted odds (aOR), average marginal effects (AME), and predicted probabilities (PP) of reasons for uninsurance among those with and without a history of cancer and across sociodemographic strata.</p> Results <p>“Available insurance plans don’t meet patient needs” was more commonly cited by those with a history of cancer (aOR: 2.25; 95% CI: 1.23–4.15; AME: 11.24% point difference, P:0.01; PP: 23.0% vs. 11.7%). Cost was the most prevalent reason among both groups (PP: 55.2% and 60.5% in those with and without histories of cancer), and “some other reason” was the second-most prevalent (PP 34.1% and 40.7% in those with and without histories of cancer). Reasons for uninsurance differed significantly across sociodemographic strata.</p> Conclusions <p>Available insurance plans do not meet the needs of rural cancer patients and survivors as consistently as those of the general rural population, and cost is a significant barrier regardless of cancer history. High predicted probabilities of “some other reason” in both groups indicate that reasons beyond those investigated in this study may drive uninsurance in both groups. Our results support targeted, inclusive insurance options and care delivery reforms to address unmet needs of the rural population, particularly those with histories of cancer.</p>