The Affordable Care Act seeks to improve access to health care for Americans. Great strides have arguably been made in doing so, but as we approach the nation’s second health insurance open-enrollment period, disparities remain. In particular, America’s rural communities continue to struggle with healthcare access, both on the exchange and in providers’ offices.Before the Affordable Care Act’s initial open-enrollment period concluded, 7.8 million rural Americans were among the nation’s 41.3 million uninsured. As of 2012, there were 27 million adults age 19 to 64 living in the United States who lived in a rural area or outside a metropolitan area; 22 percent were uninsured. When 2014 open enrollment commenced:
- Half of uninsured rural adults had incomes that made them eligible for Medicaid in states that expanded the program
- 4 in 10 uninsured rural adults had incomes that made them eligible for premium tax credits when they purchased coverage from their state’s health insurance exchange
- 9 percent of uninsured rural adults could purchase exchange-based coverage at full cost
For the sake of comparison, the outlook for the 11.3 million self-employed Americans ages 18 to 64, of whom 31 percent were uninsured, was as follows:
- 32 had incomes that made them eligible for Medicaid in states that expanded the program
- 45 percent had incomes that made them eligible for premium tax credits when they purchased coverage from their state’s health insurance exchange
- Nearly a quarter (23.5 percent) could purchase exchange-based coverage at full cost
To understand what distinguishes rural individuals and families from other uninsured populations, it helps to understand the primary barriers to health insurance in these communities. The most common are as follows:
- Lack of job-based coverage — Many who live in rural areas work in industries with low rates of employer-sponsored insurance and high rates of uninsured, such as agriculture, construction, and wholesale/retail/trade.
- Affordability — Those in rural communities tend to earn less money. The median household income for rural adults is $40,060 compared to $47,200 for non-rural adults.
- Lack of information — Reaching the uninsured has been difficult in general. According to a recent Kaiser Family Foundation Health Tracking Poll, 9 of 10 uninsured Americans do not know when the second open-enrollment period begins and two-thirds say they know “only a little” or “nothing at all” about the law’s online insurance marketplaces. A little more than are unaware that they could qualify for financial assistance to help them buy health insurance.
- More likely to fall into the coverage gap — In states where Medicaid was not expanded, a coverage gap was formed that includes those who make too much to qualify for Medicaid and too little to qualify for a premium tax credit when purchasing exchange-based coverage. Those who live in rural areas are more likely to fall into this coverage gap—about 15 percent of rural residents, compared with 9 percent of metropolitan residents. Furthermore, 65 percent of uninsured individuals in rural areas lived in states that did not expand Medicaid in 2014, as opposed to 50 percent who live in metro areas.
- Difficulty enrolling — Spotty Internet service and living a significant distance from in-person assistance have also been cited as barriers to health insurance enrollment among rural individuals.
Additionally, some cite independence and aversion to government involvement as reasons those living outside metro areas may be averse to health insurance enrollment. A St. Louis Post-Dispatch analysis of HealthCare.gov enrollment by ZIP code in Missouri and Illinois found that urban and suburban areas had higher signup rates than rural areas. Ryan Barker, vice president of health policy of the Missouri Foundation for Health, told the newspaper, “There’s a lot of misunderstanding in the rural areas about what this is … There’s just a lot of mistrust and hatred of Obamacare.”
Nonprofit groups reach out to rural uninsured
Reaching out and raising awareness remain the focus when it comes to enrolling more rural Americans in 2015 health insurance plans. Assisters, including navigators, in both state-based and federally facilitated health insurance exchanges helped an estimated 10.6 million consumers apply for health insurance coverage in Marketplace plans, Medicaid and the Children’s Health Insurance Program during 2014 open enrollment. Many nonprofit community groups have received funding to continue expanding and improving these efforts.
The federal government awarded $60 million in Navigator Cooperative Agreements to 90 organizations for 2015 open enrollment. These recipients serve federally facilitated and state partnership marketplaces. State-based marketplaces can use their federal ACA exchange establishment funds to “create parallel, in-person, non-navigator assistance programs that perform the same functions as navigators.”
Communicating for America (CA), a nonprofit organization that advocates on behalf of self-employed and small business owners in rural America, is among the organizations assisting rural enrollees in Minnesota, where 23 percent of the population is rural. In early September 2014, CA was selected as a MNsure Outreach Grant recipient and will work with partner organizations in Ottertail, Wilkin, Grant, Becker and Clay counties to reach and enroll insured and underinsured Minnesotans, especially those in communities where health disparities exist.
Patty Strickland, CA’s president and a navigator herself, says the organization emailed its members information about plan categories and benefits, suggesting potential increases in costs and personal needs, providing guidance on calculating net healthcare costs, and providing them with contacts for additional assistance
To help raise awareness as the second open-enrollment period nears. The email reminds it members that plans, benefits monthly premiums and out-of-pocket costs may change, and reminds consumers that their personal needs may also change.
“The goal was to make our members aware of the options they now have … and make certain they shop,” Strickland said in an email. “We have also offered to help members determine their cost of insurance.”
Strickland explained that among the biggest impacts 2014’s ACA changes had on rural communities is that consumers now have better options without worrying about preexisting conditions.
“Consumers can lower deductibles and change copays based on their situation at the time of open enrollment,” Strickland said. “Pre-existing conditions would have made it difficult at best to locate another plan previously. This is all new for the consumer, which is why it is important to review what they have and determine how it works for them.”
Prior to 2014, those who had a larger deductible could not move to a lower deductible without underwriting. As such, Strickland said, “a large number of people were locked in at a higher deductible due to pre-existing [conditions]. This is no longer the case.”
Groups like CA will help rural consumers understand these facets of the new law as they help them enroll in the state exchanges. Like CA, they are sending letters and conducting outreach events such information sessions at clinics, libraries and other community venues.
Consumers in all areas may locate navigators and assisters that can provide enrollment help in-person and over the phone through their state-based or federally facilitated health insurance exchange. They may also check their exchange websites for upcoming events. For state-by-state health insurance information, visit info.healthcare.com/states.
 The Henry J. Kaiser Family Foundation. “The Uninsured: An Interactive Tool.” Jan. 2014. http://kff.org/interactive/the-uninsured-an-interactive-tool/.
 Carey, Mary Agnes. “Uninsured Still Know Little About Health Law as 2nd Enrollment Period Draws Near.” Kaiser Health News. Oct. 21, 2014. http://kaiserhealthnews.org/news/uninsured-still-know-little-about-health-law-as-2nd-enrollment-period-draws-near/.
 Newkirk, Vann and Anthony Damico. “The Affordable Care Act and Insurance Coverage in Rural Areas.” The Henry J. Kaiser Family Foundation. May 29, 2014. http://kff.org/uninsured/issue-brief/the-affordable-care-act-and-insurance-coverage-in-rural-areas/.
 Toland, Bill. “As ‘Obamacare’ Enrollment Window Reopens, Many Uninsured Unaware of Subsidies.” Pittsburgh Post-Gazette. Oct. 26, 2014. http://www.post-gazette.com/business/2014/10/26/As-Obamacare-enrollment-window-reopens-many-uninsured-unaware-of-subsidies/stories/201410260030.
 Shapiro, Jordan and Walter Moskop. “Missouri Sees Urban, Rural Divide in Obamacare Signups.” St. Louis Post-Dispatch. Oct. 20, 2014. http://kaiserhealthnews.org/news/missouri-sees-urban-rural-divide-in-obamacare-signups/.
 U.S Department of Health & Human Services. “HHS Announces $60 Million to Help Consumers Navigate Their Health Care Coverage Options in the Health Insurance Marketplace [Press Release].” Sept. 8, 2014. http://www.hhs.gov/news/press/2014pres/09/20140908a.html.
 Luthra, Shefali. “Minnesota Gearing Up for Rural Outreach on Health-Insurance Enrollment.” MinnPost. Sept. 8, 2014. http://www.minnpost.com/health/2014/09/minnesota-gearing-rural-outreach-health-insurance-enrollment.
 Communicating for America, Inc. “Communicating for America, Inc. Awarded MNsure Outreach and Enrollment Grant [Press Release].” Sept. 3, 2014. PDF.