Even before Meryl Rice officially became an ACA navigator in 2015, she traveled around Tennessee helping folks apply for health insurance. (Photo courtesy of Meryl Rice)

Even before funding was available for “navigators” — the people who help individuals enroll in Obamacare — Meryl Rice trekked across rural Southwest Tennessee spreading the word about the Affordable Care Act.

“In 2013, there was no money for advertising, so my husband and I and a few recruited volunteers visited public libraries, churches, doctor’s clinics, and pharmacies across rural West Tennessee making sure that our neighbors knew that they could get health coverage,” Rice said. “We even did educational forums, tabling, and enrollment events after we took the online training offered by the feds.”

Rice, who has served officially as an ACA navigator since 2015, now covers 10 counties in Southwest Tennessee. She’s determined to keep helping people enroll in Obamacare, even though the task is getting tougher.

“We’ve always operated on a shoestring budget, well, actually ¼ of a shoestring budget,” she said. “This year I’ll just have to work a little harder.”

In August, the Trump administration cut the advertising budget for this year’s ACA enrollment period by 90%. In addition, funding for navigators like Rice was cut by 41 percent.

Along with fewer resources to do their jobs, navigators will also have less time to get people enrolled. The open enrollment period previously lasted into January of the next year. This year, insurees have only from November 1 to December 15 to sign up.

Rural Americans  could be more vulnerable to losing insurance because of changes in ACA. Enrollment is already challenging in rural areas, which have higher rates of uninsured residents. Trump also cut subsidies for enrollees who have lower incomes, and rural residents earn less than urban residents.

In Tennessee, about 260,000 individuals receive healthcare coverage through the ACA, with more than half of those receiving cost-sharing reductions. Nationally, about 12.2 Americans got insurance through the Marketplace in 2017.

Lower insurance enrollment could also mean less revenue for rural hospitals. Tennessee leads the country in the rate of rural hospital closures, with the 10th rural hospital, Copper Basin in Polk County, shutting its doors after its GoFundMe page failed to raise the necessary amount. Rice has seen four hospitals close within 100 miles of each other.

“We really try to work with local providers and leaders to help them understand,” she said. “Despite the politics of Obamacare, they should want people insured.”

Since 2013 when the insurance Marketplace came online, rural navigators have dealt with unique enrollment challenges ranging from hostile politics to poor broadband connectivity, which makes it harder for residents to use the Marketplace website to sign up.

Rice said navigators have looked for creative ways to overcome these barriers, but there’s no silver bullet.

“Once I sent over 2,000 flyers home in the report cards of kids enrolled in the Wayne County school system, which has a really high uninsured rate,” she said. “I only got five referrals from that batch.”

Other approaches worked better.

“We’ve had the most success with morning radio shows and local television programming. After my pitch, I get a flood of phone calls, one after the other. I still leave flyers and business cards wherever people will let me do that. Oh, and rural accountants. People do their taxes and realize they’re going to get penalized for not having insurance: their accountant ends up making the pitch!”

Even rural Tennesseans who aren’t navigators are volunteering to get people  covered. Sandy Rice (not related to Meryl), a retired nurse practitioner living in Sewanee, Tennessee, plans to submit letters to the editor to every rural newspaper within 60 miles of her home to make sure people know the ACA is still the law of the land and to ask rural community members to help get the word out about open enrollment.

Rural community leaders are also being asked to step up to the plate. Jacy Warrell, executive director of the Tennessee Health Care Campaign, the state’s leading nonprofit consumer health care advocacy group, said going through businesses is one way to promote enrollment.

“[Leaders] should connect with businesses that have direct contact with those who qualify for assistance and encourage them to protect both their health and finances by enrolling in ACA,” Warrell said.

Aftyn Behn, LMSW, is engagement manager for the Tennessee Justice Center. She works across the state, especially in rural areas, to build relationships that strengthen healthcare-security advocacy. Aftyn previously worked for the United Nations High Commissioner for Refugees in Switzerland developing community-based protection policies for refugee groups. She is from Knoxville and holds a master’s degree from the University of Texas at Austin Steve Hicks School of Social Work.

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