[imgcontainer] [img:pennsylvania-rural-health-facilities_small.jpg] [source]Source: Rural Assistance Center[/source]

Click the chart for a full-size version. The authors worked with the Columbia County Volunteers in Medicine to help enroll rural residents in health-insurance programs. Columbia County, shown in red, is far from the urban centers of Philadelphia and Pittsburgh, which received more federal funding for Affordable Care Act outreach.

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The Affordable Care Act (ACA) has been spun as the worst assault on the free market and quality health care since communism.  On the other end of the spectrum, the enrollment of 4 million individuals by the end of February is hailed as evidence of unmitigated success, even as website issues and logistical changes continue.

The reality of ACA implementation is, of course, less cut-and-dry and more overcast with an uncertain forecast.  In rural areas, which received little federal funding for public education and enrollment assistance, it is especially difficult to assess where things stand.

We are rural sociologists who have been working with a group of undergraduate students, university faculty and local health-care providers to support ACA implementation in rural central Pennsylvania. We have observed first-hand the unique challenges and possible contributions of the ACA for rural areas.  We hope our observations can help support efforts by other groups to deliver ACA to rural areas around the country.

In central Pennsylvania, we’ve focused on three actions: education, enrollment and evaluation.

Based on conversations last summer with the coordinator of a free health clinic in our region, we realized that there would likely be no resources for education or enrollment assistance coming our way.  When the Navigator grants were awarded, the federal funding pooled in the urban areas of Philadelphia and Pittsburgh with little to no assistance for the rural areas of the state. Neither did the Republican governor offer support, as he did not expand Medicaid.

Our educational target, then, was rural communities and individuals without health insurance.

After receiving training about the ACA from the Pennsylvania Health Access Network, an advocacy organization based in Philadelphia, we worked to identify appropriate avenues for public education in rural areas.  Communication works differently in rural areas. Social spaces and social networks tend to be more dispersed and less visible than they are in regions with higher population densities.  In addition, access to and interest in communication technologies like the Internet are more variable than in urban centers.  Twitter and Facebook need not apply.

[imgcontainer right] [img:Sam_and_Adam.jpg][source][/source]

Two college students, Adam Bishop (center) and Sam Jacobsen (left) provide enrollment assistance at a library.

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Instead, we gave talks at Kiwanis Club meetings and at local libraries, for audiences of five to 35 people.  We were guests on a popular local talk-radio show.  Folks who heard those talks spread the word.

As we’ve educated the community about ACA enrollment, we’ve learned that residents also need education about social services, other health-care programs and health literacy in general.

One thing we learned is the technology-centric nature of enrollment.  By far the most straightforward way to enroll for the ACA Marketplace is by creating an online account, filling out an online application and reviewing the insurance plan options online.  Access to this information goes a long way toward helping people feel agency within the bureaucratic iron cage of social services.

However, for many rural residents, access to computers and the Internet is a challenge, as are the skills to navigate computer-based systems.  Enter enthusiastic, tech-savvy college students.  There are several small public and private universities in our area. Many of these students have little experience with the region, but they want to learn more. Helping with ACA enrollment gave them that opportunity.

Our volunteer counselors, who included students, faculty and community members, were able to offer official enrollment assistance in our region. Volunteers trained on the federal government’s Certified Application Counselor system. That was available to us because the free health clinic we work with is a Certified Application Counselor Organization.

Reaching our rural residents required us to pay attention to the social and cultural details of our area.  We reached people through the classified-ads section of local newspapers, on local radio and television programs and through other social-service providers.  We also heard from state legislators’ offices (all of which were Republican) who wanted help responding to constituents who were seeking assistance.

Casting a wide net about enrollment assistance has brought in a broad range of individuals, couples and families from around the region.  For some, the ACA provides a means of having health insurance for the few years in one’s early 60s after retirement and before Medicare.  For others, the cost of health insurance when working full-time at minimum wage is barely tenable, and the Marketplace offers more reasonable options, even if insurance premiums still demand a portion of one’s income. For farmers and those working in natural resources, individual health insurance has never been an option due to the high cost, and this is the first time for many adults to have health insurance.

[imgcontainer] [img:nocomputeraca.jpg][source]Source: Healthcare.gov[/source]

Access to technology is a problem for some potential health-insurance enrollees. The deadline for uninsured Americans to apply is Monday, March 31.

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Because we are in a state whose governor chose not to expand Medicaid, there are also many people who try to enroll only to find that they fall in the Medicaid gap (in Pennsylvania, any adult earning less than 100% of the federal poverty level who does not meet other, non-income-based requirements like having a specific health need, is not eligible for assistance from ACA).  The health-care reform law is neither silver bullet nor kamikaze.

Providing good health-insurance counseling to rural residents requires counseling organizations to know more than just the provisions of the ACA. They also need to know their specific rural communities and institutions. The needs of potential enrollees will differ by area. In our region, aging populations and high rates of informal employment (primarily in agriculture and natural resources) mean that we have had to learn about a range of related social-service programs to best help those seeking enrollment assistance.

To paint a more complete picture of what it takes to implement ACA in rural areas, we hope to learn from groups working in other rural places. By sharing what we know, we hope to improve the effectiveness of ACA for everyone.

Kristal Jones holds a Ph.D. in rural sociology from Penn State and is project coordinator of the Central Susquehanna Affordable Care Act Project. Brandn Green also holds a Ph.D. in rural sociology from Penn State and is director of Place Studies Program at Bucknell University.

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