Two tales of rural enrollment in the ACA: Kentucky and Iowa

A few days ago, the Washington Post ran a story haling Kentucky's success at enrolling rural residents in the state's Medicaid expansion at part of the Affordable Care Act.  Of the 640,000 uninsured Kentucky residents, 56,422 have signed up for health insurance as of 22 November.  Among those, more than 80% have enrolled in Medicaid, while the remainder now subscribe to private plans.

Stephanie McCrummen's story features a navigator (one paid to assist with enrollment) named Courtney Lively, working patiently with residents of Breathitt County, population 13,878, poverty rate 30%.  An excerpt follows:

But in a state where the rollout has gone smoothly, and in a county that is one of the poorest and unhealthiest in the country, Courtney Lively has been busy signing people up: cashiers from the IGA grocery, clerks from the dollar store, workers from the lock factory, call-center agents, laid-off coal miners, KFC cooks, Chinese green-card holders in town to teach Appalachian students.

McCrummen's story recounts Lively's interactions with several residents who represent different family and employment profiles--in short, all profiles of need. Most of those profiled have lived what most of us would characterize as unhealthy lifestyles, including smoking and abuse of substances.  Several are concerned about whether dental benefits will cover their need to have teeth extracted.  Most have not seen a physician in the last decade or more.  A few have never had health insurance.  For educated folks living in metropolitan areas, it's a pretty startling lineup.  Here's how Lively explains the options the ACA provides to 60-year-old Woodrow Wilson Noble, who has never had health insurance.

If you go to the doctor, all you’re going to pay is $1.  If you’re in the hospital for an extended period, you should only be billed $5. . . . If you get medicine, generics are $1 and brand is $4. . . . You can go to the dentist once a month — exams, X-rays and cleanings are covered. . . . Now for your teeth, the plan does take care of having them pulled and does take care of fillings, but not bridges, because that’s considered cosmetic.

As McCrummen observes, this is the law working as its proponents envisioned.  Indeed, Abby Goodenough for the New York Times also recently reported on Kentucky's success, with a similarly glowing profile of a busy navigator.  That story was oriented to a Louisville navigator who was also serving the surrounding area, including LaGrange, Kentucky, population 8,082.  Here is the link to an accompanying slide show.

Contrast those reports of the Kentucky experience with this NPR story out of rural Iowa today, where the report is not so optimistic.  The dateline is Des Moines, Iowa, where Broadlawns Medical Center, a public hospital, is also helping those from surrounding small towns and rural areas sign up for coverage under the ACA.  But a key difference between Iowa and Kentucky is that the former has not invested as much in navigators as the latter.  The story by Sarah McCammon suggests that Iowa is spending only the $600K it received from the federal government to finance navigators.  (The stories out of Kentucky do not indicate whether the state is paying part of the cost of the navigators there).  McCammon quotes Iowa Insurance Commissioner Nick Gerhart who comments on the limits of what that sum can accomplish:

You have to hire staff, train staff, hold events.  I mean, that's expensive.

* * *

When you think that some of the navigators are going to be working in 60-plus counties, that's a heavy lift for just a few people, quite frankly.   

As a consequence, Iowa currently has only a dozen navigators working full-time, plus a few working part-time.  McCammon notes that no navigators are working in 27 Iowa counties, which represent more than a quarter of the state's 99 counties.

In those areas, people with questions have some options. They can turn to insurance agents or certified application counselors like Joe Heitritter. 

Heitritter, director of outreach at Greater Sioux Community Health Center, which serves four rural counties in northwest Iowa, has been visiting local Head Start programs, churches and food banks, looking for people who need help. And he's getting some really basic questions. 

"There are a lot of people we're seeing who've been uninsured for a lot of years," he says. "Just understanding what health insurance is, what premiums and deductibles are are, may be new to some people." 

Heitritter says he and his colleagues have helped several clients narrow down their options, but he doesn't know of any who've finished the sign-up process yet.

Wow!  Perhaps no one has finished the registration process in four counties in rural Iowa.  That's pretty discouraging.  Is the difference between Iowa and Kentucky down to the difference in the number of navigators working on the task?  

Here's a chart showing the state of enrollment in each of the 50 states and the District of Columbia between 1 October and 2 November.