Expanding Obamacare in rural America

Nearly one year has passed since many of the major provisions of the Affordable Care Act (ACA) have come into effect, including: guaranteed issue, which prevents insurers from denying individuals coverage based on a pre-existing condition; the individual mandate, a fee charged to those who fail to obtain health coverage; and the expansion of Medicaid eligibility to include families and persons whose incomes fall within 133% of the federal poverty level, regardless of whether they have children, in states that have opted into the expansion.

Though the number of uninsured persons in the United States is at its lowest since the 1990s, millions of Americans, many of whom live in rural communities, still do not have health coverage. This is due, in part, to the fact that rural Americans face significant obstacles to obtaining healthcare. Perhaps the most significant barrier is the failure of many states to participate in the Medicaid expansion. Among the states that have failed to implement the Medicaid expansion are Alabama, Alaska, Florida, Georgia, Idaho, Kansas, Louisiana, Maine, Mississippi, Missouri, Montana, Nebraska, North Carolina, Oklahoma, South Carolina, South Dakota, Tennessee, Texas, Virginia, Wisconsin, and Wyoming. Many of these states have large populations of rural persons who would be eligible for Medicaid coverage under the new expansion criteria. 

Another barrier to healthcare facing rural populations is that of distance. Although there are "navigators" hired to educate and assist consumers in choosing healthcare plans and navigating the enrollment process, they are often located at a great distance from rural communities. Those living in rural areas are thus discouraged from enrolling in healthcare plans because they must travel longer distances, often at great financial cost, to obtain in-person assistance. Moreover, although individuals may enroll in healthcare plans online, rural areas are less likely to have dependable internet access. Conversely, Kentucky, which has opted into the Medicaid expansion, has received ample media attention for its success in enrolling rural residents into healthcare plans, due in large part to the success and number of navigators. For a further discussion on Kentucky's success in this regard, click here.

Furthermore, states and nonprofit groups must work to alleviate challenges for rural individuals and families who have successfully obtained health coverage. For example, although guaranteed issue under the ACA prevents insurers from charging higher premiums or refusing coverage based on a pre-existing condition, the ACA allows insurers to take geographical factors into account when setting premiums. Although healthcare costs have always been higher in rural areas as a result of the general shortage of doctors and medical facilities, the ACA has exacerbated the "rural-urban cost divide" in healthcare, as many insurers hike up premiums for individuals living in certain rural areas.

Although the ACA has enabled millions of Americans to obtain coverage for healthcare, multitudes of rural Americans continue to face obstacles in accessing health coverage. These obstacles include distance from services designed to educate and assist rural Americans in enrolling in healthcare plans, and the refusal of several states with significant rural populations to participate in the Medicaid expansion. Moreover, as a result of the ACA, many rural residents who have successfully obtained health coverage face higher premiums based on where they live. Going forward, states and nonprofit groups should focus on (1) making enrollment assistance more accessible in rural areas, (2) garnering support for Medicaid expansion in states that have not yet implemented it, and (3) narrowing the rural-urban cost divide for populations that have successfully obtained health coverage.