Rural gap found in subsidized health coverage

A smaller share of people in North Carolina’s 80 rural counties who are eligible for subsidized health insurance under the federal Affordable Care Act have enrolled to get that coverage than the share that have enrolled in the state’s six urban counties or 14 suburban counties, a new study says.

Throughout the state, 51 percent of people estimated to be eligible to buy subsidized coverage through a “marketplace exchange” during the first two open-enrollment periods had enrolled by the end of the 2014 open-enrollment period, says the report, “Enrollment Deficits under the Affordable Care Act.”

In rural counties, which are home to over four million people, or 42 percent of the state’s population, the “enrollment deficit” totaled 210,855 people, or 39 percent of the rural population eligible for coverage, says the study, which was prepared by the School at Law at Wake Forest University and supported by the Kate B. Reynolds Charitable Trust in Winston-Salem.

The enrollment gap in urban counties, which are home to over 3.1 million people, or 33 percent of the state’s population, totaled 184,880, or 35 percent of those eligible, while the gap in suburban counties, which are home to over 2.4 million, or 25 percent of the state’s population, totaled nearly 137,951 people, or 26 percent of those eligible.

In rural counties, the study says, income and eduction levels are noticeably lower than in urban or suburban counties and might affect enrollment efforts.

“Enrolling in the marketplace is not a simple process to understand or accomplish,” the study says. “Those with lower education may find it more difficult to complete this process.”

Individuals with lower income also “may face more transportation difficulty in meeting with an insurance agent or enrollment assister, especially those living in areas that lack public transportation.”

Language or cultural barriers among foreign-born residents also may pose an enrollment hurdle, the study says.

“Many foreign-born residents are citizens and so are potentially eligible, but so too are noncitizen legal immigrants,” the study says.

On the whole, it says, foreign-born residents account for 4.2 percent of the population of rural counties, 6.7 percent of suburban counties, and 10.8 percent of urban counties.

That overall concentration of foreign-born residents in rural counties ranges from less than one percent in individual rural counties to over 10 percent.

A low concentration of foreign-born residents can present special difficulties where it indicates “the absence of an identified immigrant community with developed resources and institutions that can provide the more specialized enrollment assistance required,” the report says.

While average rural enrollment is within one percentage point of the statewide average, the study says, the enrollment gap ranges from nearly two-thirds of those eligible for marketplace subsidies in some rural counties, to less than one-third in other rural counties.

The report was written by Edwin Shoaf, a research associate, and Mark A. Hall, a professor of law and public health, both at Wake Forest University School of Law.

Todd Cohen

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