2
7.8 million of whom live in rural areas.
3,4
The National Advisory Committee on Rural Health
and Human Services (the Committee) believes that the U.S. Department of Health and Human
Services (HHS) needs to do more to ensure rural Americans are able to take full advantage of the
ACA’s insurance expansion.
Educating people about the Health Insurance Marketplaces will continue to require substantial
coordinated outreach efforts from federal and community stakeholders. The Committee is
concerned, however, that there is a tendency to focus outreach efforts on areas with a higher
population density where more people can be reached. The Committee’s concerns about
implementing the Affordable Care Act in rural areas hinges primarily on the need for more
information, promotion, and technical assistance to enable these populations to effectively: 1)
consider purchasing health insurance in the Marketplace; and 2) select a plan and enroll for
coverage either online, with a paper application, by phone, or in person with an assister. The
Committee sees the need to increase HHS efforts around outreach, education, and enrollment
(OE&E) in rural areas not only for the remainder of this open enrollment period, but in each of
the upcoming enrollment periods.
BACKGROUND
1. The Rural Uninsured
Both the need for and potential benefits of the ACA’s coverage expansion are particularly
notable in rural areas where the population is disproportionately older, chronically ill, lower-
income, and uninsured compared to people living in urban areas.
5
Historically, rural residents
are not only more likely to be uninsured (18 percent of non-metro residents are uninsured
compared to 15 percent metro-residents
6
), but also suffer longer spells of uninsurance.
Additionally, as population density and proximity to an urban area decrease, the uninsurance rate
increases.
7,8
Alternatively stated, the more highly rural and isolated a person is, the less likely he
or she is to be insured. This presents an obstacle for OE&E efforts because more rural non-
elderly uninsured individuals are spread over a larger geographic area. The challenge for HHS is
to ensure that rural individuals eligible for health insurance and financial assistance are made
aware of their options and how to obtain coverage.
3
Skopec, L. and Gee, E. Fifty-Six Percent of the Uninsured Could Pay $100 or Less per Month for Coverage in
2014. ASPE Issue Brief. U.S. Department of Health and Human Services. 16 September 2013. Retrieved from
http://aspe.hhs.gov/health/reports/2013/Uninsured/ib_uninsured.cfm.
4
The Affordable Care Act – What it Means for Rural America. U.S. Department of Health and Human Services.
September 2013. Retrieved from http://www.hhs.gov/healthcare/facts/factsheets/2013/09/rural09202013.html.
5
Jones C. A., Parker T. S., Ahearn M., Mishra A. K., and Variyam J. N. Health Status and Health Care Access of
Farm and Rural Populations. Economic Research Service. U. S. Department of Agriculture. Economic Information
Bulletin No. 57. August 2009.
6
National Advisory Committee Presentation: The Eligible Uninsured in Non-Metropolitan Areas. Office of the
Assistant Secretary for Planning and Evaluation. U. S. Department of Health and Human Services. 4 September
2013.
7
Holmes, M. and Ricketts T. C. Rural-Urban Differences in the Rates of Health Insurance Coverage. North
Carolina Rural Health Research and Policy Analysis Center. University of North Carolina at Chapel Hill. 2003.
8
Lenardson J. D., Ziller E. C., Coburn A. F., and Anderson N. J. Profile of Rural Health Insurance Coverage: A
Chartbook. Maine Rural Health Research Center. University of Southern Maine. June 2009.