July/August 2014 Issue • Volume 42 • Issue 6

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Sociologists Tackle Access to Health Care in a Rural Community

Brandn Green, Bucknell University; Kristal Jones, Penn State University; and Carl Milofsky, Bucknell University

The students, faculty, and community partners of the Central Susquehanna Affordable Care Act Project.

The students, faculty, and community partners of the Central Susquehanna Affordable Care Act Project.

On April 1, 2014, the White House tweeted with the hashtag #7MillionAndCounting, in reference to the surge of applications for health insurance through the federal and state-run Affordable Care Act (ACA) Marketplaces. A volunteer group of faculty and students in rural central Pennsylvania helped perhaps 150 of those 7 million individuals submit an application online and offered counsel to many more whose circumstances were more complex than a simple online application could handle. As sociologists at a liberal arts university, we are interested in research questions about inequality and exclusion in access to health care in the rural context. As educators, we have used the volunteer opportunity that the ACA has offered our students to support their engagement with the local region—from which they are otherwise often sequestered. And as private citizens, we have all experienced a range of emotional and intellectual challenges in trying to understand, explain, and work within the unwieldy health care and social service systems of which the ACA is a part. Along the way, we have gained a first-hand look at how expanding access to health insurance impacts access to health care in the broader context of rural communities.

Understanding Health in the Rural Context

Two years ago, a superintendent of a local school district asked us to help him with an evaluation of the health impacts of building a new track at the high school. His hope was that by creating a central, public space for exercise, activity in the community would increase and with it physical health and social well-being. We created an evaluation project that drew on a broad range of actors and interested individuals in a wide radius around the school itself, in order to fully understand the scope of health-related services, organizations, and activities that might contribute to community health and well-being. We received an ASA Community Action Research Initiative www.asanet.org/funding/fundinggrants.cfm grant to support our research along with several of our students, and over the course of a summer, we interviewed 30 key informants and the students completed an inventory of health associations to better understand the influences at work in our region.

One of the people we met was a woman named Bette, who runs a free health clinic in a small town in the region. When we asked Bette what the most important issues related to community and public health were in the region, she answered without hesitation, “a lack of infrastructure to implement the Affordable Care Act.” She told us that there were no federal resources being disbursed in our area (Pennsylvania received $2 million in federal funding for Navigator organizations, all of which are located in the urban center of southeastern or southwestern Pennsylvania), that the local political leaders had all opposed the ACA along party lines, and that social service and nonprofit agencies were not adequately organized to provide help to their clients who might benefit from the ACA and access to affordable insurance. She connected these issues to the broader context of a lack of health literacy in a region without a robust network of health care institutions, and she suggested that there was much work to be done in educating people about the ACA and then providing enrollment assistance.

Implementing ACA in Rural PA

After talking to Bette, we became interested in ACA implementation in our region as a research project, a teaching opportunity, and a personal interest of all involved. We reached out to a health advocacy organization, the Pennsylvania Health Access Network based in Philadelphia, and received training in educating the public about the framework and basic features of the ACA. Throughout early fall 2013, we gave public presentations in towns across the region. People asked us at the end of talks, how can I check this out? Our answer was, by calling a toll-free phone number or online. Access to the Internet and computers, as well as computer skills, are not, however, realistic for many rural residents and in many rural communities. This is where  technologically savvy undergraduates with an interest in helping others, learning about public health, and getting to know the community in which their universities are located enter. In addition to technological challenges, many residents with whom we spoke were not personally familiar with health insurance, and wanted the chance to see the Marketplace options and talk about their choices with someone in person.

Initially, we thought that perhaps we could support social service agencies in the region in their implementation plans. However, in a state that has neither expanded Medicaid nor put any resources toward ACA education or enrollment, there simply was not a mandate for any government agency to help. Our interest in creating place-based educational experiences for students and our personal desire to help implement the ACA led us to create the Central Susquehanna Affordable Care Act Project. Four faculty coordinators, one project coordinator, and Bette, the manager of the local free clinic, as well as 25 students from a range of disciplines went through the federal training to become Certified Application Counselors, and have provided enrollment assistance at local libraries, churches, and the free clinic since November. We advertised our project in the local newspaper and on the radio, and we consistently received calls from individuals looking for help as well as from local social service agencies and state representatives’ offices.

Lessons Learned

Providing enrollment assistance has generated research questions related to rural livelihoods and access to health care in the context of the ACA. Eligibility for a tax credit to supplement the cost of insurance, for example, is based on income level, with those falling below 100 percent of the Federal Poverty Line channeled out of the Marketplace and into the Medicaid system. However, Medicaid expansion was ruled by the Supreme Court to be a state-level decision, and Pennsylvania to date has declined the offer of funding for expansion. This creates what is referred to as the Medicaid gap, which is especially pronounced in rural areas where people have family and social networks that allow them to get by on very low incomes. Helping our students understand these and many other complex aspects of health and social service policies has broadened their grasp of how politics, policy, and place-specific characteristics can create particular types of inequalities. Some of them participated  in a rally in the capital in mid-April to express their support for Medicaid expansion. As educators, we are proud of our students for translating learning into actions, and are excited for the ongoing contributions that the ACA project can make to our community in a variety of ways—from providing education and enrollment assistance to increasing political awareness and engagement.

Brandn Green has a Ph.D. in rural sociology and is Director of the Place Studies Program at Bucknell University. Kristal Jones has a Ph.D. in rural sociology and is the coordinator of the Central Susquehanna Affordable Care Act Project. Carl Milofsky is a Professor in the Sociology Department at Bucknell University.

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