North Carolinians are fanning out across the state to spread the word about Affordable Care Act eligibility.

By Taylor Sisk

Catherine Gaines’ sights were set on Beauty Spot Methodist Church, in the Robeson County community of Purvis. Her GPS landed her in a cow pasture.

So it goes: another day in the field for Gaines, a cancer patient navigator with Southeastern Health and now a member of the Affordable Healthcare Coalition of Robeson County. Two steps forward, one step back – through the hollows and down a few dead ends, in search of the uninsured.

Catherine Gaines of the Affordable Healthcare Coalition of Robeson County says, “We have to partner to survive.” Photo credit: Taylor Sisk

Gaines and her AHCRC colleagues are part of a statewide team of individuals, many of them volunteers, dedicated to spreading the word about the Affordable Care Act. Their objective is to educate and otherwise offer guidance to those who might be eligible and to suggest alternatives to those who aren’t.

It’s an all-hands-on-deck effort.

How’re we doing?

First, some numbers:

In 2013, before the first ACA open enrollment period, North Carolina’s uninsured rate was 18.2 percent, almost 2 percent higher than the national average. By 2015, the state’s rate had dropped to 14.6 percent, but was still 3.9 percent higher than the national average.

Rural Rx: NC Health News coverage of rural health issues. This week: Robeson County

But North Carolina has beaten expectations for ACA enrollment. As of the end of June, only four states – Vermont, Maine, Florida and California – and the District of Columbia had enrolled a higher percentage of those eligible for ACA coverage. Forty-six percent of just over a million potential enrollees were signed up.

And the state has the third-highest percentage (91.6), after Mississippi and Wyoming, of residents enrolled who are receiving financial assistance in the ACA marketplace.

The 2016 open enrollment period began on Nov. 1 and runs until Jan. 31, and ACA assisters are deploying from Ranger to Rodanthe (i.e., mountains to sea). As expected, rural areas have lagged behind the more urban ones in enrollment, due in some degree to the fact that because rural areas are less densely populated, and there’s more terrain to cover, it’s harder to reach folks to assist them.

The rural perspective

According to an October Wake Forest University School of Law study, almost 40 percent of the North Carolinians eligible to enroll but who haven’t yet done so live in the state’s 80 rural or largely rural counties.

Median income in those counties is $39,679; it’s $52,382 in the state’s urban counties.

Health care-wise, rural residents face, as a whole, more challenges than those in urban areas. They have access to fewer services and what’s available is more dispersed. They’re more likely to be self-employed, seasonally employed or work for a business that doesn’t provide health insurance.

According to the federal Health Resources and Services Administration, rural families pay almost 40 percent of their health care costs out of pocket.

A full-out assault

The need is critical in rural communities, and ACA navigators are responding with enthusiastic creativity.

Vanessa Abernathy, an Enroll America fellow, is helping spearhead an all-out effort. Photo credit: Taylor Sisk

Robeson County, just to the southwest of Fayetteville, is an ACA success story.

Robeson is approximately 40 percent Native American, 30 percent white and 25 percent black, and now has an expanding Latino population. A third of the county’s residents are uninsured, the highest rate in the state.

Enrollment efforts in the county have entailed what Sorien Schmidt, state director for Enroll America, calls “a great convergence in focus and energy and commitment.” It includes health care providers, federally qualified health centers and other nonprofits, faith communities, business owners, barbers – it’s a community-wide campaign.

“In the business world, they call it total market coverage,” said Vanessa Abernathy, an Enroll America fellow. “You’ve got all these different groups and entities that are moving toward the same goal, which is enrollment.”

A ‘shining example’

In September, the federal Centers for Medicare and Medicaid Services awarded the North Carolina Navigator Consortium $2.6 million to help get North Carolinians enrolled in the ACA during this year’s open enrollment period.

Legal Aid of North Carolina is one of 14 members of the consortium and has been an active presence here in Robeson County. They’ve been joined at the forefront by churches – trusted sources of information in the community.

“If you know anything about Robeson County, you know there are many churches,” said Francine Chavis, a Legal Aid of NC paralegal, born and raised in the Robeson town of Pembroke, and now a certified navigator.

Francine Chavis is working in the community in which she grew up to get people educated about the ACA. Photo credit: Taylor Sisk

Pastors will talk about the ACA from the pulpit or over Sunday supper in the home of a congregation member. And the coalition has held a number or enrollment events in churches.

“A lot of times, you may have half a dozen to a dozen people, 20 people at the max, there to listen to you,” Abernathy said, “and most of them are Medicare people. But what we count on them to do is spread the word.”

Gaines said awareness of health risks is a major factor in Robesonians’ desire to find affordable health insurance. Prevalence of obesity, heart disease and cancer is high in the county; life expectancy is low. Robeson has the highest smoking rate in the state.

The sum is what Gaines calls “the burden of disease.”

Helping people with, or at risk for, cancer is what Gaines does at Southeastern Health and is her primary motivation for combing the community for eligible ACA enrollees.

“We have to partner to survive,” she said.

“It’s very exciting to see,” Schmidt said of the Robeson campaign. It indicates to her that this work is “less about financial resources and more about a strong, collaborative, dedicated effort to get the word out.”

“They really are a shining example not just in North Carolina but nationwide of what you can do with a strong collaborative effort,” Schmidt said.

Francine Chavis assists Sandra McCallum at an enrollment event in Maxton. McCallum’s father owns the barbershop next door to where the event was held. She saw the sign and came in to learn more. Photo credit: Taylor Sisk

Harder to reach

Sampson County – just to the northeast of Robeson and also rural – ranks among the state’s bottom five counties for rate of enrollment. The county is home at least part of the year to a lot of seasonal farmworkers, who tend to be harder to reach.

“But there has been a concerted effort in Sampson to get those workers enrolled,” Schmidt said, with progress made this past summer.

The Benson-based North Carolina Farmworkers’ Project came on board as an ACA facilitator in the summer and has played a leading role in this effort. The organization works primarily with H-2A agricultural workers, and that requires an all-out education effort in the summer.

Mackenzie Mann, a Farmworkers’ Project health educator, said she and her colleagues are often out till midnight trying to reach the uninsured.

Cooperation from growers has been generally good, Mann said. A few have invited educators to come out or have allowed workers time off to attend an enrollment event.

She said there have been no significant differences from county to county in the difficulty of reaching farmworkers; it’s primarily a matter of how well they’ve built relationships with individual worker camps.

“We’ve learned a lot this year,” Mann said, a lot about logistics. Going forward, she said, rather than doing much enrollment over the phone they’ll set up marketplace accounts for as many workers as possible, allowing them to upload documents, saving time and effort.

Something on every visit

Of the 38 federally qualified health centers, or FQHCs, in the state, 35 received federal funding for ACA enrollment.

Elizabeth O. Gilmore, a congregation leader at Dothan Presbyterian Church in Maxton, helped organize an enrollment event at the church. Photo credit: Taylor Sisk

“Number one is building trust,” said Alice Pollard, outreach and enrollment coordinator for the North Carolina Community Health Center Association, “and health centers have built it over the years as the health care home for so many people.”

“We like to say that a consumer never leaves an appointment with an enrollment assister with nothing,” Pollard said. If ineligible for ACA coverage, or unready to sign up, they can be given a referral to an FQHC or another provider in the community, or gain a better understanding of how the ACA works.

Small businesses have been allies for FQHCs in the enrollment effort; child-care centers and pediatric clinics too.


Many challenges remain.

“The Medicaid gap continues to be an enormous problem,” Pollard said, “especially for rural areas. There are so many consumers who are not able to [get coverage] because we haven’t expanded Medicaid in North Carolina.”

Finding options for these people, she said, is a “huge challenge.”

As for those who are eligible, Vanessa Abernathy said that what’s kept a lot of them from exploring their options is the belief that it’s not going to last: “They’re so afraid that something’s going to happen and it’s not going to be here.”

“My response to that is, ‘Take advantage of it now while you can,’” she said.

“‘At least be seen to learn what’s going on with your body,” Abernathy tells her neighbors.

Her job is to spread the word.

“We just want to say, ‘Do you have health insurance? Do you know about the Affordable Care Act? Would you like to get that information?’ And if they say, ‘No, no, no,’ we say, ‘Can you pass this along to somebody else in your family? Somebody in your neighborhood? Or pass it on to your church?’

“That’s how you get to ‘yes.’”

[box style=”2″]This story was made possible by a grant from the Winston-Salem Foundation to examine issues in rural health in North Carolina. [/box]

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Brenda Porter-Rockwell

Brenda Porter-Rockwell's experience spans more than a decade of writing, reporting and managing publications (for- and non-profit businesses and public relations agencies) on topics ranging from local...

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