The Affordable Care Act, often called “Obamacare,” took a big step forward Oct. 1, despite being a factor in the federal government shutdown, when new health insurance marketplaces opened for enrollment. Rural families are more likely to qualify for subsidized coverage, but reaching them to sign up will be part of the challenge.
So, will farm country take advantage of new health insurance subsidies? That’s the question in Nebraska.
Almost 200,000 Nebraskans don’t have health insurance. Nearly half of them are spread across the state’s rural areas.
In rural Wheeler County in northcentral Nebraska, 18 percent of residents are uninsured, compared to 13 percent statewide.
Bob Bernt and his wife Kristine sell cheese and ice cream from their Clear Creek Organic Farms on the banks of the Cedar River. They grow corn and vegetables, and make butter and cheese. They also raise grass-fed pork and beef, along with their 12 children.“Maggie, Christopher, Katie, Rosie, Raymond, Jenny, Tommy, Eddie, Frankie, Becky, Patrick, and George,” Bernt said with a smile. “But if you ask me their ages I’ll pretend I didn’t hear you.”
I sat with Bernt in a booth inside the family’s dairy shed, where he took off his cap to talk about health care. From the farm it’s at least a half-hour drive to the nearest hospital, in Albion, Neb., and that’s as close as he cares to be.
Bernt said it has been 20 years since he or his wife had health insurance. It started when one of their children was born prematurely, with cerebral palsy. The family was left with a load of debt. Then, a dispute with their insurance carrier emptied their bank account.
“It left us in a really bad way,” Bernt said. “We were unable to purchase any food-- nothing. And that’s when we walked away from (insurance).”
After their experience, the last thing Bernt wanted to do is pay for more health insurance. So, for 20 years, every doctor, dentist, or delivery has been paid out-of-pocket. For the last seven years it has been the same for their kids.
Starting next month, Bernt has the option to shop for coverage in the health insurance marketplace. The marketplace is part of the Affordable Care Act designed to bring more people into coverage, spread the risk, and send more people to primary care instead of the emergency room.
Bruce Ramge, director of Nebraska’s Department of Insurance says the marketplaces are open to everyone.
“However, some individuals will qualify for a subsidy,” Ramge said. “And the only way to qualify for a subsidy would be to shop on the exchange or marketplace.”
Nebraska is one of 27 states that are part of a federal marketplace at www.healthcare.gov. Other states like Colorado are setting up their own marketplaces. But they are all intended to work like self-guided travel or tax preparation sites: Users enter their social security numbers and tax information and are able to compare plans and learn if they qualify for assistance.
Subsidies are available for individuals or families that earn 100-400 percent of the federal poverty level. The largest subsidies will go to those right at the poverty line, an annual income of $11,490 for an individual or $23,550 for a family of four. Subsidies decrease as income rises.
“The amount of the subsidy slowly decreases until you get to 4 times the poverty line,” said Roger Furrer, executive director of Community Action of Nebraska, a non-profit that will help people sign up for the exchanges.
Four times the federal poverty level comes to about $45,960 for one person or $94,200 thousand for a family of four.
Coverage under plans from the marketplace starts January 1, 2014, but the deadline to buy insurance on the exchange runs through March 31. By then, no matter where you live, anyone without insurance will pay a fine at tax time.
Farmer Bob Bernt said the high cost of health care is a persistent concern.
“There’s got to be some way people can live with security and not have to go to bed at night worrying about what might happen and how they could lose their farm or lose their small business because of the ever-growing cost of health care,” Bernt said.
But he disagreed that insurance is the way to provide that security. Although his family may qualify for a subsidized insurance plan, Bernt said he will go without coverage and pay the fine, which is modest the first year. In 2014, uninsured families will pay $95 per adult, up to $285 or one percent of their income, whichever is higher.
Bernt believes the way for the government to reduce health care costs is to promote healthier diets and lifestyles rather than promote more health insurance. In fact, 58 percent of rural Nebraskans think Obamacare will fail to reduce costs and just 13 percent believe it could work.
Brian Depew, executive director of the Center for Rural Affairs, said he thinks people will get past issues with politics and policy once they learn more about the new marketplaces.
“We’re working really hard to get beyond the politics because at the end of the day there are parts of the Affordable Care Act that can benefit everybody, no matter what your political stripes,” Depew said.
Just getting the word out is a big stumbling block in rural areas. Keith Mueller, a rural health policy professor at the University of Iowa, said when the Medicare Part D drug plan came out in 2005, it made slow progress at first.
“It’s just challenging to reach anyone and even more challenging if you don’t have the advantages of mass marketing that you do in an urban area,” Mueller said.
But Depew thinks the Affortable Care Act could have a big upside in rural America. For instance, a larger proportion of rural than urban families are expected to qualify for subsidized insurance. So perhaps more farm families may be able to afford comprehensive coverage rather than just a basic plan as a safety net.
“It’s as much an insurance plan on their farm as it is on their health,” Depew said.
Bernt is aware that holding out on health insurance is a calculated risk. It's the same with agriculture. Last month, back-to-back hailstorms wreaked havoc on the farm’s 20-acre vegetable field.
“We lost all of our watermelons,” Bernt said. “All of our vine crops got wiped out through the hail. All of our winter squashes got wiped out.”
The vegetables were not insured, either. But Bernt said they save up for inevitable bumps in the road, whether they have to do with hail or health.
The question starting in October will be how many of the nation’s roughly 8 million rural uninsured step up to the health marketplaces and how many decide to go their own way.