Implementing the Affordable Care Act in Central Pennsylvania.

The Central Pennsylvania area referred to as the Susquehanna Valley is a rural cultural region identified by political strategists as the unpredictable and conservative area between the urban centers of Pittsburgh and Philadelphia. It contains a rural population of nearly 4 million people. Although the region is served by a number of large health care systems, there has been little assistance given to residents navigating the Affordable Care Act (ACA) in the midst of a demonstrated need, despite evidence that rural residents are more likely to be chronically uninsured than urban counterparts. Within this policy and cultural setting, we have worked with undergraduate students, community partners, and fellow academics to create and implement the Central Susquehanna ACA Project as a response in the midst of limited federal and state-level support for enrollment assistance. Pennsylvania has not, at this time, expanded Medicaid, creating a “gap” in coverage for those making less than 100% of the federal poverty level. The governor has offered a counter proposal that analysts expect to be rejected. Navigator organizations have been stretched heavily as the $2 million provided by the federal government was quickly exhausted to meet staffing needs in mostly urban settings. The medical centers and hospitals of the Central Susquehanna region have provided enrollment assistance, as have private insurance agents, but these entities face complicated financial and staffing decisions when ACA enrollment assistance is added to existing responsibilities. As we have been engaged in providing public education about the ACA, enrollment assistance, and evaluation research about implementation, we have begun to identify opportunities for improving the fall 2014 enrollment cycle. In the remainder of this commentary, we offer specific ideas for improving ACA enrollment in rural communities. The health care marketplace requires a basic computer skill set often absent in rural residents. Phone service as provided by the Centers for Medicare and Medicaid Services (CMS) has been marked by inadequate and narrow information, as it is particularly focused on website navigation or enrollment using paper forms that do not allow for immediate interaction about insurance possibilities. If the goal of the ACA is increasing access to health care, then assistance professionals accessible via the federal support phone number need to also provide basic information about complementary and alternative statelevel medical assistance programs. We suggest creating state-specific experts who can provide assistance over the phone, not only for navigating a website but for navigating basic levels of social service programs, especially for individuals who fall into the Medicaid gap. Social network density in rural locations disperses basic information about the ACA, assistance opportunities, and political opinion in a rather specific manner. Towns