Rural Provider Perceptions of the ACA: Case Studies in Four States


The Affordable Care Act (ACA) expanded health insurance coverage to previously uninsured populations by allowing states to expand Medicaid coverage to adults with incomes up to 138% of the federal poverty level (FPL) as well as by creating health insurance marketplaces to subsidize affordable coverage. However, states with a higher number or proportion of rural residents were less likely to expand Medicaid than were more urban states. In addition, rural residents eligible for insurance coverage through the new health insurance market place were less likely to enroll in coverage compared to eligible urban residents.

Expanding health insurance coverage to the uninsured, through both Medicaid and the new health insurance marketplaces, may improve the financial well-being of rural hospitals and Federally Qualified Health Centers (FQHCs) by reducing the provision of uncompensated care. Even a small increase in revenues due to expanded coverage may have a meaningful impact for rural prospective payment system (PPS) hospitals and critical access hospitals (CAHs), which generally have lower median operating margins than do urban hospitals or larger rural referral centers.

In order to inform timely policy development, the North Carolina Rural Health Research Program surveyed rural providers' early experiences of the ACA in four states: two that chose to expand Medicaid (Arizona and North Dakota), and two that chose not to expand Medicaid (Georgia and Maine). Our findings brief, Rural Provider Perceptions of the ACA: Case Studies in Four States summarizes perceptions from these states regarding the early effects of the ACA, including changes to patient populations, financial health, and capacity for rural hospitals and rural FQHCs.

North Carolina Rural Health Research and Policy Analysis Center
Brystana Kaufman, Pam Silberman, Mark Holmes