Pam Silberman, JD, DrPH

North Carolina Rural Health Research and Policy Analysis Center

Phone: 919.966.4525
Email: pam_silberman@unc.edu


Completed Projects - (6)

Early Rural Experiences of Changes to Medicaid
This project will 1) develop baseline state-level snapshots of rural enrollment in Medicaid and 2) estimate and model enrollment expansion in each state. We will also conduct a baseline provider key informant interviews in late 2013 to gauge expected effects, with follow up interviews in Summer 2014 as a sentinel warning system of early effects of changes to Medicaid in order to inform timely policy development.
Research center: North Carolina Rural Health Research and Policy Analysis Center
Topics: Federally Qualified Health Centers (FQHCs), Health insurance and the uninsured, Health policy, Hospitals and clinics, Medicaid and S-CHIP
Impact of The Medicaid Budget Crisis on Rural Communities: A 50-State Survey
The impact of the Medicaid budgetary crisis on rural communities across the US will be assessed through a 50-state survey of state Medicaid agencies, state Offices of Rural Health and state rural health associations.
Research center: North Carolina Rural Health Research and Policy Analysis Center
Topics: Health policy, Medicaid and S-CHIP
Medicaid Managed Care in Rural Areas: Innovative Case Management Strategies
Research center: North Carolina Rural Health Research and Policy Analysis Center
Topic: Medicaid and S-CHIP
Premium Assistance Programs: Exploring Public-Private Partnerships as a Vehicle for Expanding Health Insurance to Rural Uninsured
This project examines the experience of states that have implemented premium assistance programs in rural areas to determine whether there are certain design features or certain types of rural communities where these programs may be more feasible.
Research center: North Carolina Rural Health Research and Policy Analysis Center
Topic: Health insurance and the uninsured
State Facts about Medicaid: Rural Specific Data
This project will develop state-specific fact sheets which will include information on the groups covered (and income eligibility), structure of the state's SCHIP program, services covered, delivery system, some provider payment information for certain safety net providers, and percentage of the state's rural and urban population that are enrolled in Medicaid. Additional information comparing urban and rural areas of the state will be provided, when available. The rural and urban comparisons will include total numbers of Medicaid recipients, Medicaid expenditures, and enrollment in different types of managed care plans.
Research center: North Carolina Rural Health Research and Policy Analysis Center
Topics: Medicaid and S-CHIP, Rural statistics and demographics
Tracking the Implementation of Medicaid Managed Care in Rural Areas
Research center: North Carolina Rural Health Research and Policy Analysis Center
Topic: Medicaid and S-CHIP

Publications - (12)

  • Best Practices for Health Insurance Marketplace Outreach and Enrollment in Rural Areas
    Fact Sheet
    North Carolina Rural Health Research and Policy Analysis Center
    Date: 12/2014

    The Affordable Care Act provided coverage through the Health Insurance Marketplace to nearly seven million people during the first open enrollment period. Yet, research suggests that the enrollment rates for eligible individuals living in rural areas was less than enrollment rates for those living in urban areas. That may be due, in part, to specific challenges in rural communities, including lack of internet access, low population density, travel barriers to obtaining help, or strong political opposition to “Obamacare.”

    Among rural communities, there was considerable variation in the enrollment rate. The North Carolina Rural Health Research Program conducted key informant interviews of navigators, health centers, Certified Application Counselors (CACs), and other partner organizations in nine rural counties with high enrollment rates in seven states to try to identify best practices for marketing, outreach and education, in-reach (identifying eligible current clients), and enrollment in rural communities.

  • Design of Enhanced Primary Care Case Management Programs Operating in Rural Communities: Lessons Learned from Three States
    North Carolina Rural Health Research and Policy Analysis Center
    Date: 03/2003
    Discusses state programs that provide enhanced benefits to Medicaid beneficiaries such as enhanced primary care case management (PCCM). Examples from three states: Florida, North Carolina and Oklahoma.
  • Effect of Market Reform on Rural Public Health Departments
    North Carolina Rural Health Research and Policy Analysis Center
    Date: 01/2000
    This study seeks to determine how rural health departments and populations they serve have been affected by recent health system changes, especially Medicaid managed care.
  • Geographic Variation in Plan Uptake in the Federally Facilitated Marketplace
    Policy Brief
    North Carolina Rural Health Research and Policy Analysis Center
    Date: 10/2014

    Combines the recently released data on plan selection in the Federally Facilitated Marketplaces with estimates of the population likely to qualify for the marketplace (i.e. “eligibles”) to calculate the percent of potential eligible individuals who chose a health insurance plan (the “uptake rate”). Contains a heat map that shows variation in uptake rates across the country.

  • The Impact of Medicaid Cuts on Rural Communities
    North Carolina Rural Health Research and Policy Analysis Center
    Date: 08/2005
    Medicaid is a critical program in both urban and rural areas, but it is particularly important in rural areas because of high levels of poverty and less access to employer-sponsored insurance. This study assesses the perception of state Medicaid staff and individuals from State Offices of Rural Health (SORH) and Rural Health Associations (RHA) regarding the impact on rural areas of state Medicaid policy changes that occurred between 2002 and 2004. Despite the importance of this program to rural communities, our study suggests that few people are specifically concerned with the unique challenges Medicaid changes may pose to rural communities. This study presents insight to the potential rural impact of Medicaid policy changes, especially those that could adversely affect the ability of rural residents to access services or that might potentially affect the overall rural health infrastructure.
  • Impact Of The Medicaid Budgetary Crisis On Rural Communities
    North Carolina Rural Health Research and Policy Analysis Center
    Date: 08/2003
    Provides an overview of the Medicaid program and options states have to reduce program costs. Steps states have proposed or taken to reduce Medicaid costs and the potential impact of these changes on rural areas are discussed. The potential impact on rural communities of federal proposals to redesign Medicaid is assessed.
  • Innovative Primary Care Case Management Programs Operating in Rural Communities: Case Studies of Three States
    North Carolina Rural Health Research and Policy Analysis Center
    Date: 01/2003
    Medicaid managed care programs have been continually growing in the past decade, but this system has posed some problems to rural areas. In order to address these problems, some states have developed alternative managed care strategies, including enhanced primary care case management (PCCM). This study examines three states that have implemented PCCM and provides an overview of each program including their strengths and weaknesses. The states studied are Florida, North Carolina, and Oklahoma.
  • Premium Assistance Programs for Low Income Families: How Well Does it Work in Rural Areas?
    North Carolina Rural Health Research and Policy Analysis Center
    Date: 01/2006
    Reports results of a study on the viability in rural areas of premium assistance programs use Medicaid or State Children's Health Insurance (SCHIP) funding to subsidize the premium costs of employer-sponsored insurance or private non-group policies for eligible individuals. Because of the characteristics of rural residents and their employment markets, many stand to benefit from premium assistance programs, but there are also reasons to believe that these programs may be less successful in rural communities. Findings form the telephone survey of Medicaid or SCHIP officials in 14 of the 16 states with at least one premium assistance program indicate that premium assistance programs have not lived up to their potential. Enrollment in most of the states' programs has been small, and while positive in concept, these programs have inherent limitations that may preclude more widespread enrollment. Of particular concern is that rural residents are more likely to work for small employers who do not offer health insurance or have higher premiums or less comprehensive benefits. However, with creative program design, premium assistance programs may be a useful tool for states to expand health insurance coverage to the rural uninsured.
  • Rural Medicare Beneficiaries Have Fewer Follow-up Visits and Greater Emergency Department Use Post-discharge
    North Carolina Rural Health Research and Policy Analysis Center
    Date: 09/2015
    Compares rates of post hospital discharge care among Medicare beneficiaries in rural and urban settings. Discusses the effect on policies for follow-up care and readmission penalties.
  • Rural Provider Perceptions of the ACA: Case Studies in Four States
    Policy Brief
    North Carolina Rural Health Research and Policy Analysis Center
    Date: 02/2015

    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.

  • State Profiles of Medicaid and SCHIP in Rural and Urban Areas
    North Carolina Rural Health Research and Policy Analysis Center
    Date: 08/2007
    This final report is one component of a larger project that includes the development of web-based State Profiles of Medicaid and SCHIP in Rural and Urban Areas. The report provides national data comparing Medicaid enrollment and expenditures in rural and urban counties. A summary of these and other data found in the State Profiles is included.
  • Tracking Medicaid Managed Care in Rural Communities: A Fifty-State Follow-Up
    North Carolina Rural Health Research and Policy Analysis Center
    Date: 08/2002
    Updates a 1997 study examining implementation of rural Medicaid managed care programs. Among its findings are that there have been significant state-level changes in the types of programs offered; there has been an overall increase in the percentage of urban and rural counties with Medicaid managed care programs; and SCHIP expansion has had little impact on the operation of fully capitated Medicaid managed care programs in rural areas because the increased number of children covered has not been large enough to affect health plans' participation. Concludes that looking only at the increase in rural Medicaid managed care since 1997 could lead to a false impression. While the number of rural counties with fully capitated programs has increased, states' more recent experiences suggest that health plans are pulling out of rural areas just as they are pulling out of urban ones. States may find it difficult to find commercial HMOs willing to participate in Medicaid managed care at prices that states can afford.