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Going Local: Where are Southerners signing up for health insurance—and what's next?

Going Local: Where are Southerners signing up for health insurance—and what's next?

The South as a region is booming—and not necessarily for the reasons you might think. Despite the region near unanimously rejecting one of the core components of the Affordable Care Act—Medicaid expansion (except Kentucky)— we now know there were many hot spots of individuals and families securing health insurance coverage, many for the first time.

Recently published health insurance enrollment data from the federal government reveal the number of individuals who completed an application and selected a plan by zip code. The numbers show that while some states’ enrollments are strong, many metropolitan areas still have lots of people left uninsured—while the region has minimal support to find them, and some of those who already signed up will have to re-enroll if they want to change their coverage.

Using Enroll America’s methodology, found here, we created county estimates of health insurance enrollments for the South (county enrollment data for Kentucky, which operates a state-based marketplace, was found here).

Look at how enrollment compares to the number of potentially eligible individuals. While there are some limitations in this methodology, we were able to visualize the “hot-spots” for health insurance enrollment.


The map above confirms some of what we already knew: ACA health insurance enrollment in the South is concentrated in Florida, Texas, and North Carolina. These states are home to 64 percent of potentially eligible people and 66 percent of Marketplace enrollees. A metro and non-metro county break-down shows that 84 percent of individuals eligible for marketplace coverage reside within metros, compared with only 16 percent in non-metro areas.

Surprisingly, enrollment figures didn’t follow the eligibility patterns as strongly as we anticipated. Only 65 percent of marketplace enrollees live in metro areas; 35 percent were in non-metro areas. In fact, the top-15 metros (as shown on the chart below) accounted for 35 percent of allhealth insurance enrollments in the South.

These figures have implications for the second and more compressed Open Enrollment Period (November 15, 2014–February 15, 2015). Except for Kentucky, every Southern state declined to run a state-based marketplace, which means they don’t have access to the accompanying federal dollars to support in-person assisters, marketing efforts, and outreach capacity.

With these resource constraints, outreach and in-person assistance to both metro and non-metro areas will be stretched thin. North Carolina received a limited amount of funding given to nonprofit organizations to conduct outreach and enrollment efforts through federal navigator grants and grants to local health centers. MDC is part of a statewide consortium, led by Legal Aid of North Carolina, that received second-round funding to conduct outreach and enrollment activities throughout the 2014-15 fiscal years. In contrast, California, which set up a state exchange, received $155 million in 2014 to support outreach and marketing efforts to eligible populations and to further develop state-wide management of the initiative.

In-person assisters in the South will be challenged to re-enroll previous clients (those who want to re-evaluate their options as opposed to being auto-renewed), and to extend outreach and enrollment efforts into those areas that under-performed, making it difficult to build a strong foundation for the long-term future of the Affordable Care Act and expand health care access across the South.