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Even if the rollout of the online federal marketplace had gone off without a hitch, convincing millions of Americans to sign up for insurance wouldn't be easy. That's why the law includes funding for workers trained to help people find their way around the new system. In rural states with populations spread across hundreds of miles, those workers face an especially daunting challenge. Sarah McCammon of Iowa Public Radio reports.
SARAH MCCAMMON, BYLINE: Broadlawns Medical Center in Des Moines has been serving low-income residents of the city and surrounding rural areas for decades. And much like the patchwork system that confronts sick people without health insurance, this public hospital has been pieced together over time. Early-20th-century brick architecture is surrounded by newer wings with modern angles and big windows.
UNIDENTIFIED WOMAN: You would like to speak with a financial counselor?
MCCAMMON: On a recent Saturday morning, Jerrine Sanford came half an hour from the small town of Runnells, Iowa, to an event for people with questions about Obamacare.
JERRINE SANFORD: Because we are not able to afford insurance through our work or anything else right now. So we're trying to get involved in everything that we need to do so we don't get fined and get going with everything.
MCCAMMON: Sanford is 47 and out of work because of a back injury. Her daughter, a single mom, is a nursing assistant but she says she can't afford the insurance offered by her employer. They've been getting insurance through a program for low-income Iowans that's being phased out because of Obamacare. And they've come with questions.
SANFORD: Where our doctors are going to be, what type of enrollment fees we've got, if it covers dental coverage, if it covers eye coverage, hospitalization.
MCCAMMON: With more than 200,000 Iowans lacking health insurance, there are lots of potential questions awaiting to be answered but not many people equipped to answer them. Iowa Insurance Commissioner Nick Gerhart says the state got about $600,000 in federal funding for navigators, workers paid to hold outreach fairs at libraries and community centers and help people sign up for insurance.
NICK GERHART: That's not a lot of money to build up a statewide campaign. You have to hire staff. You have to train staff, hold events. I mean, that's expensive.
MCCAMMON: As of now, Iowa has only about a dozen full-time navigators and a few part-timers with a lot of ground to cover.
GERHART: Especially when you think that some of the navigators are going to try and work in 60-plus counties, I mean, that's a heavy lift for just a few people, quite frankly.
MCCAMMON: Planned Parenthood of the Heartland received a $217,000 to hire a handful of navigators responsible for a broad swath of mostly Southern Iowa. Kyle Carlson is the director of legal and public policy.
KYLE CARLSON: Our goal is to try to sign up 2,000 people through our five navigators, so it's a pretty ambitious goal.
MCCAMMON: Twenty-seven of Iowa's 99 counties don't have a navigator at all. In those areas, people with questions do have some options. They can turn to insurance agents or certified application counselors like Joe Heitritter, the outreach director for a health center that serves four counties in rural northwest Iowa. Heitritter says he's getting some very basic questions about how health insurance works.
JOE HEITRITTER: There's a lot of people who have been uninsured for a lot of years. And so just understanding what health insurance is and what premiums are, what deductibles are and the basics of health care that, you know, someone like me would take for granted is something that can be maybe new to some people.
MCCAMMON: Heitritter has been visiting Head Start programs, churches and food banks, looking for people who need help.
BETTY: Good morning. Betty.
MCCAMMON: And hospitals like Broadlawns in Des Moines are doing what they can to help patients learn about the health care law. Jerrine Sanford leaves her meeting with the financial counselor with a whole new set of questions. She'd hoped to qualify for Iowa's Health and Wellness Plan, a proposed alternative to expanding Medicaid. But she's been told her husband's disability payments may disqualify her.
SANFORD: So we have to wait and see what the decision's going to be and if they're going to switch me over to the health and wellness because we were over by $60...
MCCAMMON: Sixty dollars.
SANFORD: Sixty dollars I was over that didn't qualify me.
MCCAMMON: Sanford says she has tried to shop for other plans on the federal insurance marketplace. But like so many others, she struggled to get the website to work. With her current coverage expiring at the end of the year, she's hoping to have some answers soon. For NPR News, I'm Sarah McCammon in Des Moines.
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