FREEPORT, FL - In this rural part of the Panhandle, Christopher Mitchell finds few takers when he delivers his message about the importance of exploring insurance options under the federal health overhaul.
People in the conservative-leaning area tend to have a bad impression of President Obama's signature law because of negative messages they hear on talk radio or from friends, said Mitchell, marketing director for a network of nonprofit health clinics. Even for those with insurance, a doctor's visit may require a long drive because there are few providers in the area -- and some are selective about the coverage they accept.
Around the country, advocates spreading the word about the Affordable Care Act in rural areas face similar difficulties. Coupled with the well-publicized glitches for the online insurance marketplaces, their stories illustrate the broader challenges in meeting President Barack Obama's goal of reducing the number of uninsured in places with some of the highest percentages of uninsured residents.
"I tell people that I am not here to advocate for the law, I am here to support the law and empower people to be able to use and understand the law," said Mitchell, whose employer, PanCare of Florida, received a federal grant for outreach efforts. "But when people are hearing over and over and over that is bankrupting America, it is hard to break through."
On a recent afternoon, Mitchell made his pitch to half a dozen patients in the waiting room of a low-slung brick clinic surrounded by pine trees on the two-lane state road that serves as Freeport's main street. In areas like this -- where one-story houses and mobile homes sit far apart on lots of tan, sandy soil and pine needles -- many poor residents could benefit from federally subsidized health insurance but aren't open to it.
Among those unconvinced by Mitchell's pitch was Laressa Bowness, who brought her father to the clinic for dental care.
"I get frustrated because I hear so much stuff. The politicians who put the system into place have lost their sense of reality. They don't understand what people who work face," said Bowness, who added that most people she knows don't have health insurance because they simply cannot afford it.
In a sparsely populated area of Michigan, retired nurse Sue Cook crisscrosses the 960-square mile Sanilac County to help people sign up for insurance through the online exchange. The spread-out county has only 42,000 residents.
"There are many challenges we're facing right now," said Cook, who leads an all-volunteer team of health care professionals at Caring Hearts Clinic in Marlette, 65 miles north of Detroit. "You've got somebody in the northeast part of the county that has no transportation to get here to even sign up.
"We're finding that even if I go to the far end of the county, there's the issue of not having Wi-Fi to hook up to," she said. "Those are huge hurdles for us to try to conquer in a large county like this."
Kathy Bannister recently signed up with Cook's help after many failed attempts. The self-employed beautician secured a plan from Blue Cross Blue Shield of Michigan with a monthly payment of $215 after subsidies. She now pays $500 for a comparable plan from the same insurer.
"The whole idea was to make it easier for people," said Bannister, 51, who had a heart-valve replacement 13 years ago. "I'd been calling and calling and calling, and a lot of people would have given up. It's discouraging."
To the north, Nick Derusha is director of the health department for four Upper Peninsula counties with a high rate of uninsured residents: Mackinac, Luce, Alger and Schoolcraft. The region covers a vast expanse but only consists of about 35,000 people.
Barriers faced by people in the area include a shortage of health workers, a lack of transportation and Internet and cable connectivity.
"There are many barriers to care, as well as health care coverage alone," Derusha said.
Rudey Ballard, an insurance broker in Rexburg, Idaho -- population 25,000 -- has been selling health care policies for two decades. In addition to his brokerage downtown, his six-person office staffs a small kiosk at the local Wal-Mart, just down the hill from The Church of Jesus Christ of Latter-day Saints temple that dominates the rural skyline.
Rexburg is Republican country -- all local lawmakers are GOP, and residents voted overwhelmingly for presidential candidate Mitt Romney in 2012. Ballard sometimes finds himself the target of criticism when he's manning the Wal-Mart booth.
"I've actually had people come up to me and boo me," he said. "They come up to me and go `Boo, hiss. Boo, hiss. I will never sign up that."'
Back in Florida, Mitchell had no takers during his afternoon of trying to get people to sign up. Some in the small waiting room told him that even with federal subsidies they would face a choice between utilities, food, gas or monthly health insurance. One woman asked Mitchell about the fine for not having health insurance. She laughed and said the $95 is much more affordable than a monthly health insurance bill.
Walton County, with about 58,000 residents, stretches from the Gulf of Mexico in the south to the Alabama border in the north. While there are wealthy neighborhoods along the coast, most of the county looks more like Freeport. For the ZIP code surrounding the town, census data shows that the median household income is around $43,000 and the poverty rate is around 12 percent.
Because Florida opted not to take additional funding from the federal government to expand Medicaid coverage, many people who would qualify for Medicaid under the federal guidelines do not qualify under the state's guidelines. People can appeal their Medicaid eligibility and seek help in reducing insurance premiums, but that doesn't always work.
Florida Blue, the state's Blue Cross Blue Shield network, is the only insurer providing coverage in all of the state's 76 counties. Kevin Riley, the company's vice president, said serving rural Florida can be a challenge.
"It is tough in part because of the distances people have to drive in those large, rural counties to reach providers," Riley said.
The company has held town-hall style meetings throughout the state and has sent representatives to Wal-Marts in rural areas to discuss coverage with customers.
"There are two or three counties that only have one hospital and is a difficult piece," he said.
Walton County residents have 13 plans to choose from under the Affordable Care Act with monthly premiums ranging from $232 to $402 and deductibles from $850 to $12,700 for a 40-year-old male, according to information from Florida Blue.
The county has seven to 12 physicians for every 10,000 residents, but the vast majority of doctors is in the southern part of the county, according to a study by the Florida Department of Health. The leaves residents of rural areas north of Interstate 10 with a long drive to reach providers. Florida as a whole averages 22 physicians for every 10,000 residents, according to the 2012 study.
Part of PanCare's strategy is employing people like Joe Manning, a lifelong resident of the Panhandle who knows many people in the small towns in Walton County.
Manning said the key to finding coverage in rural Florida seems to be patience and a willingness to fill out all of the forms that might help someone get a reduction in premiums. But a mistrust of both government and technology can complicate things.
"You have to be willing to go through the whole process," he said. "Some people walk away as soon as you start asking them to put their personal information in the computer. They do not trust the government with that information."