Insurer leaves part of Va. without individual Obamacare plans; Ky. now has just one choice

Two insurers announced this week that they will stop offering individual marketplace insurance in areas of Virginia and Kentucky in 2018. It's a manifestation of insurers' deep uncertainty about the future of health care in America. Congress may still try to repeal the Patient Protection and Affordable Care Act, which established the marketplace exchanges; the Trump administration has cut funding for advertising ACA plans by 90 percent; and President Trump has threatened to withhold the federal cost-sharing subsidies that make it possible for insurers to offer deeply discounted plans for the poor. Insurers have until Sept. 27 to make final commitments for 2018, Anne Mathews reports for The Wall Street Journal.

The first insurer to announce withdrawal this week, Optima Health, will cut its Virginia footprint in half. That means that around 70,000 Virginians will have no insurance options next year unless another insurer steps in to fill the gap, Mathews writes. In other states where all insurers withdrew, others specializing in plans for low-income people have stepped in to fill the vacuums. All U.S. counties in had Obamacare insurance choices as of Aug. 25.

Bloomberg interactive map updated as of Sept. 7. Click on image to enlarge. Click here for interactive version.

Optima, owned by major hospital system Sentara, said in a press release that it would only offer individual insurance in areas supported by Sentara hospitals. "A spokeswoman for Optima Health said that the insurer’s decision was tied to other insurers' withdrawals from Virginia’s exchange, which left the company concerned that it would enroll more people than it could handle if it maintained the broad geographic footprint that it had earlier filed to offer. Anthem, which is withdrawing and pulling back from exchanges in many states, announced on Aug. 11 that it would leave the Virginia marketplace next year," Mathews reports.

Anthem similarly announced on Sept. 6 that it would cut in half the number of Kentucky counties in which it will offer individual Obamacare plans in 2018. "Anthem's decision to sell individual plans in just 59 counties in Kentucky comes more than two months after the Blue Cross Blue Shield insurer filed proposed rates for health plans in 2018 for all 120 counties in the state," Dan Mangan reports for CNBC. "So far, Anthem has announced that it will significantly reduce its Obamacare footprint next year in nine out of the 14 states where it currently sells individual health plans both on and outside of government-run marketplaces." The pullback in those states will not affect Anthem's group insurance or Medicaid plans.

The Kentucky Department of Insurance told Mangan that the areas Anthem is vacating will be covered by CareSource, which specializes in managing Medicaid programs for the poor.

Ky. shows what happens after ACA advertising cut

Proponents of the Patient Protection and Affordable Care Act fear that the recent decision to cut advertising will hurt enrollment for 2018, but Department of Health and Human Services officials argue that the money was being spent inefficiently. It's difficult to determine the truth, but research on the state of Kentucky might offer an indicator, and a roadmap for the future of the ACA under President Trump's administration. "Kentucky provides a great test case for what happens when Obamacare transfers from a supportive administration that goes all-in on enrollment to a hostile one that cuts back on outreach," Dylan Scott reports for Vox.

In 2014, then-Gov. Steve Beshear, a Democrat, embraced the ACA and created of the country's best-working insurance exchanges, or marketplaces. State officials worked hard to encourage as many people as possible to sign up for private coverage or Medicaid; many more were newly eligible for Medicaid because of Beshear expanded it under the ACA. The result? "By the end of 2015, as Beshear's tenure came to a close, Kentucky had tied Arkansas for the biggest drop in the uninsured rate under Obamacare, from 20.4 percent to 7.5 percent in two years," Scott reports.

But in December 2015, Republican Matt Bevin was sworn in as governor. He cut off all state funding for ACA advertising, which led to a four-week enrollment with no ads. "That's where a quartet of researchers associated with the Robert Wood Johnson Foundation and the Wesleyan Media Project come in," Scott reports. "They took a look at the difference between strong outreach for the law and the bare minimum — an imperfect but still telling analogue to what Obamacare will experience nationwide this coming year."

After comparing ACA enrollment in Kentucky with ads vs. without ads, the researchers found that TV advertising was responsible for 450,000 weekly page views and 20,000 unique visitors to the exchange website, but made no notable difference in calls to the exchange's call center. In other words, Scott writes, there's empirical evidence to back up the logical assumption that less advertising leads to less engagement and less enrollment. "That's bad news for the health of the marketplaces," he writes. "Sick people are probably going to find a way to sign up for insurance no matter what. It's the healthier people, whose enrollment is essential to keeping costs down for insurers, who are more the targets of Obamacare advertising."

Lack of doctors and insurers, hospital closures and more make rural health outlook 'grim,' writer says

"In many rural counties, due to a range of contributing factors — including a shortage of doctors, a sicker-than-anticipated population, lack of competition in the marketplace, the closing of hospitals and a raging opioid crisis — the outlook is grim" for health care under the Patient Protection and Affordable Care Act, John Collins writes for the liberal magazine In These Times.

Collins points to the demise of more than half of the state-based health cooperatives that provide price competition for traditional, for-profit insurers; and UnitedHealth Group's recent decision to pull out of most state Obamacare exchanges next year, coming after "other insurance providers have abandoned their less profitable rural exchanges." He notes the Kaiser Family Foundation estimate that 11 percent of policyholders will be in counties with only one insurer, and 18 percent will be in counties with two — up from 2 percent and 13 percent, respectively.

"By early 2017, The Wall Street Journal reports, it is estimated that in more than 650 counties — 70 percent of which consist of rural populations — only one option for health care coverage will be offered on the ACA exchanges," Collins writes. "According to Inovalon, the health-care information and technology firm . . . cited in the WSJ piece, rural exchanges are having trouble realizing a profit for two reasons—people are requiring more care (they’re sicker) than anticipated and the cost of that care is significantly more than it is in urban areas."

At the end of his story, Collins looks ahead and then puts his tongue in cheek: "The next administration will ultimately decide whether this six-year-old law gets put into therapy, replaced by a single-payer healthcare system for all Americans, or triumphantly repealed and replaced with something so fantastic that you can’t even imagine how good it is going to be."

Journalists' guide to covering the second open enrollment under the federal health reform law

The Patient Protection and Affordable Care Act's second annual open enrollment period has started and brings with it many changes. Journalists play a critical role in the process because "Obamacare" remains controversial and there are many nuances that can be obscured, especially because this year's enrollment period is shorter. For a journalists' guide to covering the topic, click here.

If a state doesn’t operate its own exchange for health-care benefits, citizens who want to get covered should visit the federally-run exchange, HealthCare.gov. For the 2015 plan year, 27 states with federally facilitated exchanges, seven states in partnership with the federal goverment and three state-based exchanges will use this site. Click here to check the status of specific states.

Whether they buy a plan through the federal marketplace or an exchange in their state—or qualify for Medicaid—everyone must enroll in a plan or pay a penalty. Even those who purchased plans in the marketplace last year must re-enroll and purchase or select another plan this year because plans have changed and premiums are determined by age and other factors that can change.

Two types of subsidies are available to marketplace enrollees. The premium tax credit reduces enrollees’ monthly payments for insurance coverage. The cost-sharing subsidy is designed to minimize enrollees’ out-of-pocket costs when they go to the doctor or have a hospital stay. Here is a useful Kaiser Family Foundation brief that explains the subsidies.

Here is the foundation's embeddable Health Insurance Marketplace Calculator:

Obamacare has passed the first big hurdle, but many more remain; impact differs from state to state

Monday was the deadline for starting open enrollment for policies offered through the health-insurance exchanges created under the federal health-reform law, and there were signs that final-day rush of signups pushed the total close to the Obama administration's goal of 7 million. But it remains to be seen how many of those people actually pay their premiums and how many of them are young people whose participation is considered essential to the law's success.

"With millions of people signing up, the law has cleared one long, difficult set of hurdles and has defied the darkest predictions of its critics. But that doesn't mean it's out of the woods entirely—it's just on to the next long, difficult set of hurdles," writes Sam Baker of the National Journal. "The national total doesn't say much about of the law's sustainability or what happens to premiums next year. Premiums will go up, because premiums go up every year. The size of next year's premium increases depends on enrollment and demographics in each state, and even within specific regions of each state. Some states are faring better than others," as the Kaiser Family Foundation map below shows.

"Generally, if the risk pool in a particular market turns out older and sicker than expected, insurers are more likely to raise their premiums," Baker writes. "We don't know precisely what insurers expected—they all priced their plans independently, and the law includes several programs designed to absorb any surprises and keep premiums as steady as possible. In competitive markets, insurers likely will try to keep increases to a minimum, but industry insiders caution that hikes are looking likely, at least in some parts of the country."

"The biggest question by far," said Drew Altman, president of the Kaiser Family Foundation, is how people will like their plans, and the proportion of winners (those who couldn't get affordable coverage) to losers (those who had to get more expensive policies that may not include their doctor or preferred facility). But even the winners might "sour on their coverage" as they have to pay thousands of dollars in deductibles before full coverage kicks in, Baker writes.

Charles Ornstein of ProPublica has a good look at how the success or failure of Obamacare can be judged. Chris Cilliza of The Washington Post has a good set of charts illustrating the politics of the law. For a look at how Obamacare was embraced by ruling Democrats in Kentucky, a state with a large rural population, and how it may backfire on them in upcoming elections, read this story by Louisville native and former Post political reporter Perry Bacon Jr. of Yahoo News.

Rural editor-publisher wonders why so many of his uninsured neighbors haven't signed up for coverage

With open enrollment in the new health-insurance exchanges ending March 31, at least one rural editor wonders why most people in his community who lack coverage haven't take advantage of the historic opportunity. And since he's in Kentucky, he used the state's next-to-last ranking in the latest Gallup-Healthways Well-Being Index as the point of departure for an article that took up most of his editorial page.

"Kentucky is its own worst enemy . . . and if you think this is just an Eastern Kentucky problem, you aren't paying attention," Editor-Publisher Ryan Craig, right, wrote in last week's Todd County Standard, in Western Kentucky. "Our numbers suggest we are as miserable as anywhere in the state, i.e., the nation." Craig then listed statistics for poverty, income, education and health insurance and said bluntly, "We are near the bottom in all of these categories, which are the same categories that cause Kentucky to have such a dismal ranking in the Miserable Test year after year."

Craig said Todd County, "it seems, is among the bottom of counties who signed up for the Affordable Care Act," and wondered why only 533 of the estimated 2,455 people in his county without health insurance have signed up for it: "Is it because of fear of the unknown? Politics?" President Obama got only 29.7 percent of the county's vote in the 2012 election.

"The prevailing answer people tell me is that they would rather pay the tax penalty and not have the insurance," Craig reported. "What would happen if that person or someone in their family was in a car wreck? They readily admit that they are taking a big chance, but don't see how they can afford the insurance even when it is cheaper now, especially those who are very sick and couldn't get insurance before." One man told Craig he would have to declare bankruptcy.

"The deadline to apply for health insurance through the exchange is March 31," Craig wrote. "If you don't have insurance, at least consider the process." The Standard has been judged Kentucky's best small weekly newspaper seven years in a row, but doesn't put news or editorials online. For a scan of the editorial as a PDF, click here.

Poorer counties have fewer options for health insurers, making their premiums higher

The Patient Protection and Affordable Care Act is making health insurance more affordable for millions of Americans, but leaves it still out of reach of millions more. Perversely, that is more likely to be true in poorer counties, according to an analysis by The Wall Street Journal of the 36 states using the federal health-insurance exchange.

Hundreds of thousands of Americans in 515 lower-income counties in 15 states have only one option in the exchange, and the lack of competition forces them to pay high premiums, Timothy W. Martin and Christopher Weaver write for the Journal. In 80 percent of those counties, the only insurer is an affiliate of Blue Cross & Blue Shield. For the Journal's interactive, county-by-county database, click here.

"Residents of wealthier, more populated counties in the U.S. receive lower-priced choices than those living in counties with a single insurer," Martin and Weaver report. In counties with one insurer, the average price for a 50-year-old to purchase a silver plan, the one most commonly sold, through the marketplace was $406. In contrast, citizens in counties with four insurers could purchase a silver plan for an average of $329. This phenomena represents the tactics of insurers who avoid areas with unemployment problems and high numbers of unhealthy residents, the reporters write.

For example, Aetna Inc. and UnitedHealth Group Inc. offer services "in more counties outside of the marketplaces, where plans are sold directly to consumers and federal subsidies aren't available," they write. Rebecca Stephens found out that she only had one health insurer option in Hardee County, Florida, and the plan she wanted to purchase would cost her approximately $200 more per month than a comparable plan in Tampa. "That is costs me more for health insurance than someone in Tampa doesn't seem equal to me," she told the Journal.

Coverage prices were higher in rural places even before health reform. Jon Urbanek, a senior vice president at Florida Blue, cited shortage of hospitals and doctors as a key reason for the higher premiums. "Our costs are higher," he said. "The premiums we charge reflect the cost of the providers." People in smaller cities and suburbs, too, are often limited to fewer choices and subject to higher prices. "From a consumer's standpoint, it's unfair," said Dylan Roby, a program director at UCLA's health policy research center.

Glenn Melnick, a health-care economist at RAND Corp., thinks areas with low populations will not easily attract additional insurers. "I don't think the health law can overcome those economics," he said. The Congressional Budget Office reported that approximately 20 million Americans can get income-based tax credits to reduce health insurance costs; some brokers and insurers think these subsidies will negate the price disparities for some people. Russell Childers, an insurance broker from Americus, Ga., told the Journal, "Most people are receiving a high enough subsidy for coverage that they don't care." (Read more)

Rural obstacles to Obamacare: few providers, lack of broadband, negative talk and misinformation

Enroll America booth (NPR photo: Eric Whitney)

Residents of some rural areas are not buying into federal health reform. They have expressed doubt and fear about Obamacare because of a lack of primary care physicians, a lack of insurance providers and hospitals, or because they don't qualify for benefits in states not expanding Medicaid. Also, Melissa Nelson-Gabriel reports for The Associated Press, many residents in conservative rural areas are being bombarded with negative viewpoints from friends, neighbors and conservative media, and fear the law based on those opinions.

That has caused problems for people like Christopher Mitchell, a marketing director for a network of nonprofit health clinics in Florida. He told Nelson-Gabriel, "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. But when people are hearing over and over and over that is bankrupting America, it is hard to break through." The Congressional Budget Office has estimated that the law will save money by reducing health-care costs in the long run.

But it's easy for rural residents to be wary of the act, with all the hurdles they face -- long drives to doctor's offices, lack of broadband to enroll online, and the many stories about people having trouble signing up, Nelson-Gabriel writes. Kathy Bannister, a 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," thanks to some outside help after several failed attempts to do it herself online, Nelson-Gabriel writes. Bannister told her "The whole idea was to make it easier for people. I'd been calling and calling and calling, and a lot of people would have given up. It's discouraging." (Read more)

UPDATE, Jan. 7: Understanding how Obamacare is working, or not working, is difficult because "We have no central clearing house" for information, writes The Washington Post's Sarah Kliff, who is doing the most consistent and comprehensive tracking of the question. She says that creates "what I like to think of as the battle of the anecdotes," which can illustrate how the law is affecting individual Americans, "but they can also be a really terrible way to gauge whether Obamacare is going great -- or is a complete disaster." (Read more)

Farm-paper editor identifies self-employed folks' problems with Obamacare, and hers with Congress

Farmers and other self-employed people may have special trouble maneuvering through the process of obtaining health insurance on HealthCare.gov or a state-run exchange, writes Sharon Burton, editor and publisher of The Farmer's Pride, Kentucky's statewide agricultural newspaper.

Sharon Burton

"The first thing I realized is the system doesn’t know how to deal with people who are self-employed," Burton writes. "I figure that’s just about every farmer in the commonwealth" of Kentucky, which is operating its own exchange, Kynect.

"My husband is a owner/operator commercial truck driver, so his income can fluctuate from year to year. When I adjusted our income based on that fluctuation, the system was not happy with me because I estimated our 2014 income to be different than our 2012," Burton writes, adding that her kynector, a state-paid adviser who helps people use the exchange about it, "She said she too had problems signing up anyone who was self-employed. She also warned me that we should notify Kynect if our income varied even within $1,000 or could face serious ramifications at the end of the year."

Kynect spokeswoman Gwenda Bond told Kentucky Health News, "If self-employed individuals have variable incomes there might be an extra step for them to accurately verify income. They would have to submit additional information, in some cases, because the income verification system accepts the amount reported only if it is within 10 percent of what the IRS has on file for the most recent year."

Burton adds, "There are a lot of bugs in the system. For one, if your spouse’s employer offers family coverage – even if they don’t pay any portion of it – you are not eligible for any subsidies. We all know insurance offered through companies often provides family coverage but it isn’t affordable.
Now you will be disqualified from Obamacare because that unaffordable plan is out there."

Burton has also lost patience with Congress. "The ones who voted for it spend all their time defending it, and the ones who voted against it spend their time trying to make sure it fails," she writes. "Just fix it people. Get on with it. It’s like starting a business. You have a plan, but where you end up often looks a lot different than where you start because you make changes as needed. This is a starting point; let’s move on to the next stage and stop bellyaching." (Read more)

Thursday webinar on covering ACA to focus on baby boomers and Medicare beneficiaries

The Kaiser Family Foundation's series of informative webinars for journalists covering the Patient Protection and Affordable Care Act continues Thursday from 12:30 to 1:30 p.m. ET. The fifth installment of the webinar will concentrate on how the act affects baby boomers and Medicare beneficiaries. Kaiser senior fellow Karen Pollitz "will focus on the ACA’s role for baby boomers who are not yet 65, and eligible for Medicare, and their access to new coverage options in marketplaces and/or their eligibility for premium subsidies or Medicaid expansions." Dr. Juliette Cubanski, an associate director of the Program on Medicare Policy at Kaiser, "will talk about how the ACA impacts Medicare benefits and beneficiaries." Most of the hour will be questions and answers. 

Journalists who want to register can RSVP by clicking here. Shortly after registering, each participant will receive a confirmation email that contains information about how to join the webinar. If you are unable to join this webinar but would like to receive all future updates about the series, you can email your name and media affiliation to acawebinars@kff.org. Video and transcripts are also available for the other webinars: “What Do Consumers Need to Know About Health Reform’s Changes,” “Understanding Insurance Premiums Under the Affordable Care Act," "The Impact of State Decisions," and Researching Consumer Stories, Finding New Ideas & Securing Real World Examples.

Thursday webinar for journalists on Affordable Care Act to focus on ways to approach stories

The Kaiser Family Foundation's informative series of webinars for journalists about the Patient Protection and Affordable Care Act continues Thursday from 12:30 to 1:30 p.m. ET. This webinar will focus on "approaches to covering this complex story by incorporating individual examples; provide tips and techniques for digging into the details of the law (with expert help) to describe how its provisions play out in real life; and suggest new angles and under-reported story ideas. Additionally, they will identify upcoming policy deadlines and timelines and explore how to weave these into your stories over the next several months," according to Kaiser. The event will be hosted by Kaiser staff writer Sarah Varney and Michelle Andrews, who writes a weekly health column for The Washington Post.

Journalists who want to register can RSVP by clicking here. Shortly after registering, each participant will receive a confirmation email that contains information about how to join the webinar. If you are unable to join this webinar but would like to receive all future updates about the series, please email your name and media affiliation to acawebinars@kff.org. Video and transcripts are also available for the first three webinars, “What Do Consumers Need to Know About Health Reform’s Changes,” “Understanding Insurance Premiums Under the Affordable Care Act" and "The Impact of State Decisions."

Lack of insurance providers and hospitals in rural areas lead to higher premiums under Obamacare

The Patient Protection and Affordable Care Act was designed to make it easier for uninsured Americans to buy insurance at an affordable rate. But the exact opposite is happening in rural areas, where a lack of insurance providers has eliminated competition between insurance companies, leading to higher prices, Reed Abelson, Katie Thomas and Jo Craven McGinty report for The New York Times. In the roughly 2,500 rural counties served by the federal exchange, 58 percent have plans offered by only one or two providers, and people in 530 counties only have one choice for a provider. A state-by-state interactive map is available by clicking here.

"In rural regions, several factors combine to create a landscape that is inhospitable to newcomers," the Times writes. "Developing relationships with doctors and hospitals can be costly where cities and towns are widely scattered and the pool of potential customers is small." States such as Wyoming, with a population of 600,000, are in a difficult situation. Tom Hirsig, Wyoming’s insurance commissioner, told the Times, “I think the problem was that the Affordable Care Act was designed for where the majority of the people live, in the big cities where there’s a lot of competition among health care providers. You’ve got to have some bargaining chips, and we don’t have that much."

Many rural areas only have one hospital, "giving insurers little leverage when negotiating reimbursement rates," the Times writes. "Only one Wyoming county is served by more than one hospital, said Stephen K. Goldstone, the chief executive of WINHealth. In southwest Georgia, another rural region, Blue Cross and Blue Shield of Georgia is the dominant carrier, and it is the only insurer operating in 54 of the state’s 159 counties. Only one carrier, Highmark Blue Cross, is offering coverage in West Virginia, which has high rates of obesity and chronic diseases like diabetes." (Read more; NYT chart shows states on federal exchange)

Thursday webinar on health reform to look at state decisions on coverage and financing

The third in a series of informative webinars for journalists about the Patient Protection and Affordable Care Act is scheduled from 12:30 to 1:30 p.m. ET on Thursday. The Kaiser Family Foundation webinar will look at where states stand on implementation and the impact of state decisions on coverage and financing. The event will be hosted by Robin Rudowitz and Rachel Garfield, associate directors for the foundation’s Kaiser Commission on Medicaid and the Uninsured, who will give a short presentation before answering questions.

Journalists who want to register can RSVP by clicking here. Shortly after registering, each participant will receive a confirmation email that contains information about how to join the webinar. If you are unable but would like to receive all future updates on the series, please email your name and media affiliation to acawebinars@kff.org. Video and transcripts are also available for the first two webinars, “What Do Consumers Need to Know About Health Reform’s Changes” and “Understanding Insurance Premiums Under the Affordable Care Act.”

Watch out for specious claims and defenses of Obamacare in highly politicized debate

The biggest story in the country is about to be Tuesday's opening of online health-insurance marketplaces, or exchanges, under the federal health reform law. "Obamacare" has been politicized from the start, and the current debate has featured several specious claims that journalists should be on the lookout for as they report, edit, present and choose commentary (including letters to the editor and person-on-the-street interviews) on the subject.

"There’s plenty of fodder for fact-checkers in Sen. Ted Cruz’s looong attack on Obamacare, and in President Obama’s defense of it," says FactCheck.org, the oldest of the nonpartisan political fact-checking services. It says the Texas Republican falsely claimed that spouses of United Parcel Service employees will be “left without health insurance” and forced into “an exchange with no employer subsidy.” UPS is dropping coverage only for who can get insurance with their own employer.

Conversely, "Obama greatly exaggerated when he credited the health care law for bending the cost curve on health care spending," FactCheck says. "Experts say the down economy is the overwhelming reason that national health care spending has been growing at historically slow rates in recent years."

FactCheck also took on Cruz ally Sen. Rand Paul (R-Ky.) for saying “everybody is going to pay more” for health insurance under the Patient Protection and Affordable Care Act. "The fact is, some will pay more and some will pay less," the service says. "Some currently uninsured Americans will pay little or nothing because of the law’s expansion of Medicaid."

As usual, FactCheck has a detailed accounting for its analyses, with plenty of references, here.

Webinar on health reform at 12:30 ET tomorrow; you must sign up in advance

The second in a series of webinars for journalists covering the Patient Protection and Affordable Care Act will be held tomorrow from 12:30 to 1:30 p.m. ET. This one will look at insurance rates and plan offerings in the new state-based marketplaces known as health benefits exchanges.

The co-directors of the Kaiser Family Foundation's program for the study of health reform and private insurance, Senior Vice President Larry Levitt and Vice President Gary Claxton, will give a brief presentation on the early reports of rates, how and why they vary, and what consumers would pay after taking tax credits into account. They will also answer journalists' questions about the new insurance market rules taking effect in 2014, and how to interpret insurance rates.

Journalists who want to register for the September 10 webinar can RSVP by clicking here. Shortly after registering, each participant will receive a confirmation email that contains information about how to join the webinar. If you are unable to attend the second webinar, but would like to receive all future updates on the series, please email your name and media affiliation to acawebinars@kff.org.

During the webinar series, participants are welcome to continue the conversation on Twitter with the hashtag #ACA101KFF. Archived video from the first webinar, "What Do Consumers Need to Know About Health Reform's Changes," is available on the foundation website. For more information, contact Victoria Chao at 650-854-9400 or the email address above.

Find out how many people in your county have health insurance and how many don't

With enrollment in state health-insurance exchanges four weeks away, the Census Bureau has just issued some very useful information for rural journalists: county-by-county figures, by age group, on Americans with and without health coverage.

Even better than maps like the one above is an interactive tool that allows you to map and rank counties by various factors. A little clicking reveals that Esmeralda County, Nevada, probably has the highest percentage of children without health insurance, 32.2 percent. We must say "probably" because the small samples for each county create high error margins, in Esmeralda's case plus or minus 6 percentage points. It is followed by Sherman County, Texas, 28.3 percent; Aleutians East Borough, Alaska, 27.9; Briscoe County Texas, 27; and Garfield County, Mont., 26.7. Texas dominates the top 50.

The most important numbers are for all Americans under 65, who do not qualify for Medicare. Aleutians East leads with 46 percent uninsured, followed by four Texas counties: Hidalgo, Hudspeth, Presidio and Webb, all between 39 and 36 percent. The data are from 2011, the last year available; data going back to 2006 allow you to check trends among states during those six years. Here is an example of a statewide story, mentioning individual counties.

The data can also be sliced by income levels: less than 138 percent of the federal poverty line, the new eligibility threshold for Medicaid in states that have expanded it; and less than 400 percent of the poverty line, the threshold for subsidies for insurance policies that the exchanges will offer. And you can create your own state-by-state maps, suitable for publication. The Census site is here; the interactive tool is here. To get county data, limit the geography to a state and check the Show Counties box.