By Renuka Rayasam

AUSTIN, Texas — Texas has two realities when it comes to Obamacare. It’s home to urban counties with among the highest enrollment in the country, and to two of only four rural counties nationwide with not a single enrollee in the federal health insurance exchange.

As the Affordable Care Act’s fifth open enrollment season gets underway, the divide between urban and rural Texas is set to further expand. Confusion and uncertainty are roiling markets, and residents living in the smallest towns lack access to information about when and how to select an appropriate health plan. Some who do shop their options are finding policies that come with narrow provider networks and high prices.

The Trump administration has cut its budget for national Obamacare advertising by 90 percent this year, and support for local groups that help people sign up for health plans by almost half. Unlike blue states like California and New York, Texas, which actively fought the ACA since its inception, isn’t taking steps to boost enrollment among its residents. The state is one of 19 that didn’t expand Medicaid and one of 34 that relies on the federal exchange,

People living in rural Texas are hit hardest by the state’s anti-Obamacare stance. At 16.6 percent, the state has the highest uninsured rate in the country.

“Since the state of Texas is so indifferent, it is more difficult for those in rural areas and small towns to get assistance,” Rep. Lloyd Doggett (D-Texas) told POLITICO.

Doggett, who attended an open enrollment event in Austin on Monday, said the lack of state support means people in remote parts of Texas won’t have the assistance those in more populated cities get in signing up for coverage.

“Texas officials appear to be doing nothing to promote enrollment, while other states, like California, are investing millions to get folks covered,” he said.

In Texas’s big cities, where Obamacare enrollment is high, local groups are stepping up to fill the void left by the federal government.

Houston-based Legacy Community Health, a federally qualified health center with 32 clinics in Southeast Texas, launched for the first time a $25,000 radio and social media campaign in English and Spanish to combat confusion among potential enrollees about the status of the health law.

In Harris County, which includes Houston, 240,000 people had Obamacare plans this year, making it third in the nation for signups. Four insurers are offering plans in the city.

“We’re the only ones talking about signing up for the Affordable Care Act,” said Kevin Nix, director of communications at Legacy Community Health. “The energy around [open enrollment] and the volume and decibel level — we need to increase that.”

Meanwhile, without national advertising, rural residents in sparsely populated areas have little information about open enrollment.

Groups working in rural Texas say that because the administration and events in Washington have been sowing confusion, many enrollees in rural parts of the state may not realize open enrollment has started and are in the dark about plan changes.

“Many farmers still do their books on notepads,” said John Claborn, who runs an insurance agency in Lubbock. “They are the ones out in the cold.”

Nearly 25 counties in the state have fewer than 100 enrollees. With local health care groups focusing their efforts on larger population centers, rural counties are particularly at risk of losing out on even modest coverage gains under the ACA. At the same time, because of limited employment, rural residents are more dependent on exchange coverage than their urban counterparts.

Don McBeath, who heads the state’s rural hospital association, said that unlike big city hospitals in Austin or Dallas that have mounted coordinated campaigns to boost Obamacare enrollment, rural hospitals do not have the “staff or resources” to do so.

One exception: the Sutton County Hospital District. This year Sutton County had 159 Obamacare enrollees.

The hospital district pays for a radio spot once a week and a local newspaper ad, but CEO John Graves and others working in rural Texas say that despite their efforts they have seen more people in rural parts of the state give up on exchange plans.

Those familiar with the health plans being offered for 2018 are less than thrilled about fewer options and rising prices. Nearly 100 of the 254 counties in Texas have only one insurer.

Others have become frustrated by insurers’ narrowing networks. Health plans available in rural counties may not cover local health care providers, requiring people to drive long distances to receive in-network coverage at bigger city hospitals.

And for rural residents who don’t qualify for subsidies, plans have simply become too expensive.

“People are choosing not buying health care,” said Graves. “They pay the penalty and pray that their family stays healthy.”

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