The Affordable Care Act provided coverage through the Health Insurance Marketplace to nearly seven million people during the first open enrollment period. Yet, research suggests that the enrollment rates for eligible individuals living in rural areas was less than enrollment rates for those living in urban areas. That may be due, in part, to specific challenges in rural communities, including lack of internet access, low population density, travel barriers to obtaining help, or strong political opposition to "Obamacare."

Among rural communities, there was considerable variation in the enrollment rate. The North Carolina Rural Health Research Program conducted key informant interviews of navigators, health centers, Certified Application Counselors (CACs), and other partner organizations in nine rural counties with high enrollment rates in seven states to try to identify best practices for marketing, outreach and education, in-reach (identifying eligible current clients), and enrollment in rural communities.