PRAIRIE VILLAGE, KS — Back when Al Cross was a newspaper reporter, he now admits, “I avoided healthcare stories like the plague. I just didn’t want to take the time to learn about it.”

Now, as the director of the University of Kentucky’s Institute for Rural Journalism and Community Issues, the former Louisville Courier-Journal scribe spends much of his time trying to convince small-town editors and reporters not to make the same mistake he did.

But, he says, “It’s a Sisyphean struggle.”

As implementation of the Affordable Care Act moves along, the law has far-reaching and sometimes unique implications for rural communities—yet few rural newsrooms seem ready or able to cover the story in all its complexity.

Cross and one of his students, Justin Richter, recently conducted a content analysis of ACA coverage in Appalachian Kentucky, “one of the unhealthiest and poorest regions of the country.” They found that newspapers there “gave their readers limited information” about the law in the two months leading up to the launch of the online insurance exchanges on Oct. 1, and coverage “was dominated by opinions of public officials, largely those opposed to the law.”

“Opinion almost outran news,” Cross says, “and almost one-fourth of the coverage consisted of the opinions of Mitch McConnell”—the Republican Senate minority leader who is running for reelection in Kentucky—either in the form of guest columns or stories recording his views on the health law.

Here in the Midwest, a corresponding review of ACA coverage in smaller communities would reveal similar patterns—a surplus of opinion, often in the form of guest editorials and video news releases from politicians, and a dearth of unbiased, explanatory reporting on the law and its effects.

And those effects are multifaceted. Rural Americans are more likely to be underinsured and low-income—and in a position to benefit from ACA subsidies. But rural areas also tend to have fewer options when it comes to doctors, hospitals, and insurers—scarcities that the ACA mandates and other reforms could exacerbate. Kansas, Nebraska, and Missouri, like many other “red” states in the Midwest and South with large rural populations, so far have refused to accept the ACA’s Medicaid expansion, leaving many low-income residents still unable to get affordable insurance. And these health coverage gaps are mirrored by media-coverage gaps, which the local politicians who drive much media coverage aren’t eager to help fill.

“I would say that health policy issues in general, particularly the ACA … have been very unevenly covered in Kansas,” says Mike Shields, managing editor of the nonprofit Kansas Health Institute news service, one of the few outlets in the region to have done sustained, in-depth Obamacare coverage.

Where to look, and what to ask

In fairness, every small-town or even regional newsroom has limited resources, and a set of editorial priorities that doesn’t typically include national political issues.

“Virtually every community newspaper in this country is interested in covering only their community, and they leave larger issues to the larger papers,” Cross says. “Their coverage tends to stop at the county line or the township line.”

But as California-based columnist Joe Mathews argued last month, while the Obamacare fight was national, implementation of the Affordable Care Act is in many ways a local story. According to Mathews, “the wisest thing most of us can do is focus on our own home regions—the prices our neighbors are paying for insurance and healthcare, the health of people in the neighborhood and the mix of hospitals, doctors’ groups, clinics and insurance plans near us.”

In other words, local sources are valuable. That’s what Cristina Janney of Kansas’ McPherson Sentinel discovered when reporting her December piece about Obamacare’s effects on hospitals—one of the few ambitious ACA stories to emerge from small-town reporters in the region.

“I started with my local sources, went to my local hospital administrators, and then I branched out from there,” Janney says.

To tackle the story from another perspective, Cross notes, a reporter might start with insurance agents. Shield adds that now that the law has fully taken effect, “it should be easier for a reporter to go out and find someone in their own back yard, so to speak…. If you’re a reporter in Hays, KS, you don’t necessarily need to find an expert in Bethesda, MD.”

Still, with an issue as complex and far-reaching as the ACA, it is essential to, in Cross’s words, “take the time to learn about it.” That means knowing where to look for help and whom to ask.

Janney, for instance, was able to do a long-form ACA story only with the support of her paper’s parent company, GateHouse Media, which last year awarded three journalists the opportunity to devote four weeks to an investigative piece.

The Sentinel has done some local reports on the health law, but, Janney acknowledges, “there is no way that I would have had the time to delve in and do the reporting for this project had I not had the help from our parent company.”

Partnerships and pickups

When that sort of backing is not forthcoming, help is also available from the nonprofit world.

Perhaps the most respected independent source for healthcare journalists is the Kaiser Family Foundation, which offers a wealth of web resources, media-ready experts, and its own news service.

Partnerships between Kaiser Health News and local news organizations have produced some of the better ACA stories in the Midwest—including pieces from the St. Louis Post-Dispatch on Missouri’s Medicaid coverage gap and Iowa Public Radio on the difficulties faced by rural patients in signing up for the exchanges.

For newsrooms that don’t enjoy such a direct relationship, Kaiser is a fount of ACA-related story ideas: on enrollment numbers, Medicaid expansion, doctor shortages, coverage “churning,” workplace health incentives, accountable care organizations, and quality-care measures, to name a few.

“This is a revolution that’s underway in the US,” says John Fairhall, editor in chief for Kaiser Health News, “and you can localize every aspect of it.”

In addition to Kaiser, a spate of nonprofit health news services have cropped up at the state level, including Georgia Health News, Health News Florida, and Reporting on Health (California), as well as Kentucky Health News, which is published by Cross’s Institute for Rural Journalism, and the Kansas Health Institute news service.

The KHI news service was formed in 2006, in direct response to the health news coverage gap in the Sunflower State, according to managing editor Shields.

“Most of the news outlets in the state were generally reliant on what they were getting from the wires, and there was very little effort to localize it,” Shields says.

The growth of nonprofit journalism may not be “a cure-all for a lack of mainstream coverage in smaller communities, but it’s one answer,” he adds.

Indeed, KHI and other nonprofits have produced some of the best recent coverage in the region—much of which can be lifted wholesale by community papers. “We’ve been on the front page of all the smaller dailies and weeklies in the state at various times,” says Shields. Fairhall and Cross emphasize that stories from their outlets can be picked up for free, too—“just credit and link,” Fairhall says.

Ultimately, though, relying on statewide or national news services is a stopgap fix for the rural health coverage gap. Successful local news organizations have unique relationships with their readers—it’s the marriage of that local understanding and outside resources that can deliver essential coverage.

“I used to be a rural newspaper manager,” Cross says. “I know what papers go through. I know how tough it is. I just want them to raise their sights a bit.

“From time to time, there are really big issues they need to tackle, and if there ever was one, it’s the Patient Protection and Affordable Care Act.”

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Deron Lee is CJR's correspondent for Iowa, Missouri, Kansas, and Nebraska. A writer and copy editor who has spent seven years with the National Journal Group, he has also contributed to The Hotline and the Lawrence Journal-World. He lives in the Kansas City area. Follow him on Twitter at @deron_lee.