DES MOINES - All parts of Iowa are not created equal when it comes to health insurance.
By national standards, the economically stable state has a relatively low number of people without any health coverage - just 10.7 percent of the population under 65, according to 2010 Census data. But a closer look at the numbers shows that some Iowa counties are far needier, with up to 18 percent of that age group lacking insurance, based on the Small Area Health Insurance Estimates survey.
The question many experts in the state are now asking is whether President Barack Obama's health care overhaul will help reduce those numbers. The law was designed to drive down the number of people without health insurance, both through an expansion of Medicaid and with new health care marketplaces where people can shop for private coverage and apply for government aid to pay premiums. People can start signing up for plans Oct.1, with the coverage to start Jan. 1.
But so far there has been little marketing or outreach in the state and few residents know how it will work. Keith Mueller, a professor who heads the Department of Health Management and Policy at the University of Iowa, thinks the new federal law can help get more people insured, but he warned it could take some time.
"Once word begins to spread, that will be what helps it take off," Mueller said. "It may take into the second year. It's going to take a lot of grassroots, person-to-person organizations to get out there and help folks."
Rural residents in Iowa appear to have a tougher time accessing insurance coverage than urban dwellers. The farm-heavy Allamakee County in northeast Iowa has 18.2 percent of people under 65 without insurance, the highest percentage in the state. The lowest number came in Warren County, part of the Des Moines metro area, where just 7.8 percent of people lacked insurance.
"The reason for the difference in insurance rates is very typical for rural areas," said Mueller. "Those who are employed tend to be self-employed or working for very small firms."
Other areas with high rates of people without insurance were Davis County in southeast Iowa, where 17.9 percent were without insurance, and Crawford County in western Iowa, where 16.8 percent of people lack insurance.
Residents of Allamakee County cited a variety of reasons for their lack of insurance - typically they were working a job or jobs that didn't provide benefits or couldn't afford a plan. Dorothy Newman, 43, said she had started working recently at a slaughterhouse in Postville, but her job wouldn't provide any coverage until she had been there three months.
"You work your butt off and what if you need it before then?'" said Newman, noting one of her daughters needed a physical to start school.
Newman said she didn't know much about the new health care law.
The federal law will expand state-run low-income health care in Iowa and will set up new health care marketplaces where people can shop for private coverage and apply for government aid to pay premiums.
Under the new law, insurance plans must all include some features, such as emergency care, maternity coverage and prescription coverage. In Iowa, the state has approved six companies to participate in Iowa's exchange, including two - Coventry Health Care of Iowa, Inc. and CoOportunity Health - that would offer coverage to individual buyers throughout the state. The other four companies have applied to offer plans with regional limits or that apply only to group insurance. No information has been released on what the premiums will be for those buying on the public exchanges in Iowa. Those who don't have health insurance will be subject to fines when they pay their federal taxes, though the very poor could be exempted.
Iowa Insurance Commissioner Nick Gerhart said the federal government was expected to handle much of the marketing for the program, though the state is trying to get the word out. The agency staffed a booth at the Iowa State Fair and hopes to organize town hall style meetings around the state. The state is trying to get permission from the federal government to repurpose some grant money to use on outreach and messaging.
Gerhart said convincing Iowans they will benefit from the program will be key to its success.
"I've learned in this job that you cannot predict consumer behavior. Insurance is never really bought, it's sold. People don't wake up and say I need more life insurance. It takes an adviser or a friend to tell you, you need it," Gerhart said.
One semi-retired rural Iowa doctor said he'd noticed a change in how patients approach their medical treatment in recent years, largely due to the costs.
"For my career, until recent times, rarely have people said what do you charge," said surgeon Dr. Phil Caropreso, who until recently practiced in Keokuk in southeast Iowa. "Clearly in the last couple years, this is a topic that half of the patients have concerns about costs."
But Caropreso said he also hears skepticism about the new health care law.
"We're not talking about the dog, the kids, or the weather. It's what do you think about Obamacare," he said. "Most of the sentiments I get from my patients, they think it won't help. They think they're not going to qualify or they think they'll have to jump through so many hoops."
One more lingering question for Iowa is whether there will be enough doctors, as some rural areas already are dealing with shortages. Iowa ranked 40th for the ratio of doctors to residents, according to a 2011 report from the Association of American Medical Colleges.
"We have challenges in rural areas of our state to recruit sufficient numbers of physicians," said Victoria Sharp, president of the Iowa Medical Society. "If we have more people that have insurance, it doesn't mean you'll have access to care, just because there's not enough physicians."
Gerhart acknowledged that access to doctors could become an issue.
"A lot of doctors aren't taking new patients," he said.
For now, many Iowans will continue to ask questions as the law unfolds in the coming months.
Elena Suvorova, 48, owns a shop called Trendy Vintage in Postville. The Russian immigrant said she couldn't afford insurance, but wasn't convinced the new law would help her.
"Thank God I'm not sick," she said.