DETROIT (AP) - Sue Cook is going to the ends of the earth, or what feels like it, to help people try to sign up for insurance under the new federal health care law.
The retired nurse is director of a free health clinic in Sanilac County, the largest county in Michigan's Lower Peninsula at more than 960 square miles. And Cook, who also travels the big county in the state's rural Thumb region with a laptop to navigate the troubled federal health care exchange, is finding just how long the road to success will be.
"There are many challenges we're facing right now," said Cook, who leads an all-volunteer team of health care professionals at Caring Hearts Clinic in Marlette, 65 miles north of Detroit. "You've got somebody in the northeast part of the county that has no transportation to get here to even sign up.
"We're finding that even if I go to the far end of the county, there's the issue of not having Wi-Fi to hook up to," she said. "Those are huge hurdles for us to try to conquer in a large county like this."
The issues in Sanilac County are common among Michigan's many rural counties, which have some of the highest rates of uninsured residents and are coupled with concerns about accessibility and doctor shortages. Sanilac has the state's 27th highest rate of uninsured residents at nearly 16 percent, and the Upper Peninsula's Mackinac County has the highest uninsured population - the state's only county above 20 percent. According to the most recent Census numbers, Michigan's overall uninsured rate is 13.6 percent.
The stories of Sanilac, Mackinac and their rural county counterparts underscore broader challenges in rolling out President Barack Obama's health care overhaul, which aims to cut the number of uninsured by expanding low-income health coverage and the new insurance marketplaces where people can buy plans. Problems have plagued the website since its October launch, and enrollment still lags behind projections despite improvements.
Americans had until Dec. 23 to sign up for coverage that starts Jan. 1, and many are expected to wait until the last minute. They have until March 31 to find coverage and avoid a penalty for being uninsured next year.
Nick Derusha is director of the health department for four Upper Peninsula counties: Mackinac, Luce, Alger and Schoolcraft. The region covers a vast expanse from the Mackinac Bridge north and west nearly to Marquette, but only consists of about 35,000 people.
The region also has a high rate of uninsured residents and a shortage of health professionals, as well as a lack of transportation and Internet and cable connectivity. Those factors all conspire against helping people secure insurance through the exchanges, Derusha said.
"There are many barriers to care, as well as health care coverage alone," he said.
The residents of Sanilac, another spread-out county of roughly 42,000 people with 45 people per square mile - compared with 174 statewide - are slow to adopt and loath to embrace the law, health officials say.
"They're not real interested in this - there isn't anything that's incentivizing them to sign up right now," said county health director Dianna Schafer. "I don't have them pounding my door down. ... What it tells me is that something is going to happen, something is going to implode soon."
That's frustrating public and community health workers, who often are as vexed as their clients by the website's technical problems and confusing design. Cook said she attended a recent meeting with colleagues from surrounding counties and successes were few and far between.
Kathy Bannister can boast of a rare victory after many failed attempts to enroll, both alone and with Cook's help. The self-employed beautician from Sanilac County's Brown City finally managed to connect with her current insurer, Blue Cross Blue Shield of Michigan, and secure a comparable individual plan with a monthly payment of $215 after subsidies are taken into account. She now pays $500.
"The whole idea was to make it easier for people," said Bannister, 51, who had a heart-valve replacement 13 years ago. "I'd been calling and calling and calling, and a lot of people would have given up. It's discouraging."
Even with more success stories, Cook believes the free clinic will remain necessary in a county where many would otherwise go a hospital emergency room for primary care or go without it. Caring Hearts provides free care for those who are low-income, uninsured or have an insurance deductible that represents at least 10 percent of their income.
Caring Hearts Clinic director Sue Cook, left, helps Kathy Bannister with enrolling in the Affordable Care Act at the free clinic in Marlette, Mich.
"We're finding out that even (when some) get insurance, the deductible is so high, they're still going to be able to qualify for the clinic," she said.
Despite the challenges, local governments are working closely with social service agencies and health care and community organizations to bridge geographical and economic gaps. In the Upper Peninsula, for instance, some local hospitals have opened satellite clinics to reach far-flung residents, and Sanilac County's Caring Hearts Clinic relies on support from Marlette General Hospital.
"I don't know what the answer is - we just all keep plugging away and helping the best we can, Cook said. "People in our community, I find, we're close knit. We take care of one another. We know there are people in our community who need this help. We truly believe in helping those who can't help themselves."