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Determining the Impact of the Affordable Care Act in Southern New Jersey

Project Overview

A policy paper analyzing the potential of the Affordable Care Act to serve migrant laborers and improve access to health services in rural southern New Jersey.

Identifying the Problem

Because the rural areas of southern New Jersey are not federally-designated as rural, they are not eligible for federal programs designed to improve access to healthcare by the rural population. Many of the people in these areas are migrant workers who perform seasonal agricultural work. They are often undocumented, have poor English skills, and are engaged in physically demanding jobs that create serious health challenges.

Compared to residents in other parts of New Jersey, the people who live in these rural areas are more likely to be unemployed, have lower incomes, be without health insurance, and be less educated. Their rates of chronic disease—especially diabetes and hypertension—are much higher than the residents in other parts of the state.

Americans have been repeatedly assured that the Affordable Care Act (ACA) will provide access to health insurance coverage for between 30 and 33 million Americans who are currently uninsured. While the ACA is projected to greatly expand healthcare coverage to residents of NJ, what was not as clear was how rural residents would be affected.

Creating A Solution

Alexandria is passionate about ensuring access to health care for historically underserved and unrepresented populations. While working on completing her Master of Public Administration (MPA) in Health Policy and Management at the NYU Wagner Graduate School of Public Service, Alexandria realized that she had the opportunity to take on a project that would address the human rights issues that inspired her to become an HIA Summer Fellow while building a professional skillset related to her degree.

Alexandria's graduate school Capstone team carried out an eight-month project for the Centers for Medicare and Medicaid Services (CMS) Region II to analyze the potential impact that the innovative models of coverage and care in the ACA will have on the residents of rural, southern New Jersey.  CMS is a federal agency that plays a significant role in implementing the ACA. Alexandria’s report paid particular attention to the region's large migrant population, barriers in access to health services, and the availability of culturally and linguistically appropriate care.

The report concluded that the success of the innovative models of coverage and care as outlined in the ACA will be limited in southern New Jersey. Many migrant laborers are not citizens of the United States and therefore unable to benefit from the expansion of insurance coverage. The region’s provider shortage constrains opportunities to develop accountable and patient-centered care delivery, which is severely needed given the lack of culturally and linguistically appropriate care currently available. Systemic issues familiar to rural communities, such as sparse public transportation and information exchange, exacerbate the challenges faced by patients and providers.

The report made the following findings and recommendations:

  • Access to Care

To best serve southern New Jersey residents, health care providers in the region should adapt to the increase in residents who are foreign-born, do not speak English well, and may not fit neatly within reimbursement laws for health care services. Cultural sensitivity, language skills, and supports for patients unfamiliar with the health care system are all necessary to deliver quality care. To support these providers, who are already understaffed and overextended, the state and federal government should explore how to increase the capacity of Federally Qualified Health Centers (FQHC), facilities designed to serve medically underserved, uninsured, and Medicaid populations.

  • Culturally and Linguistically Appropriate Care

Both migrant workers and long-time rural residents express distrust toward health care as a formal institution. To achieve patient-centered care and build relationships between patients and providers, health professionals in the region must integrate non-clinical, local community organizations into their practice. Leveraging this connection will both demonstrate to the patient the provider’s commitment to offer culturally appropriate care and sensitize the provider to that population’s needs.

Alexandria Margolis co-authored this report with Michael Butler, Susan Hayes, and Micah Julius.

Lessons Learned

Alexandria stresses that the opportunity to collaborate with an organization like CMS was only made possible through the connections of her graduate school and her policy analysis training.  For anyone interested in working on a similar policy paper, she offers the following advice: “A quasi-academic project such as this requires the right supports so your research is positioned to actually make a difference.

The project's direct purpose is to share key findings and offer recommendations to CMS Region II, but CMS Region II and its partner organizations, including the Substance Abuse and Mental Health Services Administration (SAMSHA) and New Jersey Department of Health and Senior Services, are committed to using this information to improve the quality and distribution of health services in the region.  This will be incredibly beneficial for its marginalized, rural population, particularly migrant agricultural workers.


In order to conduct research for this policy report, Alexandria and her team travelled throughout southern New Jersey by train and car in order to meet with stakeholders and visit Federally Qualified Health Centers. Because this research was being conducted for CMS, it helped contribute resources for travel, such as providing transportation for Alexandria and her team when CMS representatives wanted to join them during their meetings. The total cost of travel was $400, and the team spent an additional $450 printing copies of their final report. NYU Wagner reimbursed Alexandria and her team for both the costs of travel and the printing costs, since the Capstone project is a degree requirement.

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Poland Poland 2011

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