The initial rollout of health insurance marketplaces was spotty at best. Stories abound of website glitches and lackluster outreach efforts, leading to uneven experiences coast-to-coast and significant consumer frustration.

As state and federal regulators seek to smooth out the process, rural hospital leaders like Ginger Henry, CEO of the 85-bed Prattville (Ala.) Baptist Hospital, remain optimistic that the marketplaces will help to offset the negative margins. However, she acknowledges, "What I don't know is bigger than what I do know."

Brock Slabach, senior vice president, member services, the National Rural Health Association expects that over time, enrollment in the marketplaces will aid rural providers. "In 2011, 16 percent of the nation's population was uninsured," Slabach says. "If that could be whittled down to 8 percent, that's obviously a significant bounce to the hospital's bottom line."

As hopeful as rural and safety net hospital leaders are that enrollment in the marketplaces and through Medicaid expansion will boost revenue, they are concerned about the rise of a different form of uncompensated care for Medicaid Disproportionate Share Hospitals.

"Patient co-shares on the bronze plans will be 40 percent; that means the patient will be responsible for providing 40 percent out-of-pocket," says Xiaoyi Huang, assistant vice president for policy, America's Essential Hospitals, formerly National Association of Public Hospitals and Health Systems. "Uncompensated care — whether bronze, silver, gold or platinum coverage — is not DSH-eligible. It's still uncompensated care, but hospitals can't claim it as a DSH expense."

Even so, Keith Mueller, director of the Rural Policy Research Institute Center for Rural Health Policy Analysis, University of Iowa, advises hospitals to continue to work with patients to help them find the best — and most appropriate — level of coverage. "When there are patients with insurance, there's a payment," he says. "That's easier than trying to collect from uninsured patients."