How Navigators Plan To Insure the Remaining Uninsured

The Affordable Care Act’s third open enrollment period begins on Nov. 1.

According to the latest HHS data, an estimated 10.5 million uninsured U.S. residents are eligible to sign up for health coverage via the exchanges. That remaining uninsured population, along with the millions of others looking to enroll or re-enroll in exchange coverage, are the prime targets for this year’s navigators.

While some obstacles, like technical glitches, to enrolling the uninsured have been eliminated, navigators don’t necessarily have an easy task. This edition of “Road to Reform” takes a look at what navigators will have to tackle as open enrollment kicks off.

What Navigators Do

For the last three years, CMS has awarded navigator grants to organizations located in states that rely on or operate an exchange in partnership with the federal government. The grants support ACA outreach, as well as navigators who offer in-person, impartial information about health plans, federal subsidies and how to enroll in coverage. States operating their own exchanges also support their own programs to fund navigators. For example, California’s health insurance exchange — Covered California — has announced plans to dole out more than $10 million in navigator grants to 68 organizations.

Last month, CMS awarded $67 million in navigator grant awards to 100 organizations in 34 states. However, unlike past navigator grants — which expired after one year — the new grants cover a 36-month period, funded in 12-month increments. A CMS spokesperson said the change in funding period aims to improve efficiency, partly by reducing annual startup time, and to provide navigator grant recipients with more consistency each year.

This Year’s Enrollment Challenges

Navigators face some unique challenges in the ACA’s third open enrollment period.

Zach Reat — director of work supplies initiatives at the Ohio Association of Foodbanks, which has received federal navigator grants for each enrollment period — said, “Many of the most severe barriers to enrollment that we experienced in the first [open enrollment] period (website failure, lack of coordination between state and federal agencies, inadequate time to prepare navigators and other assisters) have been addressed by this point.”

However, he noted, “We continue to encounter major barriers related to understanding of the law, particularly provisions that help to make coverage affordable.” He added, “People are still making decisions about the law based on false or misleading information.”

Oddly enough, one of the biggest challenges for navigators this year is the direct result of the past years’ efforts to enroll U.S. residents in coverage: a smaller, harder to reach uninsured population.

At the national level, the Obama administration in August announced that the uninsured population had dropped by about 33% since 2013.

Tia Whitaker, statewide director of outreach and enrollment at the Pennsylvania Association of Community Health Centers, noted that Pennsylvania’s uninsured rate has fallen from about 11% in 2013 to 10.3% in 2014.

In California, the U.S. Census report showed the uninsured population had fallen from 17.2% in 2013 to 12.4% in 2014. However, the decline makes the uninsured population increasingly harder to reach, according to Camey Christenson — director of business and partnership development at 2-1-1 San Diego, which is expected to receive a $250,000 grant from Covered California.

According to Reat, Ohio’s uninsured population “is smaller, has a higher income due to enrollment in Medicaid expansion, and may still be unaware of financial assistance available to help make health insurance affordable.”

The New Approaches

To better address the needs of this year’s uninsured population, navigators are adjusting their strategies and data-tracking efforts.

For example, Whitaker said her organization will conduct “focused outreach on special populations,” such as immigrants, seasonal and migrant workers, and the lesbian, gay, bisexual and transgender community.

Reat said his organization will continue to focus efforts on “getting the message about the ACA out in communities with limited English proficiency and rural communities.” He said his organization is going to work with “trusted messengers” — agencies or individuals that are trusted within communities — to share information about available services, particularly in minority communities. In addition, the Ohio Association of Foodbanks manages a multiplatform campaign — called “Are You Covered?” — that aims to raise awareness about enrollment and help state residents find local assistance.

In San Diego, Christenson said that her organization is “using social media messaging, targeted outreach events and community partnerships to seek the remaining uninsured.”

Christenson also noted that her organization has updated its metrics to gauge success focusing on the number of individuals who renew health plans through Covered California, as opposed to outreach and enrollment numbers.

Meanwhile, Whitaker’s organization — which has relied on an online, HIPAA-compliant database to track enrollment data — has expanded the metrics it collects to include breakdowns of language categories and Healthy PA enrollments. Healthy PA is Pennsylvania’s expanded Medicaid program.

The Future of Navigators

While navigators across the country have helped enroll millions of U.S. residents in exchange coverage, some have raised questions about the program’s sustainability.

Austin Bordelon of Leavitt Partners in a blog post wrote that some state-run health insurance exchanges — including Colorado, Hawaii, Massachusetts and Vermont — have experienced budget deficits or raised concerns about staying on budget in the future.

HHS also has acknowledge some budget issues, noting that premium assessments charged to participating insurers are not sufficiently covering the federal exchange’s operating costs, according to Bordelon.

Although he noted that navigator programs will continue because they are required under the ACA, he expects “marketplaces to prioritize funding for alternative outreach programs that are capable of reaching a broader audience at a lower incremental cost,” adding, “This could include giving preference to dollars used for marketing and media ad-buys, or even system enhancements that encourage additional involvement from agents and brokers.”

Tracy Gnadinger in a Health Affairs policy brief also raised concerns about the sustainability of navigators and the growing role health insurance brokers will play in enrollment. She noted that when funding for navigators decreased for the second open enrollment period, “some states began cultivating a closer relationship with brokers to maximize enrollment.”

Gnadinger highlighted the potential conflicts brokers, who typically are paid a commission from insurers, present, as they are not required by law to inform consumers about all available policies.

The role of navigators in “educating the public on the [ACA’s] requirement to have insurance, assisting with enrollment, answering difficult eligibility questions, engaging hard-to-reach populations and helping people understand how to use their insurance once they purchase a policy” is “as important as ever,” Gnadinger argued.

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