I had spent an hour reviewing Anna’s immigration documentation and the earnings from her three jobs—she is a substitute teacher, but she also drives for Uber and operates a small catering company to supplement her income—before I finally clicked the “submit” button and waited for the healthcare.gov website to process her application. Anna’s husband had recently abandoned her to return to their home country of Egypt and she could not afford full-price coverage in the Northern Virginia market on a substitute teacher’s salary. I knew that if she did not receive financial assistance, she would leave my office without insurance. As a volunteer Certified Application Counselor (CAC) most recently in late 2017, it would not have been my first time telling someone that they were ineligible for government assistance to pay for their health coverage—it never gets easier, though. Thankfully, this was not one of those times.
Once her application was accepted, we reviewed her likely costs: a $15 monthly premium and no deductible. Anna started to cry. She hugged her friend who had accompanied her to the appointment. Then she hugged me. She explained that she was crying because now she could finally get medication she needed but could not afford without insurance.
In previous years, open enrollment was still hard work, yet CACs and other enrollment specialists were helping families get affordable insurance and moving us closer to the Obama-era vision of universal coverage. But after the swift political shift of the past year, the mood in the enrollment community was starkly different.
Open enrollment for the 2018 Marketplace coverage concluded on December 15 in most states, and more recently in those few states that extended their deadlines through January. Although the Affordable Care Act (ACA) has been in place for several years and consumers have become more informed about it over time, there remains a need for robust consumer outreach and community-based programs that provide health insurance enrollment assistance directly to consumers. The Administration has already begun to deliver on promises to use regulations and other administrative mechanisms to chip away at the ACA’s protections, and a closer look at federal agency actions leading up to the most recent open enrollment period reveals a pattern of ad hoc decision-making related to crucial consumer outreach activities that threatens to undermine the stability of the health-care market in future years. This includes cuts to consumer outreach and enrollment support, and a shortened enrollment period. Additionally, political uncertainty about the future of the ACA led experts to worry further about depressed enrollment and an overall destabilized market.
Despite these obstacles, however, the ACA’s fifth open enrollment was an unexpected success, with numbers nearing last year’s total. In the 38 states using the federal healthcare.gov platform, plan selections totaled 8.8 million in just six weeks, compared to 9.2 million in those same states during last year’s 12-week period.
This year’s enrollment success is due in large part to efforts by Navigator programs, which receive federal funds to assist consumers seeking to purchase coverage in the individual and small group marketplaces established under the ACA. Navigator programs, one of the more underappreciated aspects of the ACA, benefitted this year from increased donations of money and time from local businesses, non-profits, and an enthusiastic volunteer workforce. But there is concern that the surge in support may taper off as political outrage cools and the future of the ACA becomes even more uncertain. Additionally, resources from CMS will likely not be available for important consumer support activities throughout the year outside of open enrollment, such as tax assistance, appeals, and Special Enrollment Periods that allow consumers to enroll in mid-year coverage following life changes such as marriage, loss of other insurance, and birth or adoption.
Recognizing the difficulties—for the average consumer—inherent in applying for premium tax credits, comparing health coverage options, and enrolling in a plan, the ACA, from the very start, envisioned a network of trained enrollment assisters to help consumers navigate this new health-care system. Among other things, the ACA authorized Navigator grants to fund community-based organizations that would hire and train staff—referred to either as Navigators or CACs, depending on their training and responsibilities—who could engage in community outreach and provide enrollment assistance directly to consumers.
The Navigator program created a workforce singularly dedicated to providing this outreach and one-on-one assistance to consumers seeking to purchase insurance. Since the first open enrollment in 2014, Navigator programs have been instrumental in providing free support to low- and moderate-income families, free from insurance company pressure.
As a CAC in Northern Virginia during the latest enrollment period, I found myself working primarily with consumers enrolling in coverage for the first time—and while some had only recently become eligible for coverage, many had been eligible in previous years. Evidently, the need for robust consumer outreach and education about health coverage options available under the ACA persists. This is especially true among immigrant communities and other groups that may not have had much previous interaction with the U.S. health-care system.
Yet in late August 2017, just two short months before the start of this year’s open enrollment, CMS announced plans to slash 90 percent of the budget for advertisements and outreach intended to educate consumers about health coverage options and encourage enrollment. The Administration also announced a devastating 42 percent cut to Navigator grants, which meant that 47 states saw overall Navigator program funding decrease by anywhere from 10 to 80 percent. What this means in practice is that Navigators had to develop new outreach strategies, forge new partnerships in the communities they serve, and rely on help from non-profits, local businesses, and individual volunteers. They needed to stretch limited funds. And reduced staff time also meant that Navigators in some parts of the country had to forego certain consumer education and health-care literacy activities in order to prioritize outreach and enrollment; it is likely that key Navigator functions will drop off during the rest of the year as well.
The open enrollment advertising cuts were not altogether surprising; the Administration had already cancelled these activities in the final days of the previous open enrollment, despite the fact that CMS had paid for the planned advertisements before the end of the Obama Administration. But the cuts to Navigator grants were unexpected, particularly because these cuts were based on a last-minute change in the formula CMS had previously relied upon in calculating these awards.
CMS decided in August 2017 that, for 2017-2018, awards would be based on each Navigator program’s ability to meet Marketplace “enrollment goals”—that is, the number of consumers they helped enroll in private plans, known as Qualified Health Plans (QHPs), through the Marketplace—during the preceding 12 months.
But the new formula does not align with how Navigator programs develop performance goals or track progress toward meeting such goals. Programs developed their 2017 goals based on the CMS policies that were in place at the time, leaving them blindsided by the last-minute changes. Consumer advocates further argued that the new formula would ultimately punish Navigator programs for reduced enrollment caused by factors outside of their control. In other words, enrollment would likely decrease due to advertising cuts made in the final days of the previous enrollment period, heightened mistrust of government programs in immigrant communities since Trump’s inauguration, mixed messages from the Administration about whether it would enforce the individual mandate, and overall uncertainty about the future of health reform in light of the Republican Party’s repeated promises about repealing the ACA.
This new formula also fails to account for the fact that Navigators engage in a number of important activities, QHP enrollment being just one of the outcomes measured. Only 18 percent of Navigator programs in 2016 reported that nearly all Marketplace-eligible consumers they helped actually enrolled in a QHP during their initial visit. However, the vast majority of Navigator programs met or exceeded their goals for one-on-one consumer interactions, Medicaid and Children’s Health Insurance Program (CHIP) enrollment and referrals, and outreach and public education.
The most comprehensive metric by which Navigators measure performance is in fact one-on-one assistance; 83 percent of Navigator programs met or exceeded their goals in this area. This encompasses many types of consumer interactions that involve assisting consumers in navigating through various aspects of the application and enrollment process.
Navigators and CACs also help consumers submit their application for financial assistance, which can be onerous for many as it involves predicting future household income and correctly documenting all income- and immigration-related information. This can significantly complicate the application process for consumers with multiple income sources, complex immigration statuses, multi-generational households, or family members attempting to move to the United States from their home countries. Consumers who are unfamiliar with the rules may not realize that their eligibility results are incorrect, or they may become frustrated with the process and abandon it altogether. Completing the application may have therefore deterred a good deal of enrollment absent help from trained Navigators and CACs; a number of consumers I helped had already started or submitted an application, but made an appointment because they worried they may have made mistakes or were confused about next steps.
Consumers like Anna with multiple non-salaried jobs have varied income from month to month, yet they must estimate their predicted earnings for 2018 as accurately as possible. If we overestimated Anna’s income, she may not have received enough financial assistance to be able to afford coverage; but, if we underestimated her income, she would be at risk of owing money to the IRS when she files her 2018 taxes. Additionally, accurately documenting her complex immigration status required knowledge of how the application system processes this type of information, which I was able to provide, but which is often overly complex for the average health-care consumer.
After the application is complete, consumers must compare the available plans to determine which best suits their needs. This is complicated even for individuals who have had insurance before, but for first time enrollees—especially immigrants—insurance benefit designs, deductibles, and out-of-pocket cost limits can also be extremely confusing, again leading to altogether reduced enrollment rates.
The next step is, of course, enrollment itself. During my time as a CAC, I helped one consumer seeking coverage for her elderly parents who had recently immigrated to the United States—we submitted an application and narrowed her options down to two different plans, but she wanted to consult with her spouse that evening before making a final decision. If she completed the enrollment process on her own at a later time, this would not count toward the Navigator program’s QHP enrollment numbers.
Another important type of consumer assistance is Medicaid and Children’s Health Insurance Program (CHIP) enrollment and referrals. A good number of consumers have income that is too low for Marketplace subsidies; in the 33 states that have expanded Medicaid coverage to low-income adults, these consumers are often eligible for Medicaid. Consumers found eligible for Medicaid or CHIP are not reflected in Marketplace enrollment numbers, despite the fact that the Kaiser Family Foundation found that 71 percent of Navigator programs met or exceeded their goals for helping consumers eligible for Medicaid and CHIP.
Appointments with consumers that fall into the “Medicaid gap” are similarly not reflected in the QHP enrollment metric. I volunteered as a CAC in the state of Virginia, which has not expanded Medicaid. This, unfortunately, meant that the lowest-income consumers I assisted were left uninsured, since Medicaid in Virginia is available only to very specific categories of consumers—for example, pregnant women, individuals living with disabilities, or low-income parents and caretakers. Medicaid is unavailable to low-income adults that do not meet these specific criteria, yet they cannot receive financial assistance to help them pay for private coverage. The only thing I could do was provide these consumers with instructions on how to apply for an exemption from the individual mandate—the requirement that most people maintain a basic level of insurance—and explain that they should make a new appointment if their income changes in the future.
Early on in the enrollment period, I helped a man from the Middle East who had recently become a naturalized citizen in the United States after assisting the U.S. military. He was driving a taxi to save enough money to bring his wife and child to live with him in the United States. He was looking for a second job, yet his current earnings fell far below the $12,140 he would need to rise above the poverty line.
Unfortunately, he fell into what is called the “Medicaid gap,” which captures individuals below the poverty line who are left without affordable coverage options because their incomes are too high for Medicaid and too low for marketplace financial assistance. The ACA as originally passed required all states to adopt “Medicaid expansion,” which would allow individuals below the poverty line to enroll in Medicaid. The Supreme Court later ruled that Medicaid expansion must be optional for states; however, since the ACA envisioned that individuals with incomes below the poverty line would enroll in Medicaid, the law does not authorize financial assistance for marketplace coverage for this population. This means that the lowest-income consumers in Virginia and the other 17 states that chose not to expand Medicaid are often left with two options: pay full price for a marketplace plan, or remain uninsured.
The ACA creates an exception to the rule for some immigrants (for example, Green Card holders) with incomes below the poverty line, but this consumer was a naturalized citizen and therefore this exception did not apply. I explained that he could become eligible for financial assistance at any time during the year if he is finds a second job or his earnings from driving the taxi increase. I said that it is sometimes difficult to determine whether your income will exceed the threshold, especially when your earnings fluctuate from month-to-month as is often the case for taxi drivers, so he should make an appointment if he has any doubts about his eligibility and we can help him apply again. Finally, I provided him with instructions on how to claim an exemption from the individual mandate, and expressed my regrets that I could not do more to help him. He said “that’s okay—I have never had insurance before anyway, and I’ve made it this far.”
Although I could not help this consumer enroll in affordable coverage that day, I helped him understand how the system works, advised him on the process for avoiding a tax penalty, and explained his options if his circumstances change in the future. This is important because consumers denied affordable coverage are often discouraged from reapplying again in the future, and may remain uninsured because they believe eligibility is static. Yet this type of consumer education is another example of an essential Navigator function not reflected in the QHP enrollment numbers which served as the basis for Navigator grants this year.
If you’re the kind of person to read a policy essay like this one and are still having trouble understanding this process—well, imagine being a regular American and trying to traverse it.
Navigator programs also provide post-enrollment assistance throughout the year by helping consumers with Marketplace appeals, premium payment disputes, denied claims, and more; without this support, consumers are more likely to lose or voluntarily terminate their coverage when they run into issues with their plan.
The Administration’s attempts to undermine the ACA have proven surmountable thus far, thanks in large part to the too-often unrecognized efforts of Navigators, consumer advocates, community-based organizations, and a robust volunteer workforce. But many experts believe the full effects of past and anticipated legal and policy changes are yet to come. Without the crucial support that Navigator programs have historically provided to consumers, the impacts of these changes on enrollment and coverage rates may be dire.