True Image/pictured lies: The CMS attack on ACA navigators

The Kaiser Family Foundation has done in-depth spadework to debunk CMS's Trumpishly false basis for gutting funding for the ACA navigator program, publishing rebuttal reports in 2017, when federal funding was cut from $63 million previously allocated to $36 million in actual grants, and again this month, when the grants for 2019 were slashed to a nominal $10 million.

Not to rehash the Kaiser case in detail, I want to widen the perspective a bit -- to situate navigator programs within the full array of nonprofit ACA assistance programs that evolved out of the original navigator mandate, and to spotlight the scope of Medicaid enrollment assistance left out of CMS's assessment of navigator performance.

The ACA established the navigator program to provide not just enrollment assistance but also outreach and education to consumers eligible for marketplace and Medicaid coverage. The law stipulated that the ACA exchanges -- which turned out, not by design, to be dominated by the federal exchange -- fund navigator programs. To justify this year's near zero-out for the 34 states that depend entirely on the federal exchange, CMS deemed the program ineffective, claiming that navigators enrolled less than 1% of marketplace enrollees in the states using the federal HealthCare.gov platform in 2018, vs. 42% for brokers. The supporting data is derived from HealthCare.gov tracking of enrollments in which a navigator enters an i.d. code that identifies her as assisting the enrollment.

That data in isolation provides a grossly distorted picture of navigators' impact, as Kaiser has documented exhaustively. For a variety of reasons, a majority of enrollments assisted by navigators are not credited via HealthCare.gov's electronic tracking. In any case, navigators do far more than click "enroll" as a client looks on.

The navigator programs, by mandate and in practice, focus on low income, low information, low tech access, and heavily immigrant populations. They provide sustained year-round aid not only in obtaining but also using and keeping coverage. And a large proportion of those they help enroll in Medicaid. In a note at bottom, I've summarized the key points in Kaiser's detailed rebuttal of CMS's smear of navigator programs specifically.

Navigators and their offspring

But to understand navigators' role in making the uninsured aware of ACA programs, helping them enroll, and helping them stay enrolled and use their coverage, it's important first to get a grip on their place in a larger ecosystem of ACA enrollment assistance. An earlier Kaiser report, a 2016 survey of marketplace assisters and brokers, provides the big picture. It includes for-profit brokers, who probably helped about 6 million* people enroll in ACA-compliant individual market plans in 2018. It also includes, as of last count in 2016, some 5,000 nonprofit programs deploying certified enrollment assisters of various types created by the ACA and certified by CMS or state-based marketplaces.

Collectively, these programs served about 5.3 million clients in 2016. While it's impossible to provide a definitive count of enrollments, most programs reported to Kaiser that they enrolled most of the people they worked with, either in Medicaid or in marketplace coverage -- and far more in the former than the latter. Most of these programs are staffed by Certified Application Counselors (CACs), who undergo online training similar to but less extensive than that undergone by navigators.

Navigator programs -- the programs funded by HealthCare.gov and the state marketplaces -- constitute only a fraction of this army of certified nonprofit enrollment assisters -- though a disproportionately influential one. Of the 5,000 assister programs, 10% are navigator programs** funded by HealthCare.gov and the state exchanges. Another 24% are programs lodged in Federally Qualified Health Centers (FQHCs), staffed mostly by CACs and funded through the Health Resources and Services Administration (HRSA), a division of HHS that administers -- and funds- the FQHCs' core operations. The rest -- 65% -- are CAC programs, sponsored mostly by nonprofit organizations, most of which receive no federal funding.

Navigator programs are the largest program type on average, and CACs the smallest. Of the 5.3 million people reached by all assister programs in 2016, navigator programs accounted for 17% of people helped, FQHC programs for 28%, and stand-alone CACs for 55%.

Spontaneous generation

While the ACA established the navigator program by statute, the rest of this infrastructure developed on the fly. The law stipulates that navigators will be paid out of the ACA exchanges' operating budget, which for 34 states means paid by CMS, the HHS agency that operates the federal exchange, HealthCare.gov. When the ACA launched, funding the navigators out of the operating budget proved impossible for the federal exchange, explains Karen Pollitz, senior fellow at the Kaiser Family Foundation.

"In 2014, HealthCare.gov's operating revenues were... spoken for," said Pollitz. That is, they were swallowed up addressing the website's epic technical problems. "HHS Secretary Sebelius used her budget authority to reprogram up to 1% of HHS funds to find $60 million for the first year. Everyone worried that that wasn't enough -- so HHS plussed up HRSA grants to the health centers [which, prior to the ACA already helped patients apply for Medicaid and CHIP]. Next, they created the new CAC designation." The lighter training regime made it easier for social service agencies and other organizations to train and deploy enrollment assisters, in some cases volunteers.

The FQHC funds earmarked for enrollment assistance by HRSA -- about $150 million per year -- actually dwarfs the maximum amount ever granted by CMS to navigator programs, which topped out at $63 million in 2016. State-based exchanges (including a handful that use the HealthCare.gov platform) also provided more funding than CMS -- about$ 100 million in the first year and $85 million for 2015, the last year for which Kaiser provides a total (New York has allocated $27.2 million for 2019 and each of the next five years).  Funding was always tight: only 39% of navigator programs reported to Kaiser in 2016 that more than half their funding came directly from HealthCare.gov or a state-based marketplace.  Thus, in a sense, the marketplace funding provided by statute amounted to seed funding -- which gave rise to a biodiverse landscape of enrollment assistance.

This is not to suggest that the gutting of federal funding for navigator programs will not cause severe harm to ACA functioning. Among the various types of assister programs, only navigators have a mandate to conduct community outreach.  Navigator programs tend to be larger than other types on average, and "pound for pound they do the most work," according to Pollitz. In some states, she explains, the enrollment assistance universe has a pyramid structure with a navigator group on top, providing technical assistance, coordination, and accepting referrals for hard cases.

Stacy Pogue, senior policy analyst at the Center for Public Policy Priorities in Texas, adds that while many Texas cities have an array of assister groups, "in rural areas, often the navigator is the only one out there."  Pogue further notes that while FQHCs do a busy trade enrolling their patients in whatever coverage may be available, "the funding they have makes it hard to reach outside the health center -- it's vital to have navigator groups that can serve people who aren't already patients."

Pogue notes further that CMS's cuts last year to the ACA advertising budget "raised the profile of enrollment coalitions" -- that is, drove assistance groups in urban areas to coordinate referrals. Navigator programs took a lead role in many such coalitions.

Mostly Medicaid

While denigrating navigator programs and falsifying their alleged cost per enrollee, CMS neglects to mention Medicaid at all -- notwithstanding that in states that accepted the ACA Medicaid expansion, a large percentage of those who seek navigators' help are Medicaid-eligible. Enrollment reports from various state-based exchanges bear this out:

• According to the Maryland Health Connection's 2017 annual report (p.17), brokers accounted for 24,170 QHP enrollments, and navigators just 5,311 (out of 157,637 total enrollments). Navigators also enrolled  30,171 people in Medicaid, however, and 5,637 children in CHIP.  Just 13% of navigators' credited enrollments were in QHPs.


• The Washington Health Benefit Exchange's March 2018 enrollment report (p. 13) shows 52,176 broker-assisted QHP enrollments, and 15,606 navigator-assisted.  Turn again to Medicaid enrollments, however, and navigators enrolled 186,569 people, while brokers enrolled 33,812.  The exchange enrolled 209,802 people in QHPs -- and 1,515,978 in Medicaid and CHIP.


• New York State has an army of CACs -- 6,122, compared to 578 navigators and 2,817 brokers. New York State of Health, the state exchange, enrolls people in Medicaid and CHIP; the state's Basic Health Program, a Medicaid-like program for those at the lower end of marketplace eligibility in most states; and QHPs. Together, according to the NYSOH 2018 enrollment report (p. 32), CACs and navigators account for 74% of a total of 4.3 million enrollments across all programs -- 65% by CACs and 9% by navigators. Brokers account for 13% of QHP enrollments, compared to 24% for CACs and 9% for navigators.


• According to the 2017 annual report (p. 12) from MNSure, Minnesota's exchange, navigators funded by the exchange enrolled more than 57,000 people in the three programs handled by the exchange -- Medicaid; the state's BHP, MinnesotaCare; and QHPs. They also conducted more than 4,500 outreach and education activities reaching more than 270,000 individuals. Navigator programs as a group, including those not funded by the exchange, enrolled about 89,000 out of a total MNSure enrollment of 265,537.

These reports are created by state agencies committed to insuring as many of their state's residents as possible and to making government programs work as designed. They stand in marked contrast today to CMS's political leadership, which uses manipulated statistics and unfounded assertions to push an ideological agenda and cut vital assistance to the poor and near-poor, the less educated, and immigrants.

Note: A bogus performance assessment: The Kaiser response

To summarize the key points in the 2017 and 2018 Kaiser responses to navigator funding cuts:

• For a host of reasons, navigators' i.d. codes are entered on only a fraction of the applications of people they help. Brokers, in contrast, must enter their codes to get paid. Brokers get automatically credited for customer auto-renewals; navigators don't.
• Navigators' mandate is to help the hardest prospective enrollees to reach --  people who are low income, low information, often not native English speakers, lacking access to technology. "Most consumers who seek help have limited understanding of the ACA and difficulty understanding insurance and comparing plan choices" (2017 report).
• CMS's criteria for determining usually draconian cuts to individual programs' funding was opaque and arbitrary. Not only did cuts bear little relation to programs' enrollment performance according to the Midas data - that is, enrollments electronically recorded on HealthCare.gov --  but CMS also ignored the plans' self-reported data and did not take into account other performance metrics, e.g., 83% of programs met their goals for one-on-one consumers interactions, 71% met their goals for helping consumers enroll in Medicaid or CHIP, and three quarters met their outreach and education event goal.
• CMS's assessment ignored other vital parts of navigators' mandate: providing education and outreach in public forums, helping enrollees stay enrolled by assisting with queries from the marketplace to verify identity and income data, helping enrollees understand their coverage.
• On average, the number of one-on-one encounters navigators reported was 15 times higher than the number of QHP selections recorded electronically. 
• More than half of all assisters reported that most of their clients had incomes low enough to qualify for Medicaid.

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* CMS reports that 42% of enrollees in marketplace coverage via the HealthCare.gov platform are broker-assisted. Extending that percentage to the state-based exchanges suggests about 4 million broker-assisted enrollees within the marketplace. In the 2016 Kaiser survey, brokers reported enrolling a bit more than twice as many on-exchange as off-exchange. If that percentage holds today, approximately 6 million enrollees in ACA-compliant coverage nationwide used brokers.

** A smaller program, the Federal Enrollment Assistance Program (FEAP), operates similarly to navigator programs and consists of programs that contracted with CMS to provide supplemental assistance in places where the uninsured are concentrated. FEAPs accounted for 1% of enrollment assistance programs as of Kaiser's 2016 assister survey.