The ACA at 10: The navigators' tale (preview)

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As the tenth anniversary of the ACA's passage approaches, Health Affairs is out with a landmark series of articles examining the law's history and impact.

To mark the occasion myself, I have interviewed five "navigators" -- nonprofit enrollment assisters chartered by the ACA -- who were in at the birth of the marketplace and have been helping people enroll since fall 2013.

These veterans have assisted thousands of mostly low income people in need of affordable health insurance and have been integral to the enrollment assistance infrastructure of their states -- Florida, South Carolina, West Virginia and Texas, which together account for 28% of all marketplace enrollment. All of these states use the federal HealthCare.gov platform and so have been subject to the Trump administration's 84% cut to navigation funding.

I have completed my writeup of the debriefing of these resilient, tough, devoted professionals and am currently shopping the article draft, which may yet end up here on xpostfactoid. It's a slow process. To ease my impatience, I'm here offering a snippet view of key points.

• The need for continued enrollment assistance and outreach is acute and constant. Ignorance of core ACA offerings remains widespread -- especially in red states, where the stigma of "Obamacare" has not yet worn off. The application and the offerings alike are complicated -- even multi-year enrollees need help. And always, "the uninsured pool is a  constantly moving door," says Jodi Ray, Director of the Florida Covering Kids and Families Project at the University of South Florida.


• The cuts to navigator funding hurt.  Trump's HHS cut navigator grants in HealthCare.gov states -- funded by user fees paid by insurers using the exchange -- from $63 million in fall 2016 to $36 million in 2017 to $10 million in 2018. Two program directors reported that enrollment assistance staff is well below half what it was at the peak. Outreach and education have been curtailed, as has multilingual in-person assistance and in some states, in-person assistance generally.


• Assisters have proved resilient.  In South Carolina, the Palmetto Project under Shelli Quenga's leadership transformed itself into a nonprofit brokerage to fund continued impartial enrollment assistance to primarily low income clients. In West Virginia, after a navigator grant cut from $600,000 to $100,000, First Choice Services does most of its direct enrollment assistance by phone, says outreach coordinator Jeremy Smith. In Florida, Jodi Ray has leveraged a wide network of partnerships with business, schools, hospitals and other organizations.


• Trump has put the chill on immigrants.  Fear of deportation and of the expanded Public Charge rule has immigrants passing up services for which they're eligible. Daniel Del Toro at the Centro San Vicente Health Center in El Paso bears witness.


• State markets vary widely.  In Florida, enrollment in 2020 hit an all-time high, two new insurers entered the market, and many enrollees saw lower premiums. In West Virginia, marketplace enrollment is barely half what it was in 2016, out-of-pocket costs have risen relentlessly, and provider networks have narrowed.  Many multi-year enrollees have dropped coverage, Smith reports, figuring they'll save the premiums against any medical expenses.


• Trust matters.  All of these veteran assisters have multi-year repeat customers. Many see people burned by unscrupulous brokers selling the lightly regulated short-term plans promoted by the Trump administration.  

Finally, to illustrate the complexity of the hodgepodge of subsidized offerings the U.S. has cobbled together, here is one outtake dear to my heart but too deep in the weeds to make it into any version published elsewhere.

Maricel Bernardo, a navigator who works with Smith at First Choice and has also done the work since fall 2013, helps people deal with a particular Catch-22 associated with Medicaid and marketplace eligibility criteria: While marketplace eligibility is based on annual income, Medicaid eligibility is based on monthly income. If you cross the monthly threshold, there's now a hair trigger to kick you off -- but if your annual income doesn't meet the minimum ACA threshold, the online enrollment platform, HealthCare.gov, will deem you ineligible for subsidies.

That's when you need a navigator, and Bernardo has become expert in the procedure. "When you submit a marketplace application that shows an income under 138% FPL, you have to attach that and send a "gap-filling" application to Medicaid. The enrollee is eligible for Medicaid through Dec. 31," even if their monthly income is over the threshold.

Stay tuned for more on this front, here or elsewhere. Update, 3/23: the full debriefing is here.