Monday, March 23, 2020

The ACA marketplace in year 7: The navigators' view

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The Affordable Care Act's health insurance marketplace, born on January 1, 2014, isn't a baby any more. In fact you might say it's reached maturity.

Like many children, it's disappointed its parents somewhat, insuring about half as many people as the Congressional Budget Office forecast when the ACA was passed. It's withstood multiple legislative and administrative assaults from Republicans and survived a half dozen near-death experiences via  repeal bills and court challenges to its constitutionality, one of which still looms. The marketplace's lower-profile twin, the ACA Medicaid expansion, has been more successful -- insuring more people more thoroughly for less money.

But the individual market for health insurance reshaped by the ACA is beginning its seventh year of offering comprehensive health insurance to anyone who lacks access to other insurance without regard to their medical history or current health. The ACA-compliant market serves about 13 million people, about three quarters of them subsidized, with the federal government paying about 86% of subsidized enrollees' monthly premium on average.

As the nation is faced with a major pandemic-induced recession, the marketplace and ACA Medicaid expansion stand poised to insure millions who lose employer-based insurance.

Call the midwife

There is a set of marketplace midwives who were in at the birth and have continued their intimate engagement: enrollment assisters, including nonprofit navigators established by the ACA; nonprofit and often volunteer Certified Application Counselors (CACs); and for-profit brokers who work in the individual market.

As of a Kaiser Family Foundation survey in 2016, an ecosystem of some 5,000 nonprofit assister programs lodged in nonprofit organizations and Federally Qualified Health Centers. In 2016, too, about 6 million enrollees in ACA-compliant plans were assisted by brokers.

The navigator program was designed as a nerve center for each state, chartered to provide outreach and education in the community as well as person-to-person assistance primarily to low-income potential enrollees. The Trump administration has devastated this program in the states that use the federal exchange,, as 38 did in 2020. From 2017 to 2019, Trump's HHS cut navigator funding by 84%, from $63 million to $10 million, at the same time cutting advertising by 90%.

The twelve states that run their own exchanges were protected from these cuts, as outreach and advertising are funded by user fees from insurers selling on the exchanges. Not coincidentally, enrollment dropped by 9% from 2017 to 2020 in states using, while upticking slightly in the states running their own exchanges.

Nonetheless the navigator program survives in all states, and there are veterans of these programs who have been enrolling people in ACA-compliant plans since fall 2013. I spoke to several of these veterans -- program leaders and assisters in Florida, South Carolina, Texas and West Virginia -- to get a sense of what's changed and what hasn't in seven years of enrollment.

Life after an 84% funding cut

Some experiences were common to the assisters I spoke to in all four states. First, the gutting of federal navigator funding hurt. In Florida, Jodi Ray, Program Director at Florida Covering Kids and Families, said that the group started with 120 navigators year-round in 2013 but was down to 50 during the last Open Enrollment, and just 25 in the rest of the year. "We've had to pull navigators out of half the counties," Ray said. "The lack of investment in on-the-ground assistance, as well as in education, continues to be a real deficit."

In West Virginia, navigator grants dropped from over $600,000 in the first Open Enrollment to $100,000 this year, according to Jeremy Smith, Outreach Coordinator at First Choice Services in Charleston, the sole recipient of this year's grant. "In the first years, we spent a huge amount of time doing enrollment events and outreach on TV and radio. We don't have the staff or budget to do the events now."

In El Paso, Texas, enrollment assistance staff at the Centro San Vicente Health Center is down from 11 people to 4, according to Outreach and Enrollment Manager Daniel Del Toro. "It's difficult to assist as many people, and there's not a lot of other sites assisting. There is now no navigator grant in El Paso for an organization that's physically here." While Centro San Vincente still receives funding for enrollment assistance as a Federally Qualified Health Center, it lost its share of a navigator grant for the El Paso area that was cut in 2017.

In South Carolina, Shelli Quenga, Director of Programs at the Palmetto Project in North Charleston, sees a lack of in-person assistance statewide because of the navigator cuts. In a bid for sustainability, her agency, which formerly was a navigator grant recipient, has become a non-profit brokerage.

Resilience and innovation

At the same time, these organizations, and the nonprofit statewide assistance networks of which they are part, have proved resilient, providing assistance to those who seek it. Ray in Florida leverages an extensive network of partnerships with businesses, schools, hospitals, community health centers, colleges and universities, faith communities, service agencies and elected officials. One key factor: "Several of the larger hospital systems in Florida made it possible to set up enrollment and referral sites throughout those systems."

"We're still out in the community a lot," says Del Toro in El Paso. "We had developed so many relationships with schools, food pantries, other organizations, and we go to all these community events to let the community know we're here. In summer I get three or four invites a week."

In West Virginia, First Choice has had to change its main mode of operation to reach people throughout a rural state on a limited budget.  "Our direct enrollment support is much more phone-based now.  People can still come into the office, but most of the time we help over the phone," says Del Toro.

In South Carolina, Palmetto's conversion to a brokerage model was a radical adaptation, still in progress. It takes time to build residual income as a brokerage, Quenga says, and their budget does not match the lost navigation funding. But they have been able to continue to help primarily low-income South Carolinians get coverage.

Ignorance of the ACA persists

Navigators in all four states report that the need for education and assistance has not diminished. Ray in Florida notes, "We still have to walk people through the basics -- coinsurance, deductibles, etc. And the uninsured pool is a moving target -- people who come into it change all the time. People age out of their parents' insurance, get married, get divorced -- it's a constantly moving door."

In West Virginia, as in other red states, the educational challenge is particularly intense because the ACA has always been politically toxic, particularly when associated with its pet name, Obamacare. "There's always been mass confusion here about the ACA and what it means for people. That's still true, Smith says. "Until someone loses a job with coverage or loses Medicaid, they often don't know what the marketplace is."  Researchers have found evidence that partisan hostility to the ACA drives up premiums in red states.

In recent years West Virginia's Medicaid agency has grown more adept at detecting Medicaid enrollees' income changes in real time - -and disenrolling them if they cross the eligibility threshold. That "churn" creates new educational challenges. Smith's colleague Maricel Bernardo, who has also been an enrollment assister since fall 2013, says, "I know people who have lost Medicaid, and just the concept of a premium is something they can't seem to comprehend" -- though marketplace premiums and out-of-pocket costs are relatively low for those just over the Medicaid eligibility threshold.

What about word of mouth, after six years? Quenga in South Carolina sees constraints on it. "The marketplace is also about what your income is. A person may not be proud to go to a neighbor and say 'you can get a plan really cheap like I did.'"

The ACA also still has a "political aura," Quenga says. "I had a person this year who said 'Is this Obamacare? -- I don't want that' and hung up. That kind of stuff still happens, though not as much as in earlier years."

Building trust

All the navigators I spoke to do have longstanding client relationships. "We have people we've helped for all six years," says Smith in West Virginia. "It's a comfort to meet with a navigator -- they know we study the market, study the plans. Even though they've become a lot more savvy, they always want to work with a navigator they know."

Complexity persists, even for experienced enrollees. Ray in Florida notes, "In Hillsborough County we have 77 plans this year. That's a lot of information to digest.  Even if they've been in the marketplace, things change -- income changes, maybe they have a kid -- those changes make the plans look different."

The marketplace application is a complex document. For those who have completed an application on their own, Ray says, "I always review to make sure they did it correctly. Even among those who feel like they can get through it, we see a lot of mistakes. For example, people always put in their net income instead of gross."

The lightly regulated short-term market, touted by the Trump administration as a cheaper alternative to marketplace coverage, has preyed on the general ignorance of ACA offerings. In West Virginia, Smith says, "People get scammed very easily. Imagine someone who doesn't know anything about the ACA. Most people's first impulse is to do a Google search. A lot of people don't end up on, they end up on a bunch of other websites." When people fill in contact info, "that leads to telemarketers calling them twenty times a day. A large percentage are selling limited benefit plans" -- these pay fixed amounts for designated services. The marketers are "very good at disguising what they're selling. People go months paying the premium and thinking they've got full coverage, but when they use it, they realize what it is."

The Trump chill on immigrant enrollment

All the navigators I spoke to have first-hand experience of the fear generated in immigrant communities by the Trump administration's aggressive pursuit of the undocumented, and by the administration's long looming and now implemented change to the Public Charge Rule, which threatens the immigration status of those who seek benefits including Medicaid.

El Paso is on the front lines of the Trump administration's war on immigrants, and Del Toro sees the effects. "There's fear among our residents," he says. "Even among citizens, when there's someone in the household who doesn't have documentation, they have that fear of applying for any kind of assistance. As much as I assure them, 'nobody else is going to be on this application -- just the individuals who are being insured'-- there is still that fear. Some kids end up without Medicaid or CHIP."

Del Toro also reports direct effects from the Public Charge Rule. "I had one family of legal residents, insured through the marketplace [the Public Charge Rule does not penalize recipients of marketplace subsidies]. One of them is turning 65 this coming month. I recommended she try to get the Medicare Savings Program, but she did not apply because they want to become U.S. citizens. You see that really often, and it's really sad." (MSPs to varying degrees pick up Medicare premiums and out-of-pocket costs for low-income enrollees.)

51 markets 

The navigators' testimony highlights the fact that the ACA marketplace is really 51 separate programs (D.C. has its own marketplace). The array of choices available, and the prices at different metal levels for subsidized and unsubsidized enrollees alike, vary widely by state (and not infrequently by county or even zip code).

In Florida, Ray notes that a fair number of clients got good news in 2020 as premiums went down for them. Competition is robust: nine insurers offer plans through the marketplace, up from seven in 2019.  Prospective enrollees' response to offerings varies by individual circumstances -- young and lower-income people tending to be more satisfied, older and wealthier people less so.  Since 2014, enrollment in Florida has increased every year but one, and reached a high point of 1.9 million in 2020.

West Virginia's marketplace, in contrast, is one of the nation's most troubled. While the ACA has cut the state's uninsured population by more than half, from 14% in 2013 to 6% in 2018, that progress has come almost entirely through the ACA Medicaid expansion, which extended eligibility to 157,000 West Virginians in 2019. Marketplace enrollment in the state has dropped from 37,000 in 2016 to 20,000 in 2020.  While subsidized enrollees are insulated from steep premium increases, since subsidies rise with premiums, deductibles and out-of-pocket costs have also risen sharply.

Smith has a front-seat view of the deterioration of offerings in West Virginia. "At first, people were pretty satisfied with premiums, coverage and the provider networks. Now, unless someone qualifies for Cost Sharing Reduction, they're likely to be very unhappy. That's the most frustrating part -- to work with someone who doesn't make much and still can't afford the coverage. "

A bit more than a third of West Virginia's enrollees are in silver plans with strong Cost Sharing Reduction (CSR), which reduces out-of-pocket costs to a level below that of the average employer-sponsored plan for people with incomes up to twice the federal poverty level. Most of the rest are in plans with deductibles ranging from $3,900 to $7,900 for a single person.

With the tax penalty for going uninsured gone (zeroed out by the Republican Congress as of 2019), Smith says that a lot of former enrollees decide to pass up coverage. Their attitude is, "'I'll save money from the premiums, keep it in the bank, and if something happens, use that money.' Seeing a deductible in thousands puts a lot of people off. People who sign up are the ones who are sick and use their insurance throughout the year."

Networks have also deteriorated, Bernardo notes, for the state's two insurers, Highmark Blue Cross Blue Shield and CareSource. "Two years ago, to contain costs, Highmark Blue Cross Blue Shield changed from a PPO to an EPO. Now their plans no longer have out-of-network benefits" -- often a major impediment for people in a rural state. As for CareSource, the biggest hospital in Charleston exited its network in mid-year. "We had people in the middle of treatment," Bernado recalls. "I had one client in the middle of cancer treatment. Luckily, we were able to extend coverage" to the end of the year. "Starting in January, people who had to go to that hospital had to enroll in BCBS."

*          *          *

In July 2018, CMS announced that it was cutting navigator grants from $36 million to $10 million, after a cut from $63 million in the prior year. "As the Exchange has grown in visibility and become more familiar to Americans seeking health insurance, the need for federally funded Navigators has diminished," the press release asserted.

From the navigators' on-the-ground perspective, that claim is manifest nonsense. "We're constantly getting new people in who don't understand how individual insurance works, who don't understand how the marketplace works," says Quenga. "The need for education is constant. So that means the need for outreach is constant. You still run into people who say, 'I didn't know this still existed' -- they didn't need it, so it wasn't up on their radar. That flies in the face of what the current administration has tried to tell people, that everybody knows the marketplace, so there's no need to do the same kind of outreach and marketing as in early years."

"We are vehemently in disagreement with that," Quenga continues, "because of the very nature of the individual marketplace. The lion's share of our country still gets coverage from their employer. When they're  between jobs, when they turn 26 and get off their parents' coverage, that's the time when they need to understand what the marketplace has to offer, and if they don't know it's even out there, they don't know how to ask the questions."

The complexity of the marketplace, emphasized by all of the navigators, is one of its flaws. The Trump administration's hostility to the concept of insurance as public benefit, requiring publicly funded assistance as well as financial support, has exacerbated the problems caused by that complexity. The parallel market the administration has promoted -- lightly regulated plans that exclude coverage for pre-existing conditions, promoted in many cases by brokers who seek to hide the products' limitations -- stands as a kind of Trumpian ideal, a kingdom of caveat emptor.  Yet the ACA marketplace has proved resilient as well as limited.

Committed nonprofit assisters personify that resilience, and have helped to make it possible. As the country braces for mass layoffs, and recognizes that affordable access to testing and treatment of the coronavirus is vital to controlling the pandemic, restoration and further beefing up of funding for enrollment assistance and outreach should be a top priority.

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