Under Biden, HealthCare.gov maintains its Trump era tilt toward commercial insurance brokers

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11/19: See update at bottom:  Healthcare.gov put out an email today that leads with nonprofit assisters

Obtaining health insurance from publicly supported programs in the U.S. is a complex process, necessarily supported by a variegated ecosystem of enrollment assisters.  For people under age 65, nearly 50,000 commercial health insurance brokers and agents are registered (as of 2020), along with about 30,000 nonprofit enrollment assisters (as of 2016), many of the latter supported by federal or state funding.

Enrollment of the under-65 population that lacks access to employer-sponsored insurance depends on both commercial and nonprofit assisters, who have different and to some extent complementary strengths and weaknesses. 

Nonprofit navigators and Certified Application Counselors (CACs) are certified and trained by the federal government, or by state governments in 18 states (including D.C.) that now run their own ACA exchanges. They are mandated by statute and trained to accommodate vulnerable and underserved populations, to provide culturally sensitive assistance, particularly to people with limited English proficiency, and to present all options without making a positive recommendation. They receive no compensation from insurers and depend either on government funding (navigators and assisters in Federally Qualified Health Centers)  or nonprofit funding sources (CACs). 

Agents and brokers do make positive recommendations; they are funded by insurer commissions and sometimes work for only one or in any case not all insurers selling on-exchange plans in a given area. They cost government nothing but may not offer unbiased information. They can be unscrupulous, pushing people into ACA-noncompliant plans that offer skimpy and unreliable coverage, and, alternatively, they can be worth their weight in gold. They are required by some but not all states to act in the client's best interest.

The Trump administration declared war on nonprofit assisters, reducing funding for the federal navigator program (operating in states that use the federal exchange, HealthCare.gov) by 84%, from $63 million in 2016 to $10 million in 2018 and years following (state-based exchanges have their own funding base for enrollment assistance, gleaned from user fees charged to insurers participating on the exchange).  Under the leadership of Seema Verma, CMS maligned and slandered the navigator program, exploiting weaknesses in the program's data reporting and ignoring the fact that in many states navigators, who primarily serve low income people,  enroll more people in Medicaid than in marketplace plans.

On the other side of the ledger, the Trump administration bulked up broker capabilities in ways the Biden administration is unlikely to jettison. They encouraged continuing development of a Direct Enrollment program, through which commercial online brokers and insurers could take online applications and process subsidies.  This system is dominated by HealthSherpa, an excellent online enrollment platform that thousands of brokers can use and brand privately, and which most insurers that have registered as Direct Enrollment providers also license. In 2021, HealthSherpa processed about 23% of all enrollments on HealthCare.gov.  The Trump administration also developed a Help on Demand program, administered by a private contractor, through which a visitor to HealthCare.gov can request assistance and be contacted by an agent or broker within 30 minutes. In 2020, Trump's CMS boasted, brokers assisted just shy of half of all enrollments on HealthCare.gov. (Conversely, a 2016 KFF study  estimated that nonprofit assisters helped about 5.3 million people in Open Enrollment for 2016.)

The Biden administration reversed the depredations suffered by the navigator program, allocating more than $90 million dollars to 60 navigator groups for the Open Enrollment season that began on November 1, along with an enhanced advertising/marketing budget.

But the Biden administration has not reversed the inherited tilt of HealthCare.gov toward assistance from commercial brokers and agents. As someone with a dormant login to HealthCare.gov, I have received the email pitch below six times since Open Enrollment for 2022 began (my emphasis):

That is a deployment of the Help on Demand program mentioned above, which deploys commercial brokers and agents only. Clicking through takes you to a Help on Demand form.  Hence the exclusive mention in the main body of the pitch of agents or brokers, excluding navigators and CACs. 

At the very bottom, the pitch does provide this backhand allusion to the nonprofit assistance universe:

The Find Local Help page also steers visitors towards brokers and agents:

At the top, assisters are mentioned second, and in the filters, "agent or broker" has the preferred left margin placement. Plus, there's an extra bolded prompt for the Help on Demand app, necessarily referencing only agents and brokers.  

If you click on the "learn about differences" link, that box too pulls you toward toward brokers/agents (via the colored prompt at bottom):

"Help on Demand" is a powerful application. Could navigator and CAC groups accommodate the timely response requirement -- aided by the new infusion of funding? Are there other reasons not to include them? 

The tilt toward brokers and agents may be inevitable. There are more of them. But a (slight) majority of marketplace enrollees have incomes under 200% FPL, placing them in the lowest-income quarter of U.S. households. Nonprofit assistance is better suited to people in this income category. The current messaging on HealthCare.gov doesn't reflect that.  The site is putting navigators and CACs in a corner.

UPDATE, 11/19/21: Glory be, this morning HealthCare.gov put out a "need help?" email that puts nonprofit assisters first:

I've run an email check and confirmed that this is the first of seven "need help?" emails not focused first and primarily on brokers. 

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