Friday, March 15, 2024

Biden administration to ACA enrollment assistors: Please credit yourselves

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Please add my 13-digit ID

CMS is apparently working to redress the Trump administration’s attack on the effectiveness of the nonprofit enrollment assistors chartered by the ACA and partly funded by the federal government.

Earlier this week CMS sent this memo to enrollment assistors:

The memo spells out the rationale for ensuring that navigators, CACs and EAP, who have no direct financial incentive to credit themselves on marketplace enrollments they facilitate, do so anyway:

Including your assister ID will help the Centers for Medicare & Medicaid Services (CMS) to better understand the support that the assister community provides and continue to improve the consumer experience….

Understanding your reach as an assister is important to enhancing the support CMS provides you and the consumers you assist.

There is a long history behind this exhortation.

2014-2016: An enrollment assistance ecosystem evolves

The ACA statute established the Navigator program to provide enrollment assistance, 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. During the Obama administration, funding for the Navigator program topped out at $63 million for the 38 states using in 2016.

The Navigator program was always a relatively small part — numerically, at least — of the ecosystem of nonprofit enrollment assistance that developed during the Obama administration in advance of and through Plan Years 2014-2016. The Kaiser Family Foundation (KFF) mapped out that ecosystem in a 2016 survey report, and I provided some back history (with input from KFF’s Jennifer Tolbert) here. A separate dedicated funding steam for enrollment assistance within Federally Qualified Health Centers reached about $150 million in 2016. The 13 state-based exchanges invested about $85 million in that year, according to KFF. A broad array of nonprofit groups deploying Certified Application Counselors (CACs), mostly privately funded, accounted for 55% of people helped by nonprofit assisters, according to KFF. Navigator programs, which have a unique mandate to provide outreach and education as well as enrollment assistance, accounted for 10% of all assistance programs and 17% of assisted clients in 2016, per KFF.

In all, KFF estimated that some 5,000 assistance programs deploying 30,000 assistors served about 5.3 million clients in 2016. Most programs reported to KFF 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.

2017-2020: The Trump administration’s War on Navigators

The Trump administration famously gutted funding for the Navigator program in states, abruptly reducing it from $63 million in 2016 to $36 million in 2017 (in advance of the Open Enrollment Period for 2018) and $10 million in 2018 (for OEP 2019). CMS, led by Seema Verma, justified the cuts by deeming the program ineffective, claiming that navigators enrolled fewer than 1% of enrollees for Plan Years 2017 and 2018, while brokers were credited with 42% of enrollments at far less cost to the federal government. At the same time, Verma’s CMS boosted logistical and outreach support for for-profit health insurance brokers and agents, which probably did have long-term positive effects on enrollment, as discussed in this post. )

The data point at the heart of this ideological assault is the one addressed in the CMS memo above: the low number of enrollments that record the input of a navigator in the “Application Help” segment of the enrollment application. That basis for attacking the program’s effectiveness was highly misleading, as many defenders pointed out.

Most fundamentally, Navigator programs, commissioned to find and help low-income, low-information, immigrant, rural, and other vulnerable populations, enroll far more people in Medicaid than in the ACA private plan marketplace, as they reported to KFF, and as I documented through several state-based marketplace reports in the post cited above.

Secondly, unlike brokers and agents, nonprofit assistors have no financial incentive to get themselves credited on the application. The Obama administration never particularly pressured them to do so, and neither did supervisors in many programs. Government-certified nonprofit assistors are also charged not to positively recommend any given plan, but rather to provide neutral information to inform the enrollee’s choice. In many cases it is ultimately the client who pulls the trigger. Indeed, if I remember correctly from my own CAC training, assistors are technically not supposed to operate the keyboard during the application. In any case, pushing clients to enter a “13-digit alphanumeric ID” as part of a long and challenging application is not in many service-oriented nonprofit workers’ DNA. All in all, KFF noted, the number of one-on-one encounters navigators reported was 15 times higher than the number of QHP selections recorded electronically. And again, most assistance groups reported to KFF that most clients did find coverage — mostly in Medicaid, sometimes in the marketplace.

The Biden Restoration: 2021—

When the Biden administration took office at the height of the COVID-19 pandemic, it swiftly a) opened an emergency Special Enrollment Period extending from February-August 2021; b) provided a huge boost to marketplace subsidies and subsidy eligibility, effective in March 2021; and c) threw some quick cash at the Navigator programs, which had been operating on a shoestring in the Trump years. Then, for OEP 2022, the administration boosted Navigator funding eightfold, to $80 million, quadrupling the number of navigators in the field. For OEP 2024, federal funding for Navigators in 33 states rose to $98.6 million. The Biden administration wants navigators to document that that money is well spent.

Since OEP 2021 (administered by the Trump administration in late 2020), ACA marketplace enrollment has increased by 87% — almost certainly fueled above all by the massive subsidy boosts included in the American Rescue Plan Act of March 2021 (and extended through 2025 by the Inflation Reduction Act of August 2022). When touting the results — 21% enrollment growth in OEP 2022, 13% growth in OEP 2023, 30% growth in OEP 2024 — the administration always cites the increased Navigator funding, along with other factors. Analysts and news outlets, including KFF, also name-check the program when accounting for the enrollment gains. The Biden administration appears to be seeking supporting data. As far as I know, no individual or group has surveyed or assessed the nonprofit enrollment assistance universe since KFF’s 2016 survey. (I took a qualitative dive into navigators’ experience in 2020, but that’s not the same thing.)

Registered navigator-assisted enrollments are not likely to provide much support, except relatively (perhaps rising from 1% to say 3% of enrollments on — for all the reasons noted above. I don’t know whether Navigator-assisted Medicaid enrollments through the portal will be tallied, but even if they are, a) three quarters of enrollments are in states that have refused to enact the ACA Medicaid expansion, and b) in many states, navigators use separate Medicaid enrollment portals for Medicaid-eligible enrollees, as going through can add administrative friction.

It’s also important to keep in mind that the Biden administration has continued the Trump administration’s support of for-profit brokerage, continuing to encourage development of Enhanced Direct Enrollment (EDE) on commercial online platforms (mostly HealthSherpa), where brokers enroll and track the majority of their clients in states. As I’ve noted recently, brokers execute the majority of enrollments on, and half or more of active enrollments (excluding passive auto-re-enrollment) are executed through EDE platforms. While the army of nonprofit enrollment assistors has doubtless grown from the 30,000 tracked by KFF in 2016, the ranks of brokers registered with has increased from 49,000 in 2018 to 83,000 at present.

Navigators and other nonprofit assistors play a vital role in getting vulnerable, low-income, immigrant, and hard-to-reach populations into health coverage. A comprehensive assessment of their impact is long overdue. Credited marketplace enrollments may provide a significant if minor data point in that assessment.

Caveat: The CMS memo cited above may not be unique to this year. I have searched my own mail from CMS and don’t see a prior-year version. If you know of precedents, please let me know.

Photo by Christina Morillo 

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