Obamacare enrollment at vaccination sites Part II: Navigators on their own, mostly

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A month ago, I posited that the impressive drive to vaccinate all U.S. adults is also a golden opportunity to insure the uninsured. 

Vaccinations are free to all, but in the vaccination process the uninsured must identify themselves as such. An estimated 11 million uninsured are eligible for marketplace subsidies (now often zeroing out premiums entirely), and another 7 million for Medicaid. The emergency Special Enrollment Period launched by the Biden administration on February 15, running through August 15, opens the enrollment door to anyone who's uninsured and lacks access to other coverage -- and coincides with the vaccination drive. 

As noted in the prior post, while some assister groups have done outreach at vaccination sites, and at least a couple of states have supported such efforts to some degree, the initiative has come mainly from the assisters themselves (generally operating on a shoestring through the lean Trump years), not government agencies, and efforts have been scattered.  

That is accurate. CMS confirmed to me that while the agency gives assister groups vaccine information to disseminate, "CMS...has not promoted or organized any official Marketplace outreach or enrollment events in conjunction with any COVID-19 vaccination site or event."

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.

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.

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.

No, CMS, ACA marketplace enrollment isn't up this year, and doesn't justify navigator funding cuts

To justify gutting funding for the navigators who help low income people enroll in health insurance subsidized by the ACA (Medicaid as well as marketplace), CMS is turning a bogus talking point it concocted last year inside out. Here's the current claim, as reported by KHN's Phil Galewitz:

CMS also notes that after last year’s navigator funding was reduced, the overall enrollment in Obamacare plans increased slightly (when counting people who paid their first month’s premiums) to 10.6 million people.

Comparing 2017 and 2018 totals at the end of open enrollment  (before many enrollees have paid their first premium), total ACA marketplace enrollment was down 4% this year. CMS's comparison above uses the totals from the "effectuated enrollment snapshots" from 2017 and 2018, which tracked how many people were enrolled (and had paid their first premiums) as of February in each year. The reported total at that point was 10.3 million in 2017, vs. 10.6 million this year.

As Charles Gaba pointed out last year (and revisits here), however, the 2017 "snapshot" exaggerated early attrition by failing to take into account the fact that those who enrolled between 1/15 and 1/31 (the final day of OE in 2017) did not have payments due until March 1.  There were 539,352* enrollees in that time frame.  None of them could effectuated their coverage for February, which is the population counted in the "snapshot." If those enrollees effectuated coverage at the same rate as enrollees before 1/15 (88.5%), there were 10.8 million who had effectuated or would soon effectuate as of the time of CMS's tally. That total outstrips this year's by 2% .**