Sabotage Update: ACA Navigation budget slashed 84% from 2016

As I noted back in July, in addition to the Trump Administration's Centers for Medicare & Medicaid (CMS) chopping down the marketing budget for HealthCare.Gov by 90% last year, they also slashed the navigator/personal outreach budget by over 40% as well, from $63 million down to $36 million...and this year have cut it by another $26 million, to just $10 million across all 34 states which rely on HealthCare.Gov to host their ACA exchange open enrollment functionality (there are 5 more states which are hosted by, but which I believe operate their own exchange and navigator budget: Oregon, New Mexico, Nevada, Kentucky and Arkansas). Combined, that makes an 84% reduction in navigator funding over a 2 year period.

Since then, the anemic-level navigator grants have been doled out, and the Kaiser Family Foundation has run an extensive analysis of which groups in which states are receiving what funding to try and help educate and assist people with enrolling in their 2019 ACA healthcare policies. It's not a pretty picture for some states:

...On a state-by-state basis, funding reductions ranged from 0% to 96% from the amounts grantees had previously been notified to expect for the 2017-2018 program year.

On September 12, 2018, CMS released funding awards for the federal marketplace Navigators for 2018-2019, which reduced funding to $10 million.  Compared to 2016, federal Navigator funding for the coming year marks an 84% reduction (Table 1). For the coming year, three states (Iowa, Montana, and New Hampshire) will receive no navigator funding (Map 1).  Within other states, there will be areas where no navigators provide service (for example, Cleveland, Akron, Toledo and Youngstown in Ohio, Dallas, San Antonio and Austin in Texas, all of Michigan outside of the Detroit metro area).  Most of the current, experienced navigator programs will not continue.  For the 2016-2017 year, there were 104 navigator programs serving the 34 federal marketplace states, compared to 40 for the 2018-2019 year, seven of which are new grantees (Map 2).

CMS presented several reasons in explaining the reduced funding for Navigators. They say in the FOA that as the marketplaces have evolved, public awareness of the health insurance options available through the marketplaces has grown as has consumer knowledge of how to enroll.  Therefore, Navigators should be able to shift away from resource-intensive face-to-face consumer assistance to alternatives methods. Additionally, citing data it collects from, CMS argues that Navigators have played a limited role in facilitating enrollment in the marketplaces, particularly compared to brokers.

To be fair, the claim that "public awareness/knowledge of how to enroll" has grown over the past five years is probably true to some extent...especially for the millions of people who have already enrolled in exchange policies for at least one or two years. HealthCare.Gov, which was a nightmare to use and navigate when first launched, is certainly a lot easier and more intuitive to use these days, and so forth.

However, Kaiser's research has found that there's still a lot of hand-holding needed, especially for new enrollees:

Public awareness of marketplaces remains limited.  Although the marketplaces have been in place for five years, Kaiser tracking polls continue to find that most people, and particularly those who are uninsured, have limited awareness about open enrollment.  Additionally, findings from surveys of marketplace assisters consistently found that consumers seeking help – whether from Navigators, other marketplace assister programs, or brokers – had limited understanding of the eligibility and enrollment process, or of health insurance, and lacked confidence to apply on their own (Figure 1).  For three consecutive years, assisters reported the average in-person assistance appointment took one-to-two hours.

In addition, not all populations are equal. The low-hanging fruit is presumably people who are better-educated, have already been enrolled in individual market insurance at sometime in their past and so on. According to Kaiser, however...

Navigators and brokers do not serve the same populations or provide the same services.  According to findings from the KFF Marketplace Assister Survey, while the work of brokers overlapped to a significant extent with that of Navigators and other marketplace assister programs, these professionals were not interchangeable.  Brokers were significantly less likely than Navigators to help individuals who were uninsured, had limited English proficiency, or who lacked internet at home (Figure 2). Brokers were also far less likely to help complete applications for Medicaid or CHIP for low-income consumers who learn through the “no wrong door” marketplace application process that they are not eligible for premium tax credits but may be eligible for public plan coverage.

The most disingenous claims by Trump's CMS spokespeople,  however, is that ACA navigators "only enroll a tiny percent" of people in healthcare policies. This is not only factually wrong, it also completely ignores the many other functions which navigators perform. My friend Mina wrote a thread back in July which explained how important these (and related) programs are. Note: "CAC" = "Certified Application Counselors", which aren't quite the same thing as an official Navigator:

I was an enrollment assister (a CAC, NOT a navigator, but much the same function) in rural WV for 3 Open Enrollments. I now assist health insurance consumers in NYC. Let me tell you about these people we help. 1

— Mina (@TheNewGenou) July 11, 2018

I’ve helped countless food service workers. Their hours are variable and in small town WV, they simply don’t make much. Most didn’t know they qualified for expanded Medicaid. 2

— Mina (@TheNewGenou) July 11, 2018

I’ve helped small business owners. A nursery owner who makes most of his income in the spring and summer and didn’t know how to report this to the Marketplace. A diner owner who got insurance for the first time in years because of the subsidy that helped him pay. 3

— Mina (@TheNewGenou) July 11, 2018

A gentleman who qualified for a SEP because he lost his Medicaid, just weeks before a lung cancer diagnosis. A young mother with ovarian cancer who didn’t know she could get coverage. A retiree who finally could afford a knee replacement. 4

— Mina (@TheNewGenou) July 11, 2018

And the coal miners. With each lay off or benefits fight comes fear of the unknown. I was able to offer comparable coverage via the Marketplace so they could have one less thing to worry about. 5

— Mina (@TheNewGenou) July 11, 2018

And I’ve helped people disenroll. Fabulous stories of getting jobs, marrying into insurance, becoming Medicare eligible. 6

— Mina (@TheNewGenou) July 11, 2018

And finally I was an enrollee. As a CAC I was a contracted worker who, as a cancer survivor, realllllly needed affordable insurance. I was able to get my follow up care as needed and work a job I loved because of my access to health insurance. 7

— Mina (@TheNewGenou) July 11, 2018

#NavigatorsMatter. Health insurance literacy is low, & the system is complex. The cuts that came yesterday mean folks are going to show up to empty offices looking for help, and have no trusted, unbiased source for coverage information. It’s tragic and malicious. 8

— Mina (@TheNewGenou) July 11, 2018

If you need help with insurance, reach out. I’m here. Peace.

— Mina (@TheNewGenou) July 11, 2018

Others have also noted how important these programs are:

In particular, navigators help communities of color and others that face barriers to enrollment. Cutting the program is a direct attack on those people

— Ben D'Avanzo (@BenDAvanzo) June 20, 2018

& plans change from year to year, so navs generally help the same folks annually in shopping around to decide which plan best fits needs. The CMS statement that people are familiar with how the Marketplace works now & thus navs are not needed is patently false. #NavigatorsMatter

— Mina (@TheNewGenou) July 14, 2018