April 2014; California HealthCare Foundation

The conservatives who dislike government regulation and usually fight against government licensing apparently love regulation and licensing when it comes to the navigators who help people access health insurance on state and federal health exchanges. Although the first year of Affordable Care Act enrollments has come to a close, state legislatures are taking all sorts of aim at reining in healthcare navigators beyond the standards included within the federal regulation.

The examples are endless. The Georgia assembly recently passed legislation that would end the University of Georgia Health Navigators program by making it illegal for employees of state-funded institutes to use state funds for navigator services in the healthcare exchange. According to David Bradford, a public policy professor at the university, the legislation would even prevent any state entity, specifically mentioning the University of Georgia system, from applying for funding to evaluate how the exchanges are working. Although there are some differences between the assembly bill and the one passed by the state, with Republicans dominating both chambers and a Republican governor, it seems unlikely that Georgia will walk this back.

Pennsylvania legislators are considering additional restrictions on the navigators. One of the sponsors of the pending legislation, State Senator John Eichelberger, issued a memorandum explaining his concern that navigators were likely to give incorrect information about insurance plans, inaccurately tabulate incomes to see if consumers qualified for subsidies, and violate consumers’ privacy. Republicans, who are unlikely to favor much regulation, relying on the self-correcting mechanisms of the market and the judgments of consumers, seem to be energetic in Pennsylvania, Arizona, and other states in promoting consumer protection regulation to guard against insufficiently monitored and regulated navigators.

There is a problem with the functions of navigators, but it doesn’t appear to be one of insufficient regulation or oversight. As NPQ pointed out, when the navigators grants were first announced by the White House, they were very late in the process, only several weeks before the start-up of the federal and state exchanges, followed by an even later distribution of training materials by the Department of Health and Human Services. Immediately upon the announcement of the navigators grants, congressional Republicans and some state attorneys general announced investigations of the navigators, forcing them to spend time and effort defending themselves before they had even done anything. Add to that the mess of the exchange websites, and it is nothing short of extraordinary that the navigators accomplished what they did in helping millions sign up for health insurance.

A study by the California HealthCare Foundation earlier this year documented the problems of both consumers and navigators. Not only did consumers and navigators struggle with the websites, but they also struggled with the complexity of the offerings and the documentation. Clearly California’s navigators could have benefitted from more training, but the Affordable Care Act process, including state programs such as Covered California and the various state Medicaid programs, was a compilation of complexity, much of it required by the Rube Goldberg legislation that made it through Congress.

“I think we oversold simplicity,” Frank Mecca, executive director of the County Welfare Directors Association of California, said. “As it turns out, it is not as simple as we thought.” In truth, Mecca, his colleagues, and the navigators were presented with a program of stunning complexity and told to make it work.

The California study seems to have been misreported in the press to some extent. A look at the findings of the actual study reveals the following:

  1. Most people were relieved to have gotten health insurance.
  2. Many people had significant gaps in knowledge even after they had enrolled—just like most consumers dealing with the arcane, almost uninterpretable world of insurance, health or otherwise.
  3. People “with fluctuating income or who receive payments in cash had difficulty figuring out future earnings or averaging their incomes”—nothing at all surprising about that.
  4. Choosing a plan was difficult, weighing premiums, deductibles, copays, and total out of pocket costs—again, not surprising.
  5. Applicants found documentation requirements challenging, especially for Medi-Cal applicants who had to provide proof of income, proof of residence, and immigration information.
  6. Consumers had mixed experiences with the state’s call center.
  7. Latino applicants had specific fears about whether they would face problems with their immigration status, and they were frightened by rumors that enrolling in Medi-Cal would mean the loss of their homes.
  8. Vietnamese- and Mandarin-speaking applicants were not able to use the online applications and often had to rely on English-speaking family members and friends for help.
  9. “Counselors” felt that they could have benefitted from more training and were concerned about their limited abilities to help Medi-Cal applicants.

The report’s recommended solutions were all common sense: better communications with consumers, improvements to the Covered California website, more outreach and education, and more support for the counselors, navigators, and even insurance agents.

This all adds up to the following: efforts that were nothing less than heroic by navigators, other counselors, and insurance agents to make a complex program work; specific challenges and obstacles for lower-income consumers who had to deal with the specific issues of Medi-Cal (Medicaid); and revelations that had the ACA not been legislated into virtual impossibility, the nation would have had a much easier time extending health insurance coverage to the millions of people in need.—Rick Cohen