A Compass for America’s Health Care Navigators


By Suzie Shupe, California Coverage & Health Initiatives

The Affordable Care Act’s (ACA) health insurance exchange marketplaces offer the promise of connecting millions of uninsured Americans with the health coverage and care they need. And by strengthening Medicaid, millions more will be able to get care.

It is an historic opportunity, but also an unprecedented challenge. As the 2014 launch date for these improvements rapidly approaches, states are grappling with the question of how to connect uninsured and underinsured Americans, including millions of children, with new options to see the doctor when they need to.

The ACA envisions a new type of consumer advocate – the Navigator. As the name implies, navigators will help consumers navigate the health care system by educating them about their health coverage options, assisting them in getting into or keeping coverage, and empowering them to sign up for insurance that is cost effective and helps keep them healthy. The law provides minimal information about navigator programs, and recent federal agency guidance adds only a bit more detail. For the most part, states will be given wide leeway to develop navigator programs. That means states will have to figure out who can be navigators, how they’ll be educated or trained, how they’ll be compensated, and – most importantly – what their mission and focus will be.

And the stakes are incredibly high. ACA navigators, while just one part of a much larger eligibility and enrollment system, will be important in determining whether policy changes will actually translate into care. In other words, if a state’s navigator program isn’t successful, ACA and the state’s exchange may well not deliver on the promise of reform.

California’s experience offers a useful model for other states. Since California is among the few states that have moved quickly to establish a health benefit exchange, and has consumer advocates with on-the-ground experience helping millions of children navigate into coverage, state advocates are already thinking about how that knowledge can help California’s navigators make the navigator program and the ACA a success.

California consumer advocates have developed a set of seven Guiding Principles for Consumer-Focused Navigators:

1. Duty to the Consumer

2. Accountability and Oversight

3. Health Care Expertise Across the Full Range of Coverage Options

4. Training and Certification

5. Independence and Disclosure

6. Providing a Full Range of Services

7. Cultural and Linguistic Competency

The first principle is the most important. Navigators’ primary duty should always be service to the consumer. This should help protect against navigators “steering” consumers towards particular coverage options to the benefit of the navigator, and insure consumer privacy. The rest of the principles address other critical concerns that, together, help to ensure that navigators work effectively and reach the people we need them to.

Conversations are starting now in statehouses, in back rooms, and in the newly forming exchange boards throughout the country. Leaders are beginning to talk about how to meet enrollment challenges that are a short 18 months away. There is no time to waste in beginning a serious stakeholder process in each state that designs a navigator program tailored to meet the needs of the unique populations and demographics in each distinct part of the nation.

But states don’t have to start from scratch. Adopting a set of guiding principles based on California’s model as a framework is one way to get the conversation going, and to ensure that it is heading in the right direction.