I was ready to wrap up this blog series last week when HHS announced an additional $150 million in funding for “Outreach and Enrollment Assisters” in community health centers to help connect consumers to coverage. There seems to be a wealth of assisters: navigators, in-person assisters, certified application counselors and now health center assisters. And this new pot of money sounds like a lot: $150 million in comparison to the $54 million offering for navigator grants. It will clearly help, particularly in those states where HHS will run the marketplace (FFM) solely. But altogether, it’s a slightly more than double what New York and California alone will spend on navigators and assisters. While we applaud HHS for finding additional resources for assisters, we remain very concerned about whether there will be enough boots on the ground.

How many assisters do we need? I’ve been getting this question from a lot of state partners. In the proposed rule, HHS asked for comment on the number of navigators and assisters expected, as well as number of consumers expected to receive assistance. It was an odd way to approach the question, better to look at the number of consumers that will need assistance and then estimate how many navigators and assisters are required to meet the need. Nonetheless, this request for comment finally nudged me to dig a little deeper into some research my colleague, Tara Mancini, pulled together from exchange grant proposals and navigator requests for proposals issued by states creating their own marketplace or managing consumer assistance in a partnership marketplace. Given that these states can tap federal funding – specifically, 1311(a) exchange establishment grant funds – for in-person assisters, they have far more resources for consumer enrollment assistance than states with a non-partnership FFM.

Here’s what we learned. In large states and small states, the difference is striking. California expects to assist 1,090,258 people in accessing coverage in 2014 with an estimated $57.9 million paid to 25,000 navigators and assisters. In New York, 560,000 are expected to enroll in the individual exchange, and the state will spend $27.2 million annually on consumer assistance for the next five years. Contrast that to Texas, the state getting the largest share (15%) of the federal navigator pie ($8.1 million of $54 million), where 7.35 million are uninsured of which the Urban Institute estimates a reduction of 2.5 million if the state does not expand Medicaid and 3.8 million if Medicaid is expanded.

Looking at smaller states, New Hampshire anticipates spending more than $2 million on in-person assisters to serve 83,500 and will receive another $600,000 for navigators, while Vermont will spend a total of $2 million on navigators and assisters and expects to enroll 266,500. Contrast that to Kansas, where 336,885 people are uninsured and Urban estimates an 80,000 reduction in the uninsured; the state will receive only $600,000 for federal navigators.

There’s probably a mathematical forecasting tool some smart statistician could put together to estimate the number of navigators, assisters and project leads needed based on 1) the number of uninsured; 2) the percentage expected to enroll in the first year; 3) the average number of individuals on each application; 4) the proportion that will need or want assistance; 5) the period of time for open enrollment; and 6) the average number of applications a navigator might assist given their other duties, including conducting outreach and public education. But quite frankly, we don’t need a fancy formula to tell us what we already know. Consumer assistance funding in states accessing only federal navigator and community health center grant allocations is strikingly inadequate.

$600,000, the navigator funding allocation in 13 states, even with new allocations for health centers, just won’t go very far. New Hampshire estimates that $73,000 is need to fund full-time each assister. Keep in mind that in addition to salary and benefits, there are overhead costs: office space, telephone, computers, supplies, language services and materials, not to mention travel. So in essence the navigator grants would fund 8 or less full time navigators – clearly not adequate to the meet the needs of an entire state.Look at it another way. Arkansas estimates that between outreach, application assistance and other duties, assisters will spend an average of 2.25 hours helping each consumer. They assume that 211,000 consumers will need assistance; thus a total of 475,445 total hours of assistance is needed. Assuming assisters are helping consumers 85% of their time over 6 months of open enrollment, each full-time assister represents 884 hours. Total hours of assistance needed (475,445) divided by 884 hours per assister equals an estimated number of 538 in-person assisters needed.

We continue to push for HHS to allow non-partnership FFE states to access more federal funding for assistance (states are being reimbursed for certain plan management and outreach and marketing activities). But the clock is counting down and quite frankly, it’s not clear how many FFE states (i.e. state government) would even be inclined to tap such funding. Rather than wringing our hands and gnashing our teeth, let’s roll up our sleeves and see what else can be done to make sure assistance will be plentiful enough. One thing is clear: advocates should not wait for the federal government to swoop in and solve this problem (although it can help); solutions are more likely to be found at the state and community level. It will take the larger stakeholder community coming together – foundations, health care providers, consumer advocates and community-based organizations – to pool their resources and coordinate activities. Say Ahhh! welcomes the opportunity to highlight examples of where this is happening, so please contact me if your state or community has a positive story to share.