The Centers for Medicare and Medicaid Services (CMS) announced on July 10, 2018 that they would fund up to $10 million for Navigator programs in the 34 federally facilitated marketplace (FFM) states in 2018, a 60 percent cut from 2017 funding levels, and an over 80 percent cut from the program’s original funding. CMS is also encouraging applicants to educate consumers about plans that don’t meet Affordable Care Act (ACA) standards, such as short-term limited duration (STLD) plans, association health plans (AHPs), as well as Health Reimbursement Accounts (HRAs). The funding announcement further emphasizes CMS’ decision to roll back requirements to have at least two Navigators per state as well as a physical presence in the marketplace service area. Lastly, CMS has announced that they will prioritize applicants that demonstrate “innovative and cost-effective approaches in reaching enrollment goals.” With over 80 percent of the original funding now cut, Navigator programs will have to significantly scale back services; many may shut their doors completely.

Taken together with the slew of changes to rules and regulations affecting the ACA, and drastic cuts to outreach and advertising budgets, CMS’ Navigator announcement likely means more consumer confusion and fewer people signing up for coverage. Those that do are more likely to have greater health needs, leaving the ACA marketplaces with a smaller, sicker pool of enrollees – and higher prices as a result.

Navigators have been an essential – and highly effective – part of the ACA marketplaces

The ACA created the Navigator program as a vital part of efforts to educate and help millions of uninsured Americans sign up for insurance. Navigators were intended to be embedded within hard-to-reach communities with high uninsured populations, educating and assisting consumers throughout the year. And that is exactly what they have been doing. Navigators are often based in community health centers, hospitals, universities, and legal aid centers. They assist in enrollment, education, and consumer advocacy, aiding in appeals processes and resolving application issues such as income and proof of identity inconsistencies.

CMS argues that Navigators “failed to enroll a meaningful amount of people” in 2017. This argument misses the point of the Navigator program. Like filing taxes, enrolling in health insurance can be fairly simple and quick for people who have a single source of reliable income, a stable family situation, good credit history, and no particular health care needs. Navigators and assisters can and do help these individuals, but the program was not designed for them. The Navigator program primary purpose is to help people with much more complicated eligibility and enrollment needs, such as:

• The woman who works two-part time jobs with varying and unpredictable hours and pay at each.
• The man who just obtained his permanent residency and has no credit history or previous tax filings to prove his identity.
• The mother with little to no English proficiency who needs help with translation to make sure she and her children have the right health insurance to cover medications and doctors’ visits.
• The elderly couple who are ineligible for Medicare based on work requirements and live in a state that did not expand Medicaid, wondering if they can get insurance to cover their chronic medical conditions.

For a majority of Navigators, appointments like the ones described above are common, with sessions that typically last 1-2 hours. A significant number are even longer, or take multiple follow up visits and phone calls. As a result, one Navigator may only help four people per day. However, without a Navigator’s help, a majority of these clients would not successfully enroll in insurance.

As an assister, I experience this every year. Last year, a client of mine fell just $204 under the federal poverty line because he miscalculated his income. Without my help reviewing his financial statements, he would have been caught in the Medicaid gap, facing premiums of over $900 per month, effectively leaving him uninsured. Another client had an offer of employer-sponsored insurance, but the coverage was skimpy and far more expensive than his ACA plan had been. Other Navigators and I worked with this client for weeks to figure out his best path forward, finally figuring out that he had projected his income to be higher than it actually was because he did not subtract federal holidays for which he was unpaid. Correcting his income made him eligible for ACA marketplace subsidies – and helped keep him and his family insured.

Indeed, the ways in which the federal government measures Navigator-assisted enrollment is largely flawed and unreliable. For example, the only way for a Navigator to be given credit for an enrollment is if he or she inputs their identification number on the application. Navigators are not consistently trained to do this, nor are they required to. If a consumer makes an appointment to only resolve an inconsistency or to pick out a plan, but ultimately enrolls at home, then the Navigator might not have a chance to input their identification number.

Yet Navigators have had a measurable impact. A 2015 Health Affairs study found that in-person assistance increased successful enrollment among lower-income populations from 84.9 percent to 93.1 percent. Navigators have had particular success in black and Latino communities, which have experienced record declines in their uninsured rates after the ACA was implemented. A 2016 studyon California enrollment trends confirmed the need for assisters in the Latino community, showing that of those using in-person assisters, 64 percent were Latino. Navigators are also important for individuals with higher incomes. A recent study from the Brookings Institution demonstrated that one-fifth of the decline in the uninsured rate in individuals above 400 percent FPL was due to outreach efforts, including by the Navigator program. Last week, a study of the risk pool in California’s marketplace (Covered California) found that it was 20 percent healthier than the marketplaces in other states. The authors attribute the market’s success to Covered California’s investment in outreach and enrollment assistance, which helped bring the healthy uninsured into coverage. To build on that success, Covered California intends to spend $6.5 million on Navigators for the next enrollment season, or about 22 times more than each of the 34 FFM states would receive if federal funds were spread evenly.

Sustaining last year’s successful enrollment efforts will be challenging, but states can play an important role 

In spite of large budget cuts, Navigators managed to survive last year’s enrollment season by relying heavily on charitable and in-kind donations and volunteers. Enrollments only fell about 3 percent in total, and people who paid their premiums actually increased 3 percent over last year. However, relying on charity, volunteers, and free media coverage is not a sustainable strategy for Navigator organizations or for the future stability of the marketplaces. In the wake of massive budget cuts, many Navigators are likely not to pursue the grants at all, as the amount they would receive would be unlikely to cover their costs. The cuts to the program hit FFMs the hardest, whereas state-run marketplaces can independently fund outreach and enrollment assistance. For example, states like Minnesota and California have already announced state-level funding opportunities for the upcoming 2019 enrollment season, giving Navigators a sense of stability in those states. Additionally, states like Nevada, New Mexico, and Oregon may soon begin operating their own state-run marketplaces in part to have more control over the resources devoted to outreach and assistance. As the federal government continues to pull back on this important source of support, other states may wish to follow their lead.