The novel coronavirus (COVID-19) pandemic has shed light on gaps in the United States health care system, including the fact that millions of people have no guaranteed access to affordable, quality health coverage. The number of uninsured is expected to rise as unemployment numbers continue to skyrocket across the country. As a result, Medicaid and the individual market are seeing an increase in new enrollees.
Thanks to the Affordable Care Act (ACA), almost all states have consumer assistance programs that offer health insurance “Navigators” to help consumers, especially populations with historically high uninsured rates, find an affordable coverage option. However, after the Trump administration cut Navigator funding in states using the federally facilitated marketplace (FFM), the program operates on a shoestring.*
The COVID-19 pandemic has introduced new challenges for Navigators. To learn more about their experience, and how they are helping consumers manage often unexpected transitions in coverage, I talked with six navigators across five states using the FFM to hear how they were faring.
Conveying Accurate, Up-to-Date Information to Consumers has been a Challenge
Since the start of the COVID-19 pandemic, state and federal policies have evolved to alleviate the disastrous economic effects and improve consumers’ access to COVID-19 related services and coverage. Navigators have faced challenges keeping up with the policy changes and conveying accurate and actionable information to consumers. For example, the Centers for Medicaid and Medicare Services (CMS) has not yet published guidance on how a consumer should calculate new enhanced unemployment income on an individual market application. According to the CARES Act, both the one-time federal stimulus payment of $1,200 and the expanded unemployment benefits of $600 per week should be disregarded as income under the Medicaid program. The expanded unemployment benefits, however, do count as income when calculating tax subsidies for a marketplace plan. However, CMS has never informed Navigators about whether and when the Healthcare.gov eligibility system would be updated to reflect this change in the law. This caused confusion for consumers and Navigators alike.
Due to the quickly evolving policy environment, Navigators reported spending more time with consumers than usual to calculate their projected 2020 income. Many are uncertain whether and when they will return to their jobs. Problems with the federal application also place consumers at risk of receiving the wrong eligibility determination. For example, Navigators reported that sometimes Healthcare.gov erroneously sends people to Medicaid, when in fact they are ineligible. However, Navigators reported engineering workarounds to ensure their clients enroll in the right program. For example, attempting to calculate a client’s income offline first, before trying to use the online application, can help ensure the client starts with the right program.
A Skeleton Crew to Serve the Surge of Uninsured
For most states, Open Enrollment (OE) 2020 ended on December 18, 2019. After Open Enrollment, consumers can only enroll in health insurance if they qualify for a special enrollment period (SEP), which requires the consumer to have a qualifying life event like moving or losing employer-based coverage. While some states have implemented COVID-19 specific SEPs, the Trump administration declined to do so for the FFM.
Due to funding cuts, most Navigator programs can no longer afford to keep staffing levels the same year-round; the majority of Navigators work only during the Open Enrollment season. This left a skeleton crew of Navigators in most states to help consumers through the sudden economic downturn and public health crisis. Navigators reported 40 to over 100 percent increases in consumer inquiries compared to this time last year, with one Navigator saying, “We went from 50 navigators during OE to 20. We are not situated for this level of calls for help. We’re working nights and weekends at this point.” One Navigator lamented that many consumers who are new to the Marketplace and the complexity of its eligibility system are struggling to get assistance.
A Bumpy Transition into Full-Time Virtual Assistance
Before the pandemic, many Navigators provided most of their assistance in-person. Navigators in all five states reported challenges in their transition to virtual assistance. Navigators were unanimous in describing poor experiences with the healthcare.gov call center, often leading to an inability to resolve application problems. Additionally, multiple Navigators reported that they and their clients often lacked the secure and reliable internet connection needed to provide virtual assistance. One Navigator also reported issues with the federal training platform to certify new Navigators, causing significant delays in ramping up a statewide call center. However, Navigators reported that CMS was able to relax requirements that a call center representative be on the phone for virtual appointments, improving their ability to assist consumers.
Virtual Assistance Is Not Feasible for Everyone
Many of the most vulnerable consumers need in-person assistance because they lack access to a computer or the Internet. These consumers can have trouble uploading documents to prove their eligibility for the Marketplace and SEPs. Delivering those documents safely to Navigators to upload can be an insurmountable task.
The pandemic has also introduced new challenges in reaching at-risk consumers. Previously, Navigators would sometimes have an on-site presence in the event of mass lay-offs, employment fairs, and other events where a large group of consumers might need assistance. For example, one Navigator organization in a state with a large hospitality industry reported having to turn down recent requests from multiple hotels for in-person assistance, after they laid off employees due to the pandemic. . Without the ability to have a physical presence, Navigators have a harder time reaching consumers who may be unaware of their options to enroll in free or low-cost coverage.
Navigators Are Essential for a New Normal
If anyone knew health care could be so complicated, it’s Navigators. The individual market has always been defined by churn as consumers gain or lose job-based coverage, gain or lose eligibility for Medicaid, and experience fluctuations in their income. But during this unprecedented public and economic health crisis, millions more consumers are undergoing dramatic life and coverage transitions. The Navigator programs are performing a vital role, helping people maintain coverage and limiting the risk of an unprecedented rise in our uninsured rate.
* States with state-based marketplaces (SBMs) provide their own funding for outreach and enrollment assistance and advertising, typically at higher rates than the FFM.