Signing up an estimated 30 million uninsured Americans for coverage under the health care law is shaping up to be, if not a bureaucratic nightmare, at the very least a daunting task.
While some people will find registering for health insurance as easy as booking a flight online, vast numbers who are confused by the myriad choices will need to sit down with someone who can walk them through the process.
Enter the “navigators,” an enormous new workforce of helpers required under the law. In large measure, the success of the law and its overriding aim of making sure that virtually all Americans have health insurance depends on these people. But the challenge of hiring and paying for a new class of workers is immense and is one of the most pressing issues as the Obama administration and state governments implement the law.
Tens of thousands of workers will be needed — California alone plans to certify 21,000 helpers — with the tab likely to run in the hundreds of millions of dollars.
“I would say the task we face is Herculean,” said Denise de Percin, executive director of the Colorado Consumer Health Initiative, an advocacy group that has studied what it will take to staff her state’s navigator program.
Over the short term, some workers may be funded by federal grants, state budgets or private money. But over the longer term, most of the costs are to be covered by the new health care marketplaces, called “exchanges,” being set up in every state. The money will come from fees that insurers will pay to sell their plans on the exchanges.
Groups such as unions, chambers of commerce, health clinics, immigrant-service organizations, and community- or consumer-focused nonprofits can use the grants to train and employ staff members or volunteers to provide in-person guidance — especially to hard-to-reach populations — and to provide space for them to work.
A turf war for sign-ups
Added to the logistical challenge is a political one: Insurance brokers in many states are lobbying to prohibit the navigators from giving advice on which plans to choose and to make them liable for their guidance if it results in financial harm.
The brokers, who earn commissions and fees by enrolling people in plans and who might lose business to the navigators, contend that the navigators won’t have sufficient expertise.
“What you don’t want is for our agents to be cut out and to have this force of untrained, unlicensed individuals giving advice with no financial responsibility,” said Ryan Young, head of government relations for the Independent Insurance Agents and Brokers of America, an industry trade group. “Consumers are going to get hammered.”
Under the law, the exchanges must fund enough navigators to ensure that every applicant who needs assistance can get it.
“You have to ask, how many people can one navigator help in one day?” de Percin said. “Well, the people who do this kind of work might spend an hour to three hours with folks. So the answer is not many.”
Colorado Insurance Commissioner Jim Reisberg stunned a recent gathering of state officials when he said that, to be viable, the state’s exchange will need to sign up 150,000 people, or about 800 people a day, seven days a week, over the six months of the open enrollment period, which will run from Oct. 1 through March.
“I don’t know that any corporation would set goals that high, even if they were going into it with the kind of money they have for marketing Coke or Pepsi,” Reisberg said afterward.
Compounding the difficulty, de Percin said, is that many of the uninsured struggle with English or don’t have easy access to the Internet. Others aren’t familiar with such concepts as co-payments and deductibles, let alone the subsidies that will be provided for lower-income people or the new eligibility rules for Medicaid.
“If you’ve never shopped for insurance before, it’s just not a simple task. It’s going to be a lot of new information for people,” she said.
Who pays for training?
Adela Flores-Brennan, head of the navigator program for Colorado’s exchange, said she expects to train “thousands” of navigators and other in-person helpers. But it’s unclear how much of that effort the exchange will be able to pay for.
In a kind of Catch-22, the money must come from an exchange’s operating funds, which will rely on fees from insurers. But those won’t be available until at least Jan. 1, well after navigators must be in position.
States can pitch in during the meantime. But that’s an unlikely option in Colorado, which has stringent rules governing its budget.
So Flores-Brennan is seeking grants from a third source: private foundations. She said she will also try to tap a related funding stream that the Obama administration recently offered to help states get around the federal funding catch. Essentially, Obama officials created another category of helpers — called “in-person assisters” — who will fill the same role as navigators but who can be financed through certain federal grants for exchanges.
Maryland plans to apply for some of this money to pay for as many as 250 assisters, who will supplement about 150 navigators the governor has proposed paying for with $9.8 million out of the state’s general fund.
In California, where lawmakers have adopted a law barring the use of state dollars for the exchange, practically the entire system for providing in-person help will be handled by such assisters. The state’s exchange plans to deploy about 21,000 of them to serve about 700,000 people with about $40 million in federal money already obtained for the purpose through the end of 2014.
Arkansas has adopted the same strategy to hire about 535 in-person assisters, whom officials plan to train by midsummer — albeit for a different reason.
The state is one of 32 that has chosen to let the federal government run its exchange. In these cases, the Obama administration is in charge of setting up the state’s navigator program. But Cynthia Crone, Arkansas’s director of planning for the exchange, said state officials worried that the administration was not moving quickly enough.
“Our population has a lot of uninsured, not a lot of Internet use, and is very rural and very diverse,” Crone said. “We felt like we couldn’t wait.”
Lawmakers in Virginia, Ohio and Utah, meanwhile, are considering imposing strict standards on navigators. These include proposals to explicitly prohibit them from giving advice, require them to get a state license, and mandate that they post surety bonds to cover any liability in case they provide someone with faulty guidance.
Maine and Iowa have already passed bills along those lines. Wesley Bissett, who is coordinating the lobbying nationwide on behalf of the Independent Insurance Agents and Brokers of America, said he is in discussions with lawmakers in seven more states.
Consumer advocates counter that the brokers are trying to squelch potential competition for new customers.
Claire McAndrew, a senior health policy analyst with Families USA, an advocacy group that has helped organize support for the law, added that even proposals that seem innocuous — such as prohibiting navigators from offering advice — could have a chilling effect.
To do their job well, McAndrew said, navigators will need to explain to clients how the various insurance plans compare in terms of fitting the client’s budget or including the client’s existing doctors in the plan’s network. That’s not the same as recommending one plan over another, she said — but “it’s a subtle distinction.”
Consumer groups also note that the law already requires navigators to pass a certification exam, and they say further obligations, such as taking out a surety bond, would prove too onerous for the kind of small nonprofits most likely to have ties to hard-to-reach populations.
A case in point is the National Tongan American Society in Utah, which helps immigrants in Salt Lake City find health care services and check whether they qualify for Medicaid or Medicare. The organization’s president, Fahina Tavake-Pasi, said she is keen to get her group certified as a navigator.
“Pacific Islanders are so often overlooked because of our language and cultural barriers,” Tavake-Pasi said. “Our organization is in the churches. We have a weekly radio show for Pacific islanders. We know how to get the word out to our people, and they trust us.”
Nonetheless, she added, “we only have a staff of four, and we’re already working 60 hours a week and getting paid for 30. If we have to come up with the money for a bond, we couldn’t even provide the services we offer right now.”