For insurance exchanges, states need enavigatorsf — and hiring them is a huge task
By N.C. Aizenman, February 5, 2013
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 gnavigators,h 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.
gI would say the task we face is herculean,h 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 statefs 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 gexchanges,h 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.
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 wonft
have sufficient expertise.
gWhat you donft want is for our agents to be cut out and to have this force
of untrained, unlicensed individuals giving advice with no financial
responsibility,h said Ryan Young, head of government relations for the
Independent Insurance Agents and Brokers of America, an industry trade group.
gConsumers are going to get hammered.h
Under the law, the exchanges must fund enough navigators to ensure that every
applicant who needs assistance can get it.
gYou have to ask, how many people can one navigator help in one day?h de
Percin said. gWell, the people who do this kind of work might spend an hour to
three hours with folks. So the answer is not many.h
Colorado Insurance Commissioner Jim Reisberg stunned a recent gathering of
state officials when he said that, to be viable, the statefs 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.
gI donft 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,h Reisberg said afterward.
Compounding the difficulty, de Percin said, is that many of the uninsured
struggle with English or donft have easy access to the Internet. Others arenft
familiar with concepts like co-payments and deductibles, let alone the subsidies
that will be provided for lower-income people or the new eligibility rules for Medicaid.
gIf youfve never shopped for insurance before, itfs just not a simple task.
Itfs going to be a lot of new information for people,h she said.
A funding Catch-22
Adela Flores-Brennan, head of the navigator program for Coloradofs exchange,
said she expects to train gthousandsh of navigators and other in-person helpers.
But itfs 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 exchangefs operating
funds, which will rely on fees from insurers. But those wonft be available until
at least Jan. 1, well after navigators must be in position.
States can pitch in during the meantime. But thatfs 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 gin-person assistersh — 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 statefs 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 statefs 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 statefs navigator
program. But Cynthia Crone, Arkansasfs director of planning for the exchange,
said state officials worried that the administration wasnft moving quickly
enough.
gOur population has a lot of uninsured, not a lot of Internet use, and is
very rural and very diverse,h Crone said. gWe felt like we couldnft wait.h
States consider strict rules
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 clientfs
budget or including the clientfs existing doctors in the planfs network. Thatfs
not the same as recommending one plan over another, she said — but gitfs a
subtle distinction.h
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 organizationfs president, Fahina
Tavake-Pasi, said she is keen to get her group certified as a navigator.
gPacific Islanders are so often overlooked because of our language and
cultural barriers,h Tavake-Pasi said. gOur 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.h
Nonetheless, she added, gwe only have a staff of four, and wefre already
working 60 hours a week and getting paid for 30. If we have to come up with the
money for a bond, we couldnft even provide the services we offer right now.h
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