Social Workers As Navigators To Help Consumers With Health Care Insurance Exchanges

Here come the navigators!  As the health care insurance exchanges prepare for their official rollout October 1 this year, the Department of Health and Human Services (HHS) recently announced it will award $54 million in grants to hire “navigators” who will assist people wanting to purchase health care insurance get through the maze of state-based and federally-operated insurance exchanges.  According to the Patient Protection and Affordable Care Act (Public Law 111-148), Navigators will “play an important role in facilitating a consumer’s enrollment in a Quality Health Plan (QHP) by providing fair, impartial, and accurate information that assists consumers with submitting the eligibility application, clarifying the distinctions among QHPs, and helping qualified individuals make informed decisions during the health care plan selection process.”

If there is any role perfectly suited for social workers it is the navigator.  Social workers are trained to be brokers for the underserved and are guided by a strict code of ethics.  You cannot place enough emphasis on the latter part of that statement because the Navigator Program is fraught with opportunity for abuse.  Despite guidelines published April 5^th by HHS in the Federal Register, there is much ambiguity about the training, certification and monitoring of navigators.  It is unclear if the navigators will be hired through funded agencies, or that there will be opportunities for individuals to become navigators.  It is also unclear who will be responsible for monitoring navigators to ensure they perform their duties competently and ethically.

Guidelines state that navigators should be certified, but it does not state specifically what that certification should be other than navigators should receive 30 hours of training.  In an effort to keep states from being too restrictive as to limit the availability of adequate numbers of navigators, guidelines stipulate that certification must not contradict provisions of Title 1 of the PPACA.  Obviously competing insurance companies will be looking for ways to co-opt navigators to steer consumers in their direction.  This is strictly forbidden, but regulations and laws have not prevented fraud and abuse in the past.

Despite these legitimate and very serious concerns, I think the idea of having trained facilitators assist consumers in navigating health care insurance exchanges is a very good idea if there is to be a serious effort to maximize the number of uninsured people who are able to obtain insurance.  The Congressional Budget Office projects that the combination of new subsidies for health care insurance and consumer protections will enable 14 million uninsured people to gain coverage in 2014, and 27 million by 2021.  Yet, when Enroll America did a survey last fall, it found that 78 percent of those likely to qualify for programs didn’t know it. A more recent study found 90 percent of Americans don’t know when they could start shopping on the health exchanges (answer: Oct. 1, 2013).

There are still too many people in the United States without adequate health insurance which usually translates into lack of adequate care.  According to a study by the Commonwealth Fund, about 46 percent of adults aged 19 to 64, about 84 million Americans, did not have health care insurance or lacked adequate health care insurance coverage during 2012.  Two in five (41%), about 75 million people, reported having difficulty paying for their medical bills.  The October 1^st rollout cannot get here soon enough for millions of Americans.

HHS plans to have health care insurance exchanges up and running in every state by the end of the year.  According to the Center for Budget and Policy Priorities, as of April 23^rd, 17 states and the District of Columbia were conditionally approved to create their own SBE (State-based Exchange).  Seven states were conditionally approved to establish partnership exchanges.  Twenty-six states declined to operate an SBE and will default to a Federally-facilitated Exchange (FFF).

The Patient Protection and Affordable Care Act is the most comprehensive policy initiative to be launched since Medicare and Medicaid.  There are enormous challenges facing Health and Human Services Secretary Kathleen Sebelius and her department as they prepare for the October rollout of health care insurance exchanges.  The social work profession must be deeply involved in the process to ensure its success.