The latest criticism of Obamacare has centered on the "navigator" organizations charged with helping Americans find health insurance coverage under the law. The Affordable Care Act tasks navigators with educating the public about health reform, distributing "fair and impartial" information about insurance plans, and providing enrollment assistance in some instances. In exchange for performing these duties, navigator organizations receive federal grants; $67 million was distributed to 105 nonprofits and community-based organizations just last month.
Republican critics have focused recently on whether these counselors pose a threat to privacy. "Americans will detail their very personal health and financial information to these individuals," according to an Aug. 15 release from the GOP-led House Energy and Commerce Committee. "The sheer volume of personal information collected by navigators raises serious privacy concerns." Thirteen Republican state attorneys general wrote to Health and Human Services Secretary Kathleen Sebelius expressing similar misgivings.
But the navigator program has a precedent, one that suggests the concerns may be overblown: the State Health Insurance Assistance Program, which was enacted through the Omnibus Budget Reconciliation Act of 1990 to offer free counseling to Medicare beneficiaries. SHIP counselors were the model for Obamacare's navigators. "The notion that this is some unheard of "¦ incursion into people's lives is about as far from reality as it could be," says Sara Rosenbaum, a professor at George Washington University's School of Public Health and Health Services. "This is exactly what Medicare SHIPs do all the time."
SHIP staff members played a key outreach role after Congress passed the Medicare Prescription Drug, Improvement, and Modernization Act of 2003. The legislation introduced prescription-drug benefits — Part D, which was a complicated addition to the coverage offered under Medicare available through enrollment in private plans. In the spring of 2005, just half a year before open enrollment began, 66 percent of seniors polled by the Kaiser Family Foundation said they didn't think they had enough information to understand how the benefit would affect them. Enter SHIPs.
"With Part D, they were incredibly important," said Laura Summer, a senior research scholar at Georgetown University's Health Policy Institute. In 2008, Summer coauthored a report on how the early Part D rollout went, based on the findings of a survey of 660 counselors, program managers, and others who worked with beneficiaries. "The availability of one-on-one counseling, including help from the State Health Insurance Program (SHIP) counselors, was cited most commonly in response to an open-ended question regarding aspects of the program that have been particularly helpful for Part D beneficiaries," she and her colleagues wrote.
SHIP counselors had access to information to determine whether individuals might qualify for Part D's low-income subsidy, as well as certain personal health information that helped them advise on plan selection. National Journal interviewed a number of people who studied the rollout of Medicare Part D, none of whom recalled the kind of concern over privacy voiced by today's opponents of Obamacare. Newspaper reports and congressional transcripts from 2005 to 2007 also suggest that personal information was not a key worry during the early days of Part D enrollment, although there was a broader discussion taking place in Congress over how to respect patient privacy while modernizing health-information technology.
Any new health care program is ripe for fraud. Part D was, and the Affordable Care Act is likely to be, too. Bonnie Burns, a policy specialist with California Health Advocates, a Medicare advocacy nonprofit, recalls the scam artists who have cropped up as the Medicare program evolved over the years. "Every single time there's any change in Medicare, Medicare beneficiaries get flooded with these mailings that say, "˜Your health care is changing, Congress has done X, Y, Z.' And those are attempts to reach Medicare beneficiaries to sell them something," Burns says. But she's not aware of any instances of SHIP counselors committing fraud in California in the more than two decades she's been involved with Medicare counseling.
HHS has promised that navigators, who will be required to complete 20 hours of training, will be instructed on privacy and security standards. The GOP state attorneys general counter that the government's privacy safeguards are "vague" and "will result in improperly screened or inadequately trained personnel" who will be "more prone to misappropriate — accidentally or intentionally — the private data of consumers."
But Larry Kocot, who was a senior adviser to the administrator of the Centers for Medicare and Medicaid Services during the Part D rollout and was heavily involved in its launch, says such assistance should be viewed as a case of risk versus reward. Part D showed how important in-person counseling is when explaining a complex new health care law. "With appropriate selection, safeguards, and monitoring," Kocot says, "the benefits clearly outweigh the risks."
The Obama administration faces perhaps an even more daunting challenge than the Bush administration did during Part D's early days. Half of Americans say they don't have enough information about the Affordable Care Act to understand how it will affect them and their family, according to Kaiser's August health tracking poll. Open enrollment begins in three weeks. The population the government is seeking to get covered is more diverse than the Part D constituency and may never have had insurance before — which is why counseling will be paramount. Concerns over security should be taken seriously and monitored. But the Part D precedent suggests that navigators can play an important role.