The Fight of Obamacare’s ‘Navigators’ Against Republican Hurdles

While the GOP lambasts the administration for making Obamacare difficult to access online, they’ve set up roadblocks on the ground.

A message is seen on the computer indicating that there are too many visitors on the Affordable Care Act site to continue, as navigator Nini Hadwen helps people shop for health insurance during a navigation session put on by the Epilepsy Foundation Florida to help people sign up for health insurance under the Affordable Care Act on October 8, 2013 in Miami, Florida.
National Journal
Alex Seitz Wald
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Alex Seitz-Wald
Oct. 30, 2013, 2 a.m.

As Re­pub­lic­ans in Wash­ing­ton pre­pare to grill Health and Hu­man Ser­vices Sec­ret­ary Kath­leen Se­beli­us on Wed­nes­day over prob­lems a broken web­site is cre­at­ing for ac­cess­ing Obama­care, their fel­low party mem­bers in a dozen-and-a-half states have ad­ded com­plic­a­tions for people try­ing to ac­cess those be­ne­fits through al­tern­ate means.

“Even as we im­prove the web­site, re­mem­ber that the web­site isn’t the only way to ap­ply for cov­er­age un­der these new plans,” Pres­id­ent Obama said in his weekly ad­dress Sat­urday, not­ing that ap­plic­ants could use the phone or ap­ply “in per­son with a spe­cially trained nav­ig­at­or.” The Af­ford­able Care Act provided $67 mil­lion in fed­er­al grant money that went to loc­al com­munity groups to hire “nav­ig­at­ors,” whose job it is to help ap­plic­ants through the pro­cess of ap­ply­ing for in­sur­ance.

But wheth­er by fees, back­ground checks, tests, ex­tra train­ing, cer­ti­fic­a­tions, threats of civil pen­al­ties, or delays, Re­pub­lic­an le­gis­latures and of­fi­cials in at least 17 states across the coun­try have thrown up all man­ner of bur­eau­crat­ic road­b­locks in front of the pro­gram.

The of­fi­cials say the reg­u­la­tions are ne­ces­sary to pro­tect con­sumers and their per­son­al in­form­a­tion, but health care re­form ad­voc­ates say the reg­u­la­tions, ad­op­ted only in states con­trolled by Re­pub­lic­ans, are just part of a mul­ti­pronged cam­paign to ob­struct the im­ple­ment­a­tion of the Af­ford­able Care Act at every turn.

In Geor­gia, In­sur­ance Com­mis­sion­er Ral­ph Hudgens boas­ted in a speech two months ago about a new state law that re­quires nav­ig­at­ors to be li­censed by his of­fice. “Let me tell you what we’re do­ing: Everything in our power to be an ob­struc­tion­ist,” Hudgens said to cheers.

Aman­da Ptashkin, the out­reach and ad­vocacy dir­ect­or for Geor­gi­ans for a Healthy Fu­ture and a nav­ig­at­or her­self, says she and oth­er nav­ig­at­ors had to go through a time-con­sum­ing pro­cess to get cer­ti­fied, first by the fed­er­al gov­ern­ment, which re­quires 20 hours of train­ing, and then by the state. The state’s reg­u­la­tions re­quired fin­ger­prints, passing a back­ground check, an af­fi­davit of cit­izen­ship, get­ting a driver’s li­cense photo taken, pay­ing a $50 fee, more train­ing, tak­ing a test, and wait­ing. When the ex­changes opened on Oct. 1, only four or five nav­ig­at­ors in the state had made it through the pro­cess. Al­most a month later, they’re up to 45 and things are work­ing more or less smoothly, but it’s dif­fi­cult to co­ordin­ate ef­forts in the ab­sence of state in­volve­ment. “It’s un­for­tu­nate that we don’t have lead­er­ship on the state level to help in­form con­sumers,” Ptashkin said.

To pro-Obama­care ad­voc­ates like Eth­an Rome, the ex­ec­ut­ive dir­ect­or of Health Care for Amer­ica Now, at­tack­ing the ad­min­is­tra­tion over prob­lems with Health­ while also ob­struct­ing the work of the nav­ig­at­ors in the states is “jaw-drop­ping, turbo-charged hy­po­crisy.” “These people who say they want to fix the web­site aren’t ac­tu­ally in­ter­ested in help­ing people take ad­vant­age of the be­ne­fits of the ACA,” Rome says.

“If you’re one of these con­gres­sion­al Re­pub­lic­ans, and you care deeply about how the web­site func­tions, here’s my ques­tion: How many small busi­nesses did you help get a tax cred­it? Be­cause if the an­swer is zero, then just go home and don’t ever come back to Wash­ing­ton,” Rome adds.

At least four health care groups from Ohio to Texas have de­clined or re­turned hun­dreds of thou­sands of dol­lars in fed­er­al grant money in the face of state reg­u­la­tions. Mean­while, nav­ig­at­ors in Wis­con­sin say oner­ous reg­u­la­tions pre­ven­ted them from get­ting to work soon­er.

Some states like In­di­ana are mak­ing nav­ig­at­ors pay as much as $175 for li­cens­ing, while Mis­souri and oth­ers states have passed laws lim­it­ing what kind of ad­vice nav­ig­at­ors can give to con­sumers, which ad­voc­ate say has a chilling ef­fect on their work. A law­suit in Ten­ness­ee suc­cess­fully chal­lenged a sim­il­ar law that au­thor­ized a $1,000 fine for vi­ol­a­tions. In Flor­ida, nav­ig­at­ors are barred from do­ing their work on the grounds of coun­try health de­part­ments while state reg­u­lat­ors held up li­censes. 

“Do I think it sinks out­reach and en­roll­ment? No. But do I think it’s prob­ably got­ten a little slower, and do I think it’s a big dis­trac­tion and that it makes it harder to do their job, cer­tainly yes,” says Katie Keith, a former Geor­getown health policy re­search­er who is now a con­sult­ant.

Be­fore there were nav­ig­at­ors, there was the Seni­or Health In­sur­ance As­sist­ance Pro­gram, which helps seni­ors nav­ig­ate the Medi­care Part D per­scrip­tion-drug pro­gram. “It’s what the nav­ig­at­or pro­gram was based on,” says Keith, “and you just don’t have these same kind of re­quire­ments on SHIPS as we see on nav­ig­at­ors. And then you look at the list of states and you won­der, what’s go­ing on here?”

Still, nav­ig­at­ors say they won’t let the reg­u­la­tions stop them from do­ing their work. “Even giv­en the pretty sig­ni­fic­ant road­b­locks and obstacles, the com­munity groups that we’ve worked with have con­tin­ued mov­ing for­ward and do­ing what they need to do to be­come nav­ig­at­ors,” said Christine Barber, a seni­or policy ana­lyst at Com­munity Cata­lyst, a group based in Bo­ston that sup­ports health care ad­voc­ates on the ground in 40 states.

“It’s yet an­oth­er obstacle that anti-ACA folks are put­ting in place to try to pre­vent this law from be­ing a suc­cess,” Barber says.

On top of the nav­ig­at­or re­stric­tri­ons, 27 states, mostly con­trolled by Re­pub­lic­ans, de­cided against set­ting up their own health care ex­changes and in­stead left it to Wash­ing­ton, while 15 have have de­cided not to ex­pan­ded Medi­caid.

Jake Grindle, a nav­ig­at­or with West­ern Maine Com­munity Ac­tion, says that while the web­site prob­lems have made things “rock­i­er than we ima­gined at the out­set,” the big­ger prob­lem is Re­pub­lic­an Gov. Paul LePage’s veto of a bill to ex­pand Medi­caid, which pushed about 25,000 Main­ers in­to the cov­er­age gap. “We’re get­ting a lot of people be­ing cut from Medi­caid and ex­pect­ing this to help them, but we’re find­ing them to have in­comes too low and to be in a gap that’s really heart­break­ing,” says Grindle.

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