by Anna Stelter, LMSW, MPH
After several failed repeal attempts over the summer, the Affordable Care Act (ACA) remains in place. As the next ACA open enrollment period approaches, outreach and marketing efforts have been ramping up. That is, until this past week, when the Trump administration announced a 90% cut to its overall ACA advertising budget, then abruptly stopped making payments to nonprofit organizations who provide in-person assistance to enroll uninsured populations in coverage. Many of these organizations, who employ trained outreach and enrollment staff called Navigators, had to immediately suspend operations, or seek emergency funding from local governments and hospitals.
Critics warn scaling back outreach could spell disaster for the Affordable Care Act’s marketplaces and enrollees, and represents a deliberate attempt to torpedo Obamacare from within. The Trump administration has suggested the advertising & outreach volume funded in past years isn’t needed any longer, and has remained quiet on whether it plans to resume payments to Navigator organizations anytime soon.
How could a diminished federal role in outreach spell trouble for the Affordable Care Act marketplaces? And what does the federal government’s rollback of enrollment support mean for enrollees this year?
1. Jeopardizing coverage gains. Strong outreach efforts communicate key pieces of information to the marketplace’s current and potential enrollees, such as open enrollment dates, the availability of financial assistance, and the requirement to have coverage or pay a penalty.
Without advertising and outreach, for example, many consumers might not be aware this year’s open enrollment period – lasting from November 1 to December 15 in most states – will be about six weeks shorter than in previous years. And as plan offerings change in the marketplaces, some of the 12 million consumers already enrolled may be able to save money by shopping for a new plan, or might have to re-enroll in a different plan if their current plan has been discontinued.
2. Destabilizing marketplaces. The stability of ACA marketplaces is directly linked to the overall health status of the population enrolled. Older and sicker enrollees are more expensive to cover, and a healthy marketplace needs enough younger and healthier people enrolled to balance out the cost of the highest-risk consumers. An enrollee mix comprised of too many sick patients raises costs for all enrollees, and has contributed to some insurers leaving the ACA marketplaces after finding themselves on the hook for financial losses.
ACA marketplaces have done well reaching and enrolling “low hanging fruit;” that is, people who are knowledgeable about and eager for coverage. For many of these enrollees, eagerness for coverage arises from an expected need for health services, suggesting a less healthy underlying population. In contrast, marketplaces have not been as successful enrolling healthier, but chronically uninsured populations. These tend to be younger, working age, low- and middle-income adults who may not perceive they need or can afford insurance.
Marketing and outreach efforts targeted specifically toward healthy individuals can communicate the value of coverage for maintaining good health — not simply paying for care in a crisis -- and remind consumers of the risks associated with choosing to stay uninsured. Illinois’ marketplace, Get Covered Illinois, released a (pretty humorous) series of ads aimed specifically at younger consumers who may be tempted to pass on health insurance:
3. Neglecting vulnerable populations. In most states, the healthy, young, and uninsured people marketplaces covet also tend to belong to groups who have historically faced disparities in coverage rates: people of color, limited English proficient, immigrant, and LGBTQ populations. The ACA provided an opportunity to reduce longstanding disparities in coverage rates for these groups, including many individuals who have never enrolled in coverage before.
Source: Reducing Racial and Ethnic Disparities in Access to Care: Has the Affordable Care Act Made a Difference? The Commonwealth Fund, August 2017.
To enroll culturally and linguistically diverse populations successfully, marketplaces have observed a need for in-person assistance in consumers’ preferred languages. Among populations that may be enrolling for the first time, health insurance terms and pricing can be confusing, and many have little to no experience using coverage to obtain care. These enrollees often require multiple “touches,” or instances of assistance, to have their questions answered and complete enrollment. Marketplaces also rely on in-person assisters to quell fears and address challenges unique to immigrant populations; many eligible immigrants who express interest in marketplace coverage worry their personal information could be used to identify and deport undocumented family members, who are not eligible to enroll.
Since the ACA began enrolling consumers in 2013, community-based organizations funded with federal and state grants have filled an important role building awareness of the marketplace in areas they serve. They employ Navigators who work to deliver culturally and linguistically appropriate enrollment assistance, review and vet advertising messages and materials developed by the marketplace, and partner with other community institutions like schools, libraries, and local health clinics to expand pathways to enrollment. With federal payments to Navigator organizations now on hold, it remains unclear if these cohorts of trained assisters will be sustained. The Trump administration suggests licensed insurance agents and brokers may be able to pick up some of the slack short-term, though they are not necessarily embedded in communities where need is greatest. Since brokers and agents are compensated by health plans, they also do not have to remain neutral in advising a consumer which plan to select.
The bottom line: the administration's recent decisions have introduced significant uncertainty into 2017 enrollment efforts. Unless state and local entities are able to step in with other resources to support organizations conducting outreach, a significant reduction in enrollments could be ahead, with vulnerable populations positioned to be hit hardest.
Will Francis, LMSW
Government Relations Director,
National Association of Social Workers,
Cossy Hough, LCSW
Clinical Assistant Professor, The University of Texas at Austin,
School of Social Work
Anna Stelter, LMSW, MPH
Health Policy Analyst
Texas Health Institute
Alison Mohr Boleware, MSSW
Mental Health Policy,