Who navigates the Affordable Care Act's navigators?

It’s difficult to view the Patient Protection and Affordable Care Act—often referred to as "Obamacare" in the media—solely as healthcare reform when it has become such a political battleground. After so much outrage and confusion, here’s something we can all agree on: The Affordable Care Act is a massive piece of legislation. As would follow, its rollout has been rocky.

Guiding Americans through the insurance enrollment process—determining what healthcare plans are available and which one will be the best fit— is a tall order in terms of education, especially if enrollees want to meet the December 23rd deadline to have new healthcare plans take effect on January 1st. And that’s where the ACA’s Navigator program comes in—one of the largest legislative learning initiatives that the U.S. government has ever taken on.

What is a Navigator?

The Affordable Care Act earmarked $67 million to train and develop navigators for new federally-facilitated and state partnership marketplaces. For orders of magnitude, the government plans to spend $56 million to make the necessary changes to the ACA website. States that have not opted to build their own healthcare marketplace will utilize the federally-facilitated marketplace developed by the Centers for Medicare and Medicaid Services (CMS). Regardless of a state’s healthcare marketplace setup, navigators will be there.

According to CMS, each state’s marketplace has a minimum of two organizations equipped with navigators, and at least one must be a community and consumer-focused nonprofit organization. A navigator impartially determines if a consumer qualifies for insurance affordability programs. He or she is a federally trained in-between, who also helps hands-on with paperwork.

Sunny Attitudes Toward Training

All navigators must complete training and certification by CMS, the bulk of which takes place during a 20-hour online module-based program. The online Navigator training outlines the Navigator standards as listed on the CMS website, including how to interact with customers and develop awareness of vulnerable populations. Considering the complexity of each state’s individual insurance marketplaces, several navigators we spoke with were impressed by how well the information was explained.

James Reeves, project manager of the navigator initiative at the University of Mississippi Medical Center, is tasked with ensuring the hospital complies with the parameters of the navigator grant over the next year. "Overall, the training was as comprehensive as it could be," he said. UMC received one of 105 federally issued navigator grants and is one of only nine American hospitals to receive the funding. Forty one navigators have been certified at UMC, and so far Reeves hasn’t received much negative feedback from them.

Jake Grindle, a health services navigator and program specialist at Western Maine Community Action, was also pleased with the training, particularly its scenario-based examples and assessments of comprehension. "It isn’t something you could have flipped back earlier in the book and seen the answers," he said. Western Maine Community Action, Inc. is a private non-profit agency that leads other such agencies across the state to help residents become insured.

Rebecka Brayton, the navigator and marketplace coordinator at Wyoming Senior Citizens, Inc., another private nonprofit agency to receive a navigator grant, appreciated the federal governments training efforts . "The Department of Human and Health Services is actually doing a pretty good job," she said. "I was always grateful to get any kind of information."

Still Falling Short

The 20-hour training program provided a good baseline of knowledge about the new healthcare marketplace, but the training could never anticipate the obvious complexities with the rollout of such a complex and widespread program, said Devin Griffith, vice president of Care Continuum and Support Services at Randolph Hospital in North Carolina. "There’s no way in twenty hours with the examples they provided that that could cover all the cases and all the consumer issues," said Griffith, who oversees several hospital programs, including the navigators.

Reeves at UMC agreed. He noted several examples where navigators needed to consult additional materials or call the CMS hotline, the public support number for the marketplace, to get more specific answers on topics the training did not cover.

To bolster the federal training initiative, supplemental learning efforts are supplied on the state-level. Grindle of Western Maine Community Action explained that his organization offered additional in-person training as well as talks by state experts. One of its speakers was the executive director from Consumers for Affordable Healthcare, the state’s consumer assistance program. "We were better specifically understanding how [the insurance marketplace] works in our state," Grindle said.

North Carolina is also taking steps to create what Griffith calls a state-wide "learning environment." Four navigator programs across the state participate in "big tent" meetings every other week to learn from one another’s experiences. A county-by-county resource guide also clarifies healthcare plans for all hundred counties in the state. "At the federal level, we really haven’t had anything available for navigator supervisors to come all over the country to learn about the health insurance exchanges," Griffith said. The North Carolina Institute of Medicine has been active in offering training as well.

The online modules provided by CMS, however, are not the be-all and end-all of federal education for navigators. Brayton, navigator coordinator at the nonprofit Wyoming Senior Citizens, Inc., participated in webinars led by the Department of Health and Human Services. Despite the additional discussions, Wyoming still tracks all learning initiatives on the state level. The Wyoming 2-1-1 hotline, also a navigator grant recipient, forwards residents to in-person assistance with their applications.

Correcting Misinformation

If federal training falls short in terms of depth, the issue is compounded in the field by the fact that navigators are not the first to deliver information about the Affordable Care Act. Navigators find themselves correcting a slew of misinformation perpetuated in the mainstream media. "In general, it’s been such a controversial and hot button topic that people have heard lots of contradictory things," Grindle of Western Maine Community Action said. "For us, it’s about being an impartial and trustworthy source of just the factual information about who qualifies for what."

For Reeves, the work of his navigators has also been about correcting misinformation. "People are sharing things they hear on the news that may not apply to everyone," he said. "That’s where a navigator can help: to dispel any rumors or correct any misinformation that may have been given out."

Brayton at Wyoming Senior Citizens, Inc. said the most common question she has received is "Will Medicare be ending?" She sees her job as being one of the select few who has actually sat down and read through some of the legislation.

For its part, the CMS Navigator training does put an emphasis on being impartial. "There’s a lot of information around making sure that we are culturally sensitive, culturally competent, and linguistically appropriate to all populations or all consumers that we might be working with," said Griffith at Randolph Hospital in North Carolina. Cultural sensitivity is old hat for what Griffith calls the "good old-fashioned social work" of informing community members on what resources are available. But because this legislation is so politically charged, it’s notable that navigator impartiality takes up a large portion of the CMS training.

The federal training also includes a lengthy module on consumer protection. "Basically it boiled down to ‘don’t steal a person’s identity,’" Brayton said. "We don’t keep files on any kind of information whatsoever." Reeves from the University of Mississippi Medical Center explained that his navigators also don’t retain any of their patients’ personal information. One wrong move by a navigator could be fodder for vocal critics of the ACA, enough to thrust an otherwise well-meaning health organization into the national spotlight.

Our culture of misinformation may be a product of our national media, but the ACA itself is still in flux, and unpacking truths has proved a challenge. "It would be different if it was ready from day one," Reeves said. "Navigators will continue to be here to answer any questions and at the very least help you get to the right place."

It’s as if the only definitive thing to say about the learning challenge facing Obama’s administration with respect to the Affordable Care Act is that it’s a sticky one. The discordance is not for want of trying on the side of navigators or consumers. Consider one particularly eager caller to Brayton. "I had one lady who called me up for an appointment and said, ‘Here’s my name. Here’s my phone number. And you need my social too right?’ I said, ‘No. No no no.’" People want the system to work. But with so much mudslinging and fumbled technological infrastructure as byproducts of a white-hot political controversy, in regards to the learning challenges of the ACA, we’re going to have to sleep in the hospital beds we’ve made.