Funding for the Affordable Care Act navigator program had a positive impact on enrollment, and the private health insurance industry likely would not pick up the slack if the program were cut, according to two recent research publications from the UW School of Medicine and Public Health. 

The ACA navigator program is a program funded by the federal government that provides free, one-on-one assistance to help people understand their health insurance options and sign up for health insurance, including Medicaid coverage or coverage through the marketplaces established under the ACA.

This year, the program has received nearly $100 million, according to the Centers for Medicare & Medicaid Services, a record-high amount of government funding. However, during the Trump administration, the federal government cut the amount of funding by about 80%.

To measure the impact of funding the navigator program, a research team led by Rebecca Myerson, assistant professor of population health sciences, UW School of Medicine and Public Health, compared changes in coverage outcomes in counties that were more versus less exposed to the cuts.

When funding was reduced from 2017 to 2019, enrollment in health insurance coverage – and particularly, marketplace coverage – decreased among lower-income adults, according to one of the papers Myerson’s team produced.

Cuts to the navigator program also significantly decreased insurance coverage among adults younger than age 45, Hispanic adults and adults who speak a language other than English at home.

In the counties studied, the estimated declines implied that about 109,000 people who prefer to use a language other than English lost health insurance coverage because of the cuts to the navigator program, Myerson said.

The researchers analyzed Centers for Medicare & Medicaid Services records of marketplace coverage and American Community Survey records for total coverage. The survey analysis was restricted to U.S. citizens only to avoid the potential confounding impact of other concurrent policies that may have reduced coverage among non-citizens.

“Our research showed that the navigator program impacted coverage among the same underserved communities that many navigator programs said, in their grant proposals, that they would target,” Myerson said. “The navigator program was critical to helping these consumers get health insurance.”

The navigator paper was published in the American Journal of Health Economics.

When the ACA was signed into law in 2010, it set up assister programs in each state to provide individuals unbiased help free of charge so they could better understand their health insurance options, including information on financial assistance for which they were eligible and guidance on how to enroll. The ACA required that assister services be offered by at least one community-based group and one consumer-focused nonprofit group in each state. The navigator program is the assister program that operates in states that do not establish a state-run exchange or partner with the federal government to operate an exchange.

Timing and extent of funding cuts

Money for the navigator program is provided by grants from the Centers for Medicare & Medicaid Services. In the two years before Donald Trump became president, the program received $60 and $63 million, respectively, but in 2017, the first year of the Trump administration, funding was cut to $37 million, and by 2018, to $10 million.

Of the 40 programs operating in the U.S., a survey in 2017 revealed that 89% expected to lay off staff due to the funding cuts, while others planned to reduce staff time on complex cases or reduce the amount of services provided in languages other than English, according to a report by the Kaiser Family Foundation.

Private sector did not fill the void

After identifying impacts on coverage for underserved populations, Myerson and her team wanted to understand if the private sector insurance industry would increase advertising activity.

The researchers examined the number of television advertisements purchased to attract new consumers to purchase marketplace or other non-Medicare, non-Medicaid health insurance.

The results were published in the journal JAMA Network Open.

Using television advertising data from the 2015-19 open enrollment periods, the team analyzed the changes in advertising associated with the 2017-19 cuts to navigator programs across counties with higher versus lower exposure to the cuts.

Myerson and her colleagues found no increase in the amount of private sector television advertising in the impacted counties, meaning they did not detect any additional evidence of advertising spending to offset the reduction of the navigator program in those counties, she said.

The findings were cited by the Centers for Medicare & Medicaid Services in their decision not to allow Georgia to eliminate the marketplace and navigator program and rely only on private sector outreach in 2023.

“These studies demonstrate the effectiveness of the navigator program, but more importantly the studies taken together show that people were falling through the cracks,” Myerson said. “The lack of a compensating increase in private sector advertising matches prior data suggesting that the private insurance industry may have different priorities or target different populations than government programs do.”

Now that federal funding for the navigator program has been restored, these papers can help policymakers understand the potential impact of this investment on equity in access to coverage, she said.

“In an environment where health insurance options can be complex, and confusion may arise during the enrollment process, tools like the navigator program are essential to make sure everyone has the chance to get covered,” Myerson said.