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The voyage of a navigator

An aspiring scholar’s inside observations on the Affordable Care Act’s rocky roll-out in North Carolina

Published online by Cambridge University Press:  22 December 2015

Hollie L. Tripp
Hollie L. Tripp*
Affiliation:
University of North Carolina–Charlotte
*
Correspondence: Hollie L. Tripp, University of North Carolina at Charlotte, 285-C Fretwell, 9201 University City Boulevard, Charlotte, NC 28223. Email: [email protected]
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Abstract

North Carolina, a federally facilitated marketplace under the Affordable Care Act (ACA), stumbled in 2013 when opening its health-insurance exchange. Trouble was easy to foresee, as North Carolina had instituted a law barring any state agency from assisting enrollment in health-insurance plans made available through the ACA. Trained workers were needed to help citizens and legal immigrants “navigate” to these plans. Some of these “navigators” could be paid with federal funds, but many others had to work as volunteers. I was one of these volunteer navigators. Much went wrong in training, staffing, and operations, but much still was accomplished. Here I report observations, share assessments, and offer suggestions for similarly complex situations.

Keywords

Affordable Care Act (ACA)health insurance marketplacehealth reformhealth literacynavigatorconsumer enrollmentchoice theory
Type
Perspective
Information
Politics and the Life Sciences , Volume 34 , Issue 2 , Fall 2015 , pp. 91 - 104
Copyright
© Association for Politics and the Life Sciences 2015 

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References

Eisenberg, John M. and Power, Elaine J., “Transforming insurance coverage into quality health care: voltage drops from potential to delivered quality,” JAMA , 2000, 284(16): 2100–2107.Google Scholar
Office of the Assistant Secretary for Planning and Evaluation (ASPE), 2014, “Health insurance marketplace: summary enrollment report for the initial annual open enrollment period,” http://aspe.hhs.gov/pdf-report/health-insurance-marketplace-summary-enrollment-report-initial-annual-open-enrollment-period, accessed October 13, 2015.Google Scholar
White, Sheida and Dillow, Sally, Key concepts and features of the 2003 National Assessment of Adult Literacy (NCES 2006-471) (Washington, DC: U.S. Department of Education, National Center for Education Statistics, 2005).Google Scholar
Kutner, Mark, Greenburg, Elizabeth, Jin, Ying, and Paulsen, Christine, The health literacy of America’s adults: results from the 2003 National Assessment of Adult Literacy (NCES 2006-483) (Washington, DC: U.S. Department of Education, National Center for Education Statistics, 2006).Google Scholar
Pollitz, Karen, Tolbert, Jennifer, and Ma, Rosa, Survey of health insurance marketplace assister programs (Washington, DC: Kaiser Family Foundation, 2014).Google Scholar
Wong, Charlene A., Asch, David A., Vinoya, Cjloe M., Ford, Carol A., Baker, Tom, Town, Robert, and Merchant, Raina M., “The young adult perspective on health insurance,” Journal of Adolescent Health , 2015, 56(2): S1.Google Scholar
Simon, Herbert A., “A behavioral model of rational choice,” The Quarterly Journal of Economics , 1955, 69(1): 99–118.Google Scholar
Payne, John W., Bettman, James R., and Johnson, Eric J., The Adaptive Decision Maker (Cambridge: Cambridge University Press, 1993).CrossRefGoogle Scholar
Aaron, Henry J. and Lambrew, Jeanne M., Reforming Medicare: Options, Tradeoffs, and Opportunities (Washington, DC: Brookings Institution Press, 2009).Google Scholar
The Patient Protection and Affordable Care Act, P.L. 111–148, 111th Congress, 2010.Google Scholar
Brandon, William P. and Carnes, Keith, “Federal health insurance reform and “exchanges”: recent history,” Journal of Health Care for the Poor and Underserved , 2014, 25(1): xxxii–lvii.Google Scholar
Salazar, Martha, “States have only a few months to get their health insurance exchanges up and running,” 2013 State Legislatures Magazine, http://www.ncsl.org/research/health/health-insurance-exchanges-sl-magazine.aspx, accessed October 13, 2015.Google Scholar
Dash, Sarah, Monahan, Christine, and Lucia, Kevin W., “Health Insurance Exchanges and State Decisions,” 2013, Center on Health Insurance Reforms, Georgetown University Health Policy Institute, http://healthaffairs.org/healthpolicybriefs/brief_pdfs/healthpolicybrief_96.pdf.Google Scholar
Oversight, Center for Consumer Information and Insurance, “Guidance on state partnership exchange,” January 3, 2013, https://www.cms.gov/CCIIO/Resources/Fact-Sheets-and-FAQs/Downloads/partnership-guidance-01-03-2013.pdf, accessed October 13, 2015.Google Scholar
Polsky, Daniel E., Weiner, Janet, Colameco, Christopher, and Becker, Nora, “Deciphering the data: final enrollment rates show federally run marketplaces make up lost ground at end of open enrollment,” 2014, Leonard Davis Institute of Health Economics at the University of Pennsylvania and the Robert Wood Johnson Foundation,http://ldihealtheconomist.com/media/final_enrollment_rates-federal_marketplaces_make_up_lost_ground.pdf, accessed October 13, 2015.Google Scholar
Walker, Jack L., “The diffusion of innovations among the American states,” American Political Science Review , 1969, 63(3): 880–899.Google Scholar
Volden, Craig, “States as policy laboratories: emulating success in the children’s health insurance program,” American Journal of Political Science , 2006, 50(2): 294–312.Google Scholar
Jacobs, Lawrence R. and Skocpol, Theda, Health Care Reform and American Politics: What Everyone Needs to Know (Oxford: Oxford University Press, 2012).Google Scholar
Jacobs, Lawrence R. and Callaghan, Timothy, “Why states expand Medicaid: party, resources, and history,” Journal of Health Politics, Policy and Law , 2013, 38(5): 1023–1050.Google Scholar
Lowi, Theodore J., “Four systems of policy, politics, and choice,” Public Administration Review , 1972, 32(4): 298–310.Google Scholar
Mayhew, David R., Congress: The Electoral Connection (New Haven, CT: Yale University Press, 1974).Google Scholar
Berry, Frances Stokes and Berry, William D., “State lottery adoptions as policy innovations: an event history analysis,” American Political Science Review , 1990, 84(2): 395–415.Google Scholar
State Law 2013-5, Senate Bill 4 (S4), Section 1.(c).Google Scholar
Gormley, William T. Jr., “Regulatory issue networks in a federal system,” Polity , 1986, 18(4): 595–620.Google Scholar
Centers for Medicare & Medicaid Services (CMS), “Navigator grant recipients,” 2013, https://www.cms.gov/CCIIO/Programs-and-Initiatives/Health-Insurance-Marketplaces/Downloads/navigator-list-10-18-2013_2.pdf, accessed October 30, 2015.Google Scholar
Community Care of North Carolina, “Navigator grants awarded: Eleven North Carolina organizations to field navigators,” https://www.communitycarenc.org/about-us/update-archive/navigator-grants-awarded/, accessed October 30, 2015.Google Scholar
North Carolina Institute of Medicine (NCIOM), “Data snapshot: characteristics of uninsured North Carolinians,” January 28, 2013, http://www.nciom.org/wp-content/uploads/2013/01/AppB_Uninsured.pdf, accessed October 30, 2015.Google Scholar
Jost, Timothy, “Implementing health reform: navigator grants,” August 16, 2013, Health Affairs Blog, http://healthaffairs.org/blog/2013/08/16/implementing-health-reform-navigator-grants/, accessed October 30, 2015.Google Scholar
CMS, Department of Health and Human Services, “Health Insurance Marketplace Navigator Standard Operating Procedures Manual,” August 2013, http://www.healthreformgps.org/wp-content/uploads/navigator-SOP-manual-8-26.pdf, accessed October 14, 2015, p. 217.Google Scholar
United States Government Accountability Office (GAO), “Actions needed to address weaknesses in information security and privacy controls,” September 2014, http://www.gao.gov/assets/670/665840.pdf, accessed October 14, 2015.Google Scholar
Rasmussen, Christopher, Center for Democracy & Technology, “Privacy and security in the Affordable Care Act’s data hub,” July 26, 2013, https://cdt.org/blog/privacy-and-security-in-the-affordable-care-act%E2%80%99s-data-hub/, accessed October 14, 2015.Google Scholar
Julie Appleby, “FAQ: Obamacare and coverage for immigrants,” Kaiser Health News, September 19, 2013, http://khn.org/news/health-care-immigrants/, accessed October 14, 2015.Google Scholar
Padilla, Angela, National Immigration Law Center, “The use (and overuse) of credit history: credit-based ID verification creates barriers to ACA access,” August 2014, http://www.nilc.org/document.html?id=1122, accessed October 14, 2015, p. 3.Google Scholar
Webster, Bruce H. and Bishaw, Alemayehu, “Income, earnings, and poverty data from the 2006 American Community Survey, U.S. Department of Commerce,” Economics and Statistics Administration, 2007, http://www.census.gov/prod/2007pubs/acs-08.pdf.Google Scholar
Syed, Samina T., Gerber, Ben S., and Sharp, Lisa K., “Traveling towards disease: transportation barriers to health care access,” Journal of Community Health , 2013, 38(5): 976–993.Google Scholar
Zullig, Leah L., Jackson, George L., Provenzale, Dawn, Griffin, Joan M., Phelan, Sean, and van Ryn, Michelle, “Transportation—a vehicle or roadblock to cancer care for VA patients with colorectal cancer?,” Clinical Colorectal Cancer , 2012, 11(1): 60–65.Google Scholar
Ide, Bette A., Curry, Margaret A., and Drobnies, Barbara, “Factors related to the keeping of appointments by indigent clients,” Journal of Health Care for the Poor and Underserved , 1993, 4(1): 21–39.Google Scholar
Wallace, Richard, Hughes-Cromwick, Paul, Mull, Hillary, and Khasnabis, Snehamay, “Access to health care and nonemergency medical transportation: two missing links,” Transportation Research Record: Journal of the Transportation Research Board , 2005, 1924: 76–84.Google Scholar
Escarce, José and Kapur, Kanika, “Access to and quality of health care,” in Hispanics and the Future of America (Washington, DC: National Academies Press, 2006), pp. 410–415.Google Scholar
Lisa A. Cooper, Neil R. Powe, and Commonwealth Fund, Disparities in Patient Experiences, Health Care Processes, and Outcomes: The Role of Patient-Provider Racial, Ethnic, and Language Concordance (New York: Commonwealth Fund, 2004).Google Scholar
Lipsky, Michael, “Street-level bureaucracy: an introduction,” in The Policy Process: A Reader, Hill, Michael, ed. (New York: Routledge, 1993), p. 389.Google Scholar
Garfield, Rachel, Damico, Anthony, Stephens, Jessica, and Rouhani, Saman, The coverage gap: uninsured poor adults in states that do not expand medicaid—an update (Washington, DC: Kaiser Family Foundation, 2014).Google Scholar
Helms, Ann Doss, “Charlotte health insurance broker’s tactics raise questions,” The Charlotte Observer, June 27, 2015, http://www.charlotteobserver.com/news/business/health-care/article25671634.html, accessed October 14, 2015.Google Scholar
Shugan, Steven M., “The cost of thinking,” Journal of Consumer Research , 1980, 7(2): 99–111.Google Scholar
Hamel, Mary Beth, Blumenthal, David, Abrams, Melinda, and Nuzum, Rachel, “The Affordable Care Act at 5 years,” New England Journal of Medicine , 2015, 372: 2451–2458.Google Scholar
Department of Health and Human Services Press Office, “Enrollment in the health insurance marketplace totals over 8 million people,” May 1, 2014, https://blog.aids.gov/2014/05/enrollment-in-the-health-insurance-marketplace-totals-over-8-million-people.html, accessed October 14, 2015.Google Scholar
Botti, Simona, “Freedom of choice and perceived control: an investigation of the relationship between preference for choosing and customer satisfaction,” (Unpublished dissertation, Chicago: University of Chicago, Graduate School of Business, 2004).Google Scholar
Aday, Lu Ann and Andersen, Ronald, “A framework for the study of access to medical care,” Health Services Research , 1974, 9(3): 208.Google Scholar
Andersen, Ronald M. and Davidson, Pamela L., “Improving access to care in America: Individual and contextual indicators,” in Changing the US Health Care System: Key Issues in Health Services Policy and Management, 3rd ed. Andersen, Ronald M., Rice, Thomas H., and Kominski, Gerald F., eds. (San Francisco, CA: Jossey-Bass, 2007), pp. 3–31.Google Scholar
Franks, Peter, Clancy, Carolyn M., and Gold, Marthe R., “Health insurance and mortality: evidence from a national cohort,” JAMA , 1993, 270(6): 737–741.Google Scholar
Lurie, Nicole, Ward, Nancy B., Shapiro, Martin F., and Brook, Robert H., “Termination from Medi-Cal—does it affect health?,” New England Journal of Medicine , 1984, 311: 480–484.Google Scholar
Simon, Herbert A., “Rational choice and the structure of the environment,” Psychological Review , 1956, 63(2): 129.Google Scholar
Payne, Bettman, and Johnson.Google Scholar
Simon, 1956.Google Scholar
Simon, 1956.Google Scholar
Akerlof, George A. and Dickens, William T., “The economic consequences of cognitive dissonance,” The American Economic Review , 1982, 72(3): 307–319.Google Scholar
Iyengar, Sheena S. and Kamenica, Emir, “Choice overload and simplicity seeking.” Working Paper 87 (Chicago: University of Chicago Graduate School of Business, 2006).Google Scholar
Iyengar, Sheena S. and Lepper, Mark R., “When choice is demotivating: can one desire too much of a good thing?,” Journal of Personality and Social Psychology , 2000, 79(6): 995.Google Scholar
Hanoch, Yaniv, Rice, Thomas, Cummings, Janet, and Wood, Stacey, “How much choice is too much? The case of the Medicare prescription drug benefit,” Health Services Research , 2009, 44(4): 1157–1168.Google Scholar
Hanoch, Yaniv, Miron-Shatz, Talya, Cole, Helen, Himmelstein, Mary, and Federman, Alex D., “Choice, numeracy, and physicians-in-training performance: The case of Medicare Part D,” Health Psychology , 2010, 29(4): 454.Google Scholar
The Patient Protection and Affordable Care Act.Google Scholar
Navigator Program Standards. In 45 CFR § 155.210 Code of Federal Regulations, 2010.Google Scholar
Damghani, K. Khalili, Taghavifard, M. T., and Moghaddam, R. Tavakkoli, “Decision making under uncertain and risky situations,” paper presented at the Enterprise Risk Management Symposium (Chicago, IL, April–May 2009), p. 9.Google Scholar
Kahneman, Daniel and Tversky, Amos, “Prospect theory: An analysis of decision under risk,” Econometrica: Journal of the Econometric Society , 1979, 263–291.Google Scholar
Hanoch et al. 2009.Google Scholar
Kahneman and Tversky.Google Scholar
Pollitz, Tolbert, and Ma.Google Scholar
Gorman, Anna, 2014, “California marketplace among first to post customer health plan ratings,” Kaiser Health News, January 30, 2014, http://khn.org/news/california-marketplace-among-first-to-post-customer-health-plan-ratings/, accessed October 14, 2015.Google Scholar
Aliferis, Lisa, “You’re enrolled in an Obamacare plan: will your doctor accept your insurance?” KQED News, February 11, 2014, http://ww2.kqed.org/stateofhealth/2014/02/11/youre-enrolled-in-an-obamacare-plan-will-your-doctor-accept-your-insurance/, accessed October 14, 2015.Google Scholar
Hamel et al.Google Scholar
Aday and Andersen.Google Scholar
Andersen and Davidson.Google Scholar
Franks, Clancy, and Gold.Google Scholar
Lurie et al.Google Scholar