Recent federal regulations have established complex new consumer-assistance activities under the Affordable Care Act (ACA). State and local governmental units; nonprofits, such as community health centers; and private health care facilities are all likely to become involved in education and outreach efforts to potential applicants for health insurance through the new Exchanges—and for expanded Medicaid assistance in some states.
The Department of Health and Human Services (HHS) has adopted regulations formally defining Health Exchange navigators, non-navigator assistance personnel, and certified application counselors (in the Federal Register of July 17, 2013).
The new activities will raise a variety of administrative issues for all of these linked organizations and individuals.
All Exchanges must arrange for consumer support to be provided by “navigators”, which are basically teaching, outreach, and facilitating organizations that must be free of conflicts of interest or bias. (Individuals may also be navigators). Exchanges are to provide grants, training and supervision for control over wide-ranging activities. The navigators are to have demonstrated expertise to provide consumer assistance; conduct public education campaigns; provide impartial information and facilitate enrollment; and provide referrals for complaints.
Federal Exchanges must also provide consumer assistance through non-navigator assistance (NNA) programs; state Exchanges may choose to offer such assistance. NNA programs include “in-person assistance personnel” and provide more organizational flexibility than is present for navigators. Other types of groups that want to help with ACA education and enrollment may function as NNA programs. Each Exchange is to decide how to implement its NNA activities; NNA personnel must be registered with and certified by an Exchange.
In addition, all Exchanges must make provision for the training of certified application counselors (CACs) who act as “helpers” to assist and represent individuals during the application and enrollment process. Exchanges must—either directly or indirectly through other organizations—arrange for training and certification of CACs. These counselors may be present in a variety of settings, including community health centers, health care service facilities, and local governmental facilities.
In addition to the above, there will be many types of educational and outreach groups and consumer helpers that operate outside of the formal Exchange-based arrangements. Numerous interested groups will continue to advocate for their points of view. The Exchange-based activities will thus become a formal addition to the many voices seeking to shape the ACA “brand” and influence public reactions.
All individuals involved in providing community assistance services will be bound by federal regulations that create a set of training, operational and reporting requirements that will run in parallel with the usual administrative lines of reporting. Thus, accountability will be divided in many cases.
Navigators, NNAs and CACs will all take a degree of their direction and supervision through a pathway that starts with HHS, then passes to the state Exchanges. Thus, those with management responsibility for these individuals will find themselves with only partial authority and responsibility for performance.
This arrangement may make management and decision making more difficult. Further, the dual-administration pathway may also act as a barrier to effective and efficient operations. These considerations should enter in when organizational procedures are developed and adopted by organizations that will be involved in ACA consumer-related activities.
This is installment #6 in “The Affordable Care Act and Public Administration Series.”
Previous installments of this series have addressed the shift to action for implementation of the ACA (#1) with related struggles by federal agencies (#2), and the emergence of the ACA into public view (#3) leading to new issues (#4).