Kelly Kennedy

USA TODAY

Nine states have passed navigator laws and not expanded Medicaid

Study was conducted by the George Washington University School of Public Health and Health Services

Health care enrollment data was released Monday by Department of Health and Human Services

WASHINGTON — States that have not expanded Medicaid as part of the Affordable Care Act and also passed laws limiting the ability of health care "navigators" to advise customers have compromised their residents' ability to gain access to health care, a new study released Tuesday shows.

Nine states have passed laws limiting how health care "navigators" can help customers buy insurance and learn if they are eligible for federal help to pay for it and also declined to expand Medicaid as permitted under the law.

"The navigator laws ostensibly are designed to make sure information about selecting a specific plan comes from licensed agents," said Sara Rosenbaum, the senior author for the study by the George Washington University School of Public Health and Health Services.

The laws, which required that only licensed navigators give out information about insurance plans, have created a culture of fear for health clinic employees who explain the law to the uninsured, Rosenbaum said. Combined with the states' decision to not expand Medicaid, that means residents of those states have fewer opportunities to gain access to health care, the study said.

"All they know is that they're not supposed to be telling anyone about plans; they're only allowed to talk about subsidy determination," Rosenbaum said of the navigators.

Nine states have passed navigator laws and declined to expand Medicaid: Florida, Georgia, Indiana, Maine, Missouri, Montana, Tennessee, Texas and Wisconsin. Nineteen states have passed navigator laws.

State officials said the laws were meant to keep personal information private and make sure the navigators were fully trained.

"In Texas, we are being vigilant about safeguarding privacy and keeping personal information out of the wrong hands," Insurance Commissioner Julia Rathgeber said in a statement in December. "These proposed rules address insufficiencies in federal regulations and make the training and qualifications of navigators in our state more readily apparent to consumers and service providers."

The George Washington University survey included 247 health centers in states with Medicaid expansion and 136 states that didn't. Findings included:

• States that did not expand Medicaid are less likely to notify patients of potential eligibility. Only 65% of the clinics in restricted states notified patients, while 81% of health clinics in states with expanded Medicaid did so.

• Clinics in restricted states are much less likely to help people gather documents they need to apply for the federal exchange, with 56% able to do so, compared with 77% of full-implementation states.

• Health clinic workers are less likely to help fill out paper enrollment forms, with 78% doing so vs. 86% in full-implementation states.

• Restricted state clinics are much less likely to have enrollment forms and assistance in other languages, as 60% of those states have that information available in clinics while 76% those in full-implementation states do.

• Clinics in restricted states are less likely to help select a health plan; only 29% of clinics in restricted states did that compared to 51% in states with full implementation of the law.

"What shocked me was how significant some of the findings were," Rosenbaum said. "This was not a case of some of this was a close call; they're huge differences."

She said it was remarkable that even for existing state-based programs, such as Medicaid, the center workers had access to fewer resources.

About 1,250 health centers are required by the law to help enroll medically underserved people, and the Health Resources and Services Administration gave out $150 million in grants to those clinics to assist people. That averages about $130,000 per health center, according to the researchers.

Rosenbaum said the report shows that the navigator rules did exactly the opposite of what they were purported to do.

"If anyone has any doubt, this should put it to rest," she said. "The navigator laws combined with opting out of Medicaid really stopped outreach in its tracks."

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