With HealthCare.gov working better and the first deadline to sign up for health coverage that starts in January approaching, Obamacare’s so-called navigators — the people and organizations receiving federal funds to help people enroll — are seeing more and more people come through the doors and out to their events.

Navigators are community organizations, higher education institutions and government agencies. They keep offices and phone hot lines open and go out to community events, handing out flyers and giving presentations so people know how they can get insurance under the health care reform law. If somebody needs help navigating the insurance websites, they provide it. And with HealthCare.gov finally functioning, this has been their busiest time since the Oct. 1 launch.

But in 25 states, that robust interest has a downside: Navigators are forced to tell more and more people that they probably won’t be able to get covered because their states, all of which had a GOP-controlled legislative chamber or governor, have refused to expand Medicaid.



Lynne Thorp, who is overseeing the University of South Florida’s navigator program in that state, told TPM that about one in four people who contact her team fall into that Medicaid gap.

“Those are hardest phone calls because it doesn’t make any sense to them,” Thorp said. “We have to explain that they fall into this gap where this program can’t assist them.”

It makes sense if you look at the numbers. According to the Kaiser Family Foundation, 38 percent of the U.S. uninsured have an income that’s below the poverty line — the population that won’t qualify for either Medicaid expansion or any financial help to purchase private coverage through the law in non-expanding states. About 5 million people fall in that gap in those states.

But these people probably don’t know that when they walk into a navigator’s office or attend an outreach event. They just want to find out what options are available to them — though it turns out the answer is not many.

So how are the navigators handling it?

Well, officially, they’re asked to let those people that they can still apply to purchase insurance through the Obamacare marketplaces. There’s always the possibility that the state will expand Medicaid at a later date, and this way, their information is already on file. The navigators also direct them to free clinics and other non-government assistance that can help them get care.

But without Medicaid or any tax help, actual insurance is likely to be too expensive for them to afford. These are the people with the lowest incomes. For them, Obamacare isn’t going to make much difference at all.

In some cases, those being left out seem to understand, having been left out of the health insurance complex for a while, said Cynthia Rahming, who is heading the Houston, Texas, navigator program. She did agree, though, that her team is “often” coming across people who are part of the Medicaid gap in that state.

“They were excited. They were trying to see what’s available to them,” she said. “But they’re still okay. They know it’s just a chance.”

But Thorp described angry and confused people who didn’t understand why they wouldn’t be able to get coverage under Obamacare. Like Rahming’s group in Texas, her team refers people to free health clinics. But she acknowledged that they’ve started to become “desensitized” to those experiences, focusing instead on those they can help.

On the day of her interview with TPM, Thorp said she had talked to at least 15 people who found themselves in those circumstances. One older woman, not yet eligible for Medicare, repeated over and over that she needed insurance so she could get her hip replaced — otherwise, she believed she’d become disabled.

“I feel really bad because I can’t help them, and I really can’t give them any better advice except for: ‘Here’s a free clinic,'” she said. “They just don’t really understand what the coverage gap is.”

There’s also the political element to this. One navigator declined to speak with TPM on the record for fear of political repercussions. Republican officials in Florida and Texas have imposed additional requirements on navigators. Several top GOP senators have begun to disparage navigators in their public comments.

But though some were unwilling to speak publicly, they shared some of the experiences as Thorp and Rahming.

“It’s awful,” one navigator in a non-expanding state said. “It’s basically: ‘Here are the really great options, and you can’t have them.'”