Editor’s note: This post’s description of the difference in navigator funding between Maryland and Virginia was edited on August 31. Thanks to Max Fletcher for his comment calling attention to the need for the edits.
Many observers claim that we do not have a true “healthcare system” in the United States. Instead we have fragmentation across multiple dimensions resulting in unsustainable cost increases, compromised quality, and growing inequity. Streams of public, private, and individual funding for health care – each with their own rules, requirements, and information needs – are further complicated by unsynchronized provider organizations in hundreds of cities and thousands of communities across the country. This byzantine approach has also created a cottage industry of specialists whose sole job is to navigate these requirements and make sure that patients know their health insurance options, can enroll in coverage, and get access to the services that they are entitled to.
The Affordable Care Act (ACA) addresses this complexity in a number of important ways. For example, the expansion of Medicaid to all individuals with incomes under 138 percent of the federal poverty level greatly simplifies the enrollment criteria for low-income individuals. The ACA also provides clarity on the calculation of income, penalties, types and sources of required documentation, and clearly outlines the reconciliation process for eligibility and subsidies.
While enrollment has not yet been reduced to a single mouse click or finger swipe, there is considerable uniformity across the country. Under the ACA, a family of four living in the Coachella Valley of California will follow a largely similar enrollment process to a family of four in Cambridge, Maryland. Though their choices on plans and providers will differ, the process of calculating their eligibility and enrolling in Medicaid or a health plan through an Exchange should be similar.
However, despite these improvements, public-opinion data gathered over the past three years suggests that Americans are still largely uninformed about the specific provisions of the ACA. For example, a June Kaiser Health Tracking Poll found that among those uninsured – a key target population of the ACA – 55 percent reported that they have not heard anything about the new health insurance marketplace.
In response, policymakers and private organizations have begun to mount massive public education campaigns about core elements of the law. The philanthropic sector is also getting involved. Recently, a coalition of eleven foundations and states worked together to develop a user-friendly online platform that simplifies the enrollment process. Called UX 2014, the platform is designed to make it easy for people to understand the coverage options for which they may be eligible, and further supports their enrollment decision-making.
Yet, even with these efforts and investments in simplification, the fact remains that many people will still need additional help in order to effectively navigate the steps to enrollment. And as a result, public and private sources will spend hundreds of millions of dollars to train navigators and eligibility specialists to assist families as they enroll.
To date, the approach to training these navigators has not taken full advantage of the standardizations created under the new law. Over the past year, the U.S. Department of Health and Human Services has been promulgating regulations at breakneck speed to clarify the rules of the road around eligibility and enrollment. At the same time, states and private funders are hiring stables of consultants to quickly train brokers, navigators, and eligibility assistants using various traditional methods: in person meetings, town halls, webinars, and train-the-trainer models, among others. The result of this unsystematic approach will be thousands of “trained” navigators, each with a different understanding of the eligibility rules and varied levels of competence.
That’s not to say that the training and enrollment efforts already underway aren’t admirable and widespread. In fact, there is a tremendous amount of energy being devoted to this in all regions and from all sectors. However, the work is being done in silos, resulting in uneven capacity across states. For instance, Maryland, which is running its own exchange, was awarded $16 million in federal funds and will add $8.6 million more in state funding. In contrast, Virginia will receive less than $2 million of the $67 million in navigator grants from the Department of Health and Human Services in Federally-facilitated and State Partnership Exchanges.
This broad differential in funding has expectedly led to the development of independent training and implementation structures. We see this in Maryland, where their additional funding is being used to mandate 120 hours of in-person training and grant solicitation is divided into six regions. In contrast, for states that have federally facilitated or partnership exchanges, as is the case in Virginia, the Department of Health and Human Services has specified that at least two different types of organizations must serve as navigators, and require only 30 hours of training on 15 topics. As we approach the critical first open enrollment period in just one month’s time, with millions of people entering the healthcare marketplace, now is the time to think innovatively.
To meet this challenge, we can learn from a recent development in the education sector: massive open online courses (MOOCs). These e-courses are aimed at large-scale audiences (1,000 to 100,000 people) using videos, readings, and problem sets as well as interactive user-forums that help build a community for students and instructors. Recent success with this approach can be seen in pilots nationwide and across the globe. For example, the Division of Nutritional Sciences at Cornell University recently partnered with UNICEF to create a “mini-MOOC” on feeding infants and young children. Well beyond their initial expectations, more than 900 people from 104 countries – most of them employees at universities and nongovernmental agencies – registered for and completed the course.
Though still not fully accepted by higher education, there is evidence that online learning may be better than face-to-face models of teaching – especially for standard courses and certifications. As we witnessed recently from the results of the pilot program at San Jose State University, MOOCs provide immediate feedback on students’ mastery of course content, allowing for modifications in the screening process, entrance requirements, and course structure to address deficiencies.
Why a MOOC for ACA Implementation?
A national outreach, eligibility, and enrollment MOOC could play four important roles in the successful implementation of the ACA. Specifically, it could:
- Serve as a single, definitive source of accurate information for hundreds of thousands of organizations and individuals who will be helping families enroll in Medicaid and other coverage options through Health Benefit Exchanges across the country;
- Serve as a platform for certification or credentialing to ensure quality assistance is being provided;
- Provide a mechanism for peer learning and a flexible forum for broadcasting lessons learned and any regulatory changes during the initial open enrollment period; and
- Create awareness around ACA implementation for brokers, navigators, application assistors, and the broader public, particularly in states that are not aggressively implementing the law or lack resources.
A MOOC could be sponsored and administered by either a public or private initiative. The federal government has proposed investing $50 million per year for the next 10 years in creating an Online Skills Lab to develop exemplary next-generation instructional tools and resources, and the Federal Emergency Management Agency already effectively uses a number of online courses for certification. Alternatively, a private entity with excellent content knowledge and credibility could be relied on to create a useful MOOC. However, regardless of whether the effort is led by the government or private sector, this is exactly the type of design thinking we should be exploring as we move forward.
A course on enrollment and eligibility could potentially include a series of recorded or live-stream segments led by national and local healthcare experts, coupled with a range of assignments, checklists, and resources. Initial scoping with several major MOOC providers suggests that a national course would cost well under a $1,000,000 to develop the content, create an online platform, establish interactive forums, and provide ongoing technical support for students across the country. A successful MOOC that offers standardized education for any individual in any location with an internet connection has the potential to rapidly increase the efficiency and effectiveness of patient enrollment during this critical moment in our healthcare system. While it wouldn’t entirely eliminate the need for additional support at state and local levels, the approach could provide tremendous benefits and cost a fraction of what is currently being spent to train these individuals.
With early ACA implementations and significant transformation already underway, we have finally begun to construct an American healthcare system. It is incumbent upon us to take full advantage of this foundation and keep the momentum going from here. An ACA MOOC on eligibility and enrollment would force us to think bigger, act bolder, and serve as an excellent test case for future large-scale innovations in American health and health care.