A Comparative Case Study of ACA Navigators: Enrollment Activities in Hostile and Supportive State Policy Contexts

Background and Purpose: The Affordable Care Act (ACA) has been implemented unevenly across the U.S., with enrollment of the previously uninsured ranging from 54.1% in Vermont to 5.7% in South Dakota (Kaiser Family Foundation, 2014).  Variability is attributable to states’ unique contexts, which include different health care marketplace auspices (state-based, state partnership, or federally-facilitated), expansion of Medicaid in some states but not others, and unequal resources devoted to outreach, education and enrollment assistance (i.e., navigation services).   

Within this complex landscape, navigation service providers have an important but understudied role. Guided by a street-level bureaucracy framework (Lipsky, 1980), which emphasizes conditions under which frontline workers’ discretion may undermine or support policy goals, this comparative case study examines two states with substantially different enrollment climates and insurance markets: New York (NY) with its own marketplace has expanded Medicaid and represents a state strongly supportive of the ACA, and Alabama (AL) which participates in the federal marketplace, is not expanding Medicaid, and represents a state with strong political ACA opposition. The presentation will describe the governmental investments and activities that circumscribe workers’ roles, and examine workers’ discretion in interpreting, implementing, or sidestepping policy guidelines.

Methods: Multiple data sources are the basis of the case studies.  To describe the state contexts, federal, state, and provider agency websites provide data on: the types and training of outreach and enrollment workers; characteristics of community-based organizations overseeing navigation; government funding allocated to navigation, and; key features of the insurance markets such as the uninsured population, number and costs of plans. Qualitative data on frontline workers’ activities are from focus groups and interviews with navigators.

Results:  Investments in and intensity of ACA enrollment activities differed substantially between the two states. Among all states, AL ranked near the bottom in 2010 – 2013 federal per capita ACA funding ($35.77), and NY ranked near the top ($55.96).  Across AL, 14 community-based agencies were subcontracted to provide navigation services, limiting their ability to share information and ensure broad outreach.  In contrast, hundreds of agencies had subcontracts in NY State, creating a highly-saturated environment with few access point barriers.  Qualitative data from navigators suggest they approached their roles differently.  In AL, navigators described their work as mission-driven, and acted in ways that tended to compensate for the negative context by advocating for health coverage and directly contacting potential enrollees.  In NY, navigators describe their roles as being primarily limited to providing information about plans when approached by uninsured persons, and to providing technical instructions on how to enroll. 

Conclusion and Implications: For stakeholders, including the social work profession, who seek to establish and influence policy implementation activities that will lead to equitable health care access, this study underscores ways that an understanding of state context can direct their efforts. Frontline workers’ efforts in reluctant states may need to be fortified with concrete resources such as funding and personnel, whereas continued advocacy and media campaigns focused on social justice goals may be needed in ACA-supportive states to supplement the navigators’ technical assistance functions.