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Taking Stock and Taking Steps: A Report from the Field after the First Year of Marketplace Consumer Assistance under the ACA

YEAR ONE CHALLENGES, INNOVATIONS AND LESSONS FOR THE FUTURE

The inauguration of a national network of Marketplace assisters called for an extraordinary effort to launch programs around the country in a short time-frame.

Programs and community-based partners working in the field with consumers developed innovative practices of various kinds, many of which were highlighted throughout the Roundtable discussion. These include techniques for structuring Assister Programs and building capacity for those who work in them; approaches to working with diverse groups of consumers; strategies for translating policy and terminology for the public; efforts to build learning communities and continuously improve on-the-ground practices; and creating networks so as to maximize impact. Participants also described numerous challenges faced by consumer assistance during the first open enrollment period and the several months that followed.

Discussion throughout the Roundtable focused on what facilitated and what impeded assisters’ work during their first year of operation. A number of themes were developed as participants described their experiences, as follows:

  1. The need for assisters to build relationships with many consumers prior to the enrollment process in order to successfully engage them and lay the groundwork for successful enrollment;
  2. How complicated it is to implement a new national program and adapt it to a variety of local contexts and client populations;
  3. The complexity of eligibility determinations, particularly for specific populations such as immigrants, those with special health care needs, and those who do not speak English;
  4. The nuances associated with helping consumers match their health and financial needs to plan characteristics;
  5. The extent to which clients continued to need help from assisters after initial enrollment;
  6. How various components of Marketplace assistance fit together – and the need to create a functional infrastructure that can support both assisters and consumers.

For purposes of this report, we have organized a summary of the challenges and innovations described throughout the Roundtable under umbrella headings corresponding to each of these themes.

1. Insurance Literacy and Community Engagement

Roundtable attendees reported that education and engagement were essential precursors to enrollment and grappled with challenges in both respects.

Educating consumers about insurance. Participants described insurance literacy barriers as “huge,” with implications not only for how well consumers can make plan choices and use coverage effectively, but for understanding why it is important to enroll in coverage in the first place. However many consumers didn’t understand basic concepts like how a deductible works or why premiums must be paid every month. Many consumers also had trouble understanding ACA premium and cost sharing subsidies.

A number of assisters described innovative approaches to addressing insurance literacy issues. In some jurisdictions, including the District of Columbia, Assister Programs explicitly expected front-line assisters to devote a substantial portion of their time to educational efforts. Other programs created partnerships with community-based nonprofits that could provide help with education. Another approach was to develop a lexicon that could be readily understood and interpreted by consumers – for example, some Assister Programs found that consumers understood “Advanced Premium Tax Credits” when they were described as “the monthly discount coupon,” and understood “cost-sharing reductions” when described as an “upgrade.”

Participants discussed the need to develop more and better consumer educational materials about health insurance, as well as the need for ‘generic’ educational materials that Assister Programs could brand with their contact information.

Participants also noted an on-going need for effective ways to communicate about complicated ACA concepts and issues, as well as for better terminology to replace problematic terms such as “penalty” as a descriptor for what happens to consumers if they fail to enroll. A central repository for such educational materials would enable Assister Programs to review, adapt and use materials that could work well for their clients.

Outreach in communities. Roundtable participants described lack of engagement as a substantial barrier for some consumers – including for residents of communities with historically weak connections to the health care system. For these groups, Roundtable participants reported outreach needed to start with “engagement” – a process of getting the attention of consumers and developing their trust in assisters who would then educate them about coverage and help them to apply. Such efforts were most effective when assisters interacted multiple times with consumers. Participants also emphasized the importance of case work, “accompanying” each client, in person or on the phone, through the entire process of enrollment, even as other assisters or agencies with more specialized knowledge were brought in on the case. Another model described by participants placed primary emphasis on in-person assistance through walk-in centers or door-to-door outreach and enrollment in hard-to-reach communities. Discussion at the Roundtable also emphasized the importance of developing an assister workforce with heavy representation from within communities where engagement needs to occur.

Participants appreciated that the federal and many state Marketplaces recognize the value of outreach and public education efforts. However, it was noted that a few state Marketplaces paid assisters on a per-enrollment-basis, which can discourage investment in these outreach practices.

Participants also discussed a requirement in the federal Marketplaces that all entities that are part of navigator consortia must perform all statutory duties. In several states, consortia formed with the intent of combining specialized talents and expertise – for example, some partners with close community ties would focus on engagement and outreach, referring consumers to partners who specialized in the Marketplace application process. Participants were concerned that requiring all members of a consortium to conduct all navigator activities created inefficiencies. They suggested greater flexibility so that programs could work collaboratively and coordinate the specialized skills of their consortium members.

Accessible, culturally and linguistically appropriate services. Roundtable participants also discussed enrollment barriers for non-English speakers. In many Marketplaces, educational and application materials were not translated into other languages or interpreters were not adequately deployed. Participants noted problems when Call Centers were unable to communicate with non-English speakers. Shortages of sign interpreters for people with hearing impairments were also noted. Such problems also threatened to undermine trust between community-based Assister Programs and members of their own communities, who expect culturally and linguistically sensitive forms of engagement from these grassroots organizations.

Participants suggested translation into multiple languages in time for open enrollment 2014-15, consistent availability of interpreters at call centers, and appropriate services at all levels of the system for people with disabilities.

2. Managing Early Implementation Glitches and Shortfalls

Participants discussed a number of challenges that arose in the first year because of implementation delays and technical difficulties. They noted these challenges will most likely be addressed and improved in years to come, but noted lessons learned that could also help in this process.

In particular, participants emphasized the value of feedback from Assisters to the Marketplace on how implementation is working. Often, implementation glitches were first noticed by assisters – for example, when guidance on the implementation of one state’s new Medicaid eligibility rules was communicated inconsistently by two different agencies. Assisters identified the problem so state agencies could correct it quickly. Participants suggested that feedback from Assisters be formally and regularly solicited by Marketplace, for example, through periodic conference calls or other mechanisms.

Rapidly-changing regulations, guidance, and practices. The pace of emerging information related to implementation at both federal and state levels was fast during year one. Roundtable participants described several strategies for staying abreast, including regular meetings or conference calls with State-based Marketplace staff and/or regional staff of the Centers for Medicare and Medicaid Services (CMS). In some states, web-based resources were developed through which Assister Programs could communicate and share updates and learn from their peers.

Even so, Roundtable participants noted that keeping up with changing guidance and procedures was a challenge that required monitoring multiple sources, such as the healthcare.gov web site, Regtap (an online technical assistance portal, maintained by CMS, to provide updates primarily to health insurance issuers and brokers), and sites maintained by other private sector organizations. Participants suggested that it would be helpful to have a single, reliable, up to date compilation of guidance summarizing evolving rules and regulations that would be posted online so all Assister Programs could access it.

Marketplace notices about eligibility determinations. Participants discussed problems that arose because first-year eligibility determination notices did not explain the basis for a determination. When consumers or assisters suspected a mistake, it was difficult to follow up or appeal. Others noted problems with notices advising consumers to submit additional documentation to verify their eligibility for Marketplace coverage or subsidies (for example, notices asking consumers for additional documentation of their income were the same for all consumers and offered an illustrative list of documents that might be used to verify income without specifying the type of documentation a particular consumer should submit). Lack of clarity in notices made it harder for assisters to help consumers and added work for the call centers.

In addition to improving the content of notices, Roundtable participants suggested that Marketplaces issue notices to Assister Programs as well as consumers, or otherwise notify assisters that client notices had been sent, so that assisters can help answer questions and facilitate follow up.

Call center operations. Participants at the Roundtable emphasized the value of call centers as a built-in resource for resolving emerging issues encountered by assisters and consumers in real time. Participants described some centers as working effectively in spite of an extraordinarily high volume of calls. However, participants noted that the federal Marketplace call center and some other state call centers experienced serious challenges. Participants noted long wait times, inconsistent guidance, confusion at federally-run centers about state-specific Medicaid policies, and insufficient availability of translation services for consumers who do not speak English.

Call centers worked best, from the point of view of Assister Programs, in states that developed a dedicated line for assisters, and/or a tiered system for triaging and assigning calls based on level of complexity. Dedicated lines reduce hold time for Assisters, better enable them to follow up with the same call center staff in cases involving more complex issues, and better ensure that highly trained subject matter experts will be available to answer questions.

Participants further suggested that call center capacity be supplemented, in the longer run, with comparable dedicated access to websites for assisters. These dedicated assister portals into Marketplace websites would enable assisters to check the status of a client’s application and enrollment and answer other questions directly without having to use the call center. In addition, website assister portals could be used by Marketplaces to track the work of assisters, facilitate networking among assisters, and encourage an ongoing “learning community,” along lines described in more detail below.

Coordinating with Medicaid. Roundtable attendees emphasized the advantages of a “no wrong door” approach to enrollment, as envisioned under the ACA, so that consumers can make a single application to the Marketplace that can be used to determine their eligibility for either Medicaid or a QHP. Assisters working in federal and state Marketplaces that had not yet implemented the “no wrong door” approach discussed difficulties transferring an applicant’s Marketplace eligibility information to Medicaid and backlogs that developed waiting for Medicaid determinations.

Participants discussed how additional training of assisters on separate Medicaid eligibility and enrollment procedures could facilitate Medicaid enrollment. They further suggested that staff at the national call center be better trained on cross-state differences in Medicaid eligibility rules and administrative requirements.

Participants also pointed to examples of states that have simplified Medicaid enrollment, such as in Arkansas and Oregon, where new Supplemental Nutrition Assistance Program (SNAP) beneficiaries are automatically referred to Medicaid.

3. Complicated Eligibility Requirements

Participants discussed how many clients presented at Assister Programs with complex cases and questions. Helping these consumers could require in-depth knowledge of tax rules, immigration law, family law, and other specialized areas beyond the expertise of most individuals. Participants discussed how training and technical assistance could help in several areas.

Tax-related information and requirements. Both assisters and tax professionals at the Roundtable noted that consumers raised many questions about the tax implications of subsidized enrollment, and voiced concern that they themselves needed more information to answer consumers’ questions, help inform their choices, or assist with tasks such as declaring accurate deductions for self-employed workers. In the words of one participant, “intensive focus on enrollment during this first season made it hard to focus on little-understood, untested tax implications” – and yet these implications will be very important to consumers when tax reconciliation occurs.

Discussion at the Roundtable focused on the need to combine training on tax law with referrals of consumers with complex questions to experts with more specialized knowledge.

Some Assister Programs effectively partnered with, or were planning to partner with, tax preparers in order to address this issue.   Some also suggested that the IRS and tax preparers could analyze 2014 returns to learn more about what worked well and what mistakes were made estimating income and subsidy eligibility for the first year, and use this information to tailor training and other improvements in response.

Issues faced by immigrants. Roundtable participants emphasized repeatedly that enrollment requirements related to documenting immigration status created barriers for many apparently eligible consumers. In many instances automated systems didn’t work effectively to verify an applicant’s identity or immigration status. In other instances, complex cases were difficult to resolve.

Participants suggested that Marketplaces work more directly with Assister Programs whose clients faced such problems. They suggested a casework approach to working with Assister Programs, with consumers (or their assisters) assigned to a specific call center or Marketplace representative who could work a case through to its conclusion, at least until automated eligibility and enrollment systems for legal immigrants can be resolved.

Participants also noted that additional training about immigration issues would be useful for 2014-15, and that greater access to outside experts in immigration law could help resolve complex cases.

Issues faced by seniors and disabled individuals. Discussion also focused on issues involved in sorting out eligibility for ACA assistance for individuals who may also be eligible or nearing eligibility for Medicare. Often these individuals initially reached out to Medicare or Social Security (SSA) with their questions.

Several participants pointed to the value of closer coordination between Medicare, SSA and Marketplaces to anticipate the health care and eligibility needs of these populations and to develop specific guidance and tips for them. Participants also suggested this coordination include Assister Programs, as well as other advocates who serve these populations.

What it takes for assisters to meet complex needs. Roundtable participants discussed at length the challenges to division of labor within Assister Programs presented by consumers in complicated circumstances. Discussion highlighted the need for readily-accessible expertise in at least five domains: immigration law; tax law; family law; evolving state and federal ACA-related policy; and health insurers’ administrative practices. State-based Marketplaces have experimented with a number of models to serve consumers with needs in one or more of these areas, including: (a) a single point of entry from which consumers are then referred to appropriate assisters based on the complexity of their case; (b) a hub and spokes model that links assisters together in a tight network where rapid consultation is the norm; and (c) a team model that facilitates development of specific, coordinated areas of expertise for each assister in the group. Participants agreed that any approach to organizing consumer assistance services should take into account local needs and resources.

A number of participants emphasized coordination – both within and across programs – to resolve complex cases. Many programs scheduled regular staff sessions for case reviews and problem solving. Listservs and conference calls were organized in some Marketplaces so Programs could share information and tips on complex cases.

Participants also emphasized the importance of regular, formal feedback from Assister Programs to Marketplaces so that lessons from any one case could be analyzed to strengthen systems and prevent similar problems down the line.

4. Matching Consumer Needs with Coverage

Helping consumers choose among plans. In addition to insurance literacy barriers, Roundtable discussion surfaced other challenges assisters faced in helping consumers make informed choices among health plans. The lack of plan comparison tools in many Marketplaces was one challenge. In many Marketplaces, a significant number of plans were available in each tier (e.g. bronze, silver, gold) but tools for comparing them on consistent metrics were not available. Cost sharing information proved particularly tricky to parse when many different plan variations were offered. Differences in plan provider networks could also be challenging to evaluate. The only comparative information consistently available was about premiums, but assisters also faced challenges explaining the difference between lower- and higher-premium plans.

Roundtable attendees reported that people with disabilities and other serious chronic health conditions faced other specific challenges. These individuals needed information about coverage of specific health care needs and services that weren’t always well described in summary information. For example, one participant described a consumer who selected his plan based on its stated coverage for wheelchairs, then learned after he enrolled that the plan did not cover wheelchair repairs.

Participants discussed the value of more sophisticated plan comparison tools, such as one used by the Illinois Marketplace. Among other features, this tool allows consumers to search plans based on whether their provider is in network. The tool also helps consumers compare plans based on total cost – likely out of pocket expenses (based on a consumer’s general health status) plus premium costs in a year.

Several participants described partnerships with insurance brokers to broaden their understanding of plans and how they work. Arrangements developed in both Connecticut and Texas appeared to effectively foster effective coordination between Assistance Programs and brokers.

Participants also reported a need for general information – such as published complaints data or consumer satisfaction survey data – about enrollees’ experiences in available health plans. This is particularly important for enrollees with special or chronic health needs, whose experiences can test the limits of health plan coverage.

5. Post-Enrollment

Roundtable participants emphasized that enrollment is a necessary part of gaining access to care, but for many consumers it is not sufficient. Programs around the country observed a “boomerang” effect almost immediately as newly-covered consumers returned with questions and concerns. These include difficulty communicating with insurance companies; trouble understanding how to use new coverage; difficulty with the logistics of paying their premiums; and appealing denied claims or resolving other complaints about coverage. As one Roundtable participant noted while emphasizing the importance of post-enrollment assistance, “If people aren’t satisfied with their coverage and can’t use it, they won’t stay enrolled.”

The ACA requires assisters to refer consumers to Consumer Assistance Programs (CAP) for help with post-enrollment problems. CAPs are established to help all residents in a state, not just Marketplace consumers. There was discussion of the experience in Massachusetts, where the insurance Marketplace and CAP have been in place for eight years; demand for CAP services there has increased over time. However, many Assister Programs represented at the Roundtable reported limited CAP availability in their states.

Participants discussed the fact that CAPs do not exist in every state as a result of funding constraints. They also noted that all Marketplace assisters needed to be aware of referral requirements and oversight established to ensure that clients were being appropriately referred in a timely fashion.

6. Consumer Assistance Infrastructure

Roundtable participants emphasized that Assister Programs should ideally be a lasting rather than a transitional aspect of health reform. Although the first year of operation for state-based health Marketplaces created a few specific demands for help that may diminish with time (e.g., technological issues associated with new web portals), consumers’ need for assistance navigating the terrain between mandated coverage and successful enrollment will create a lasting demand for substantial Marketplace assistance.

Under the ACA, Roundtable participants observed, complex choices and administrative requirements posed by eligibility for, enrollment in and successful use of insurance coverage will be a continual challenge for consumers. To meet this demand, participants stressed it would be valuable to build a permanent workforce of steadily-employed assisters who are paid wages that would minimize turnover. They further suggested that this workforce be supported by a unifying infrastructure that includes data collection, quality improvement and professional development. Roundtable participants noted the role philanthropy has played in developing this infrastructure to date, and their hope it will continue while a longer term vision for consumer assistance is articulated and implemented.

Adequacy of funding for Marketplace assistance. Roundtable participants expressed pride and satisfaction over how quickly the early consumer assistance capacity was established. At the same time, they noted that capacity shortfalls were also a problem. Even in New York, for example, where participants described assistance capacity as “robust,” Assister Programs could not serve all the consumers who did contact them, particularly during periods of peak demand toward the end of the open-enrollment period.1

Roundtable participants believe that assisters played an instrumental role in the success of the first open enrollment period, in large part because they are trusted by members of the diverse communities across the country in which they work. At the same time, participants voiced concern that instability in the assister workforce could result if this role is viewed as temporary, poorly remunerated, and not yet professionalized. One state, for example, reported an 80% turnover rate at its call center during the first year, because the low rate of pay provided no incentive to continue. Others worry that the part-time and seasonal nature of assister jobs in some programs could hinder efforts to build professional capacity for assisters and their long-range presence in the community.

Participants noted that Marketplace funding of Assister programs in the federal and most state Marketplaces continue to be allocated on an annual basis. Roundtable participants emphasized how funding uncertainty can hinder continuity within Assister Programs, making it difficult for host organizations, state-level officials, and other funders to plan. Participants therefore suggested longer-term grants (perhaps 3-5 years) for Assister Programs. This approach, which has already been adopted by New York for its navigator grants, can enhance strategic planning, to promote investment in information systems, skill- and team-building for staff, and closer relationships between Assister Programs and government agencies and other partners.

Participants acknowledged that funding limitations may continue in the near term and noted that in some communities local foundations and other philanthropic sources provided support to help fill in gaps. Participants noted that a longer term funding commitment by Marketplaces, even if it evolves gradually, could also help foundations and other external supporters to invest in consumer assistance strategically rather than by filling last-minute gaps in essential on-the-ground capacity.
One idea discussed by participants was to allocate a specified proportion of Marketplace revenue in each state for assister functions. This was seen to most appropriately include funding for not only the enrollment process itself, but also public education, appeals of enrollment denials or subsidy determinations, coordination among Marketplace assisters, and websites to support learning networks among assisters.

Coordination. Discussion at the Roundtable emphasized and illustrated the magnitude and multiplicity of organizations enlisted to provide enrollment assistance during 2013-14, including non-profit organizations (both local and national in scope), religious institutions, small businesses, tax preparers, state and local government agencies, and public libraries. At the same time they noted many Assister Programs worked in isolation or with limited resources. Coordination between programs could help programs operate and learn more efficiently, share resources strategically, and communicate and strategize together more effectively.

Assisters in some states, including North Carolina and Pennsylvania, developed central scheduling calendars to match consumers with assisters who have available time, thus preventing waiting times for consumers resulting from uneven workload distribution. An online scheduling platform is offered for free by Enroll America, but resources are needed to adapt the calendar for local communities and train staff to use it.

Participants emphasized that in some states, such as Maine, an umbrella agency was designated to help Assister Programs coordinate on a range of functions and to provide technical assistance and other support. The coordinating organization stayed on top of changing rules and procedures and trained an expert staff to provide technical assistance to all Assister Programs. This organization also created a way for Assister Programs to network and share information. It helped Programs design a coordinated campaign to identify and outreach to young adults, Latinos, and other key populations. And, it proactively went into communities to learn what was working and where Assister Programs needed more help.

Foundations played a key role developing and supporting this coordination function in several Marketplaces, both state-based and federally facilitated.2 Participants at the Roundtable agreed that, ultimately, coordination functions should be financed and mandated by the Marketplaces, but immediate needs should also be addressed: as one attendee put it, “we must, must avoid situations we now have where consumers have to go to 3 or 4 different sources before they can successfully enroll.” Participants were therefore hopeful that foundation investments might continue in the near term in order to continue developing and refining a variety of models for coordination, and to provide a stronger foundation for subsequent publicly-funded initiatives. They also articulated a need for evaluation studies to determine “what makes good glue” across communities, states and regions.

Training. In addition to specific issues and areas where Assister Programs would welcome further training, Roundtable participants suggested other changes in the approach to training assisters. They noted that initial training for certification is necessarily somewhat broad and general, and should be supplemented.

Participants said it would be helpful to receive training modules on enrollment needs and frequently asked questions of specific populations (such as young adults, self-employed, Indian tribes, etc.) More in-depth training on specific issues, such as immigration, disability, and tax law, as well as Medicaid, was also discussed. Finally, the need for training on Marketplace web sites was cited.

Programs in several states also emphasized the importance of forming a learning community among assisters, using approaches such as training the trainer; specialized training focus for each assister in one area combined with active collaboration so that this expertise can be tapped by all members of the team as needed; regular “learning fairs” with experts available at booths assisters can visit for additional information, resources and training; and a network approach which actively builds professionalism and skills within the community construct. Web sites on which assisters could share experiences, explore barriers and workshop solutions also played an important role in the states where they were available.

Casework. As noted above, participants at the Roundtable observed that in practice many consumers required a sequence of several or many connected interactions in order to successfully enroll. Accordingly, participants emphasized the importance of changes to promote and strengthen relationships between Assister Programs and their clients.

Participants discussed how some programs initially were concerned that privacy and security standards for collection of personally identifiable information might hinder ongoing communication with clients. Some programs developed model consent forms that included authorization for assisters to follow up with clients.

Some programs also developed data systems to track ongoing cases. In a few states, Assister Programs were provided with secure portal into the Marketplace online application system. With this, assisters could track the status of client cases and follow up when additional information or action was needed to complete an application or enrollment.

Participants also discussed approaches to referring consumers for additional assistance, including “warm handoffs” (staying on the call or accompanying consumers to the referral) to ensure consumers connect with other help, and follow up to ensure referrals were effective. The need to track and investigate cases that were lost on referral was also discussed.

Data. Roundtable participants emphasized the necessity of collecting consistent, robust data about consumer assistance which can form a solid evidence base on which to build quality and system improvement efforts.

Participants highlighted the value of comprehensive performance tracking across all programs, including: (a) Identification of components of the enrollment process and of what is and is not working well(b) Identification of how well diverse populations in each state are being reached and enrolled so gaps can be identified; (c) Tracking of individual cases to assure all issues were resolved and that consumers are not falling through the cracks; (d) Documenting the time that assisters spend on various functions (e.g., engagement; education; enrollment; post-enrollment; legal issues; immigration questions; translation) in order to begin creating a data source on which evidence-based practice guidelines could be built (e) Tracking individual assister performance on a variety of metrics in order to provide strong supervision, identify best practices and target areas for additional training.

Participants suggested that qualitative and survey data about consumers’ experiences with assistance be widely collected and used.

Promote cross-state learning and diffusion of innovative practices. Roundtable participants pointed to the importance of state-level innovation in the implementation of the Marketplaces, and their own on-going desire to learn from one-another.

Participants stressed the value of national forums, such as this roundtable and others, to facilitate this learning. Discussion also focused on the need for rigorous evaluation of emerging models so that state-level innovations can usefully inform policy development and quality improvement.

Long term planning. Finally, participants acknowledged that the evolution of consumer assistance, like other aspects of ACA implementation, will continue for a number of years and not all challenges will be overcome and improvements achieved at once, particularly in light of limited resources and the need to set priorities. As a result, discussion focused on the need for strategic planning.

Participants suggested Marketplaces adopt long range plans for stabilizing assister funding, improving coordination, adopting technological improvements, and other key changes so that improvements can build from year to year and problems can be addressed proactively instead of reactively. Participants also noted that Assister Programs themselves, and the foundations and other organizations that support them, should participate in long term planning.

From Actions to Actors: Agendas for Selected Stakeholders

Participants at the Roundtable identified key stakeholders who they anticipate will continue to play crucial roles in the implementation of consumer assistance over the next five years:

  1. Officials responsible for implementing the Marketplaces (CMS for the federally facilitated Marketplaces, state agencies for the state-based and partnership Marketplaces);
  2. The private sector, including community-based organizations who partner with assisters for outreach and public education, and foundations that fund technical assistance, coordination, and communication among the assisters;
  3. Policy-makers who determine what resources will be made on an ongoing basis.

It was noted that most recommended changes to strengthen Marketplace consumer assistance ultimately would or should be undertaken by Marketplaces directly. One exception relates to ongoing funding for Consumer Assistance Programs, which requires Congressional appropriations. However, understanding that Marketplaces face a range of other evolving functions in the near term, participants discussed how the private sector, especially foundations, might support key changes on a transitional basis.

Roundtable participants identified a number of areas in which interim support by private sector organizations and philanthropy could be particularly helpful, including:

  • Support organizations in each state to coordinate Marketplace assisters; functions would include identifying gaps in effective capacity, orchestrating outreach efforts, and serving as backup with higher level expertise for front-line assisters (at least until Marketplace-based funding becomes available)
  • Fund evaluations of different models for specialized assister expertise, with particular attention to whether certain models are more effective or reliable for different subgroups or in different geographic areas
  • Fund studies of the most effective ways of educating clients about insurance and tax rules under the ACA, with particular attention to different subgroups of consumers who are inexperienced with health care and private insurance
  • Support initiatives to develop norms of professional practice for Marketplace assisters, including expectations for continued training for different levels of expertise, and norms for collaboration and referrals
  • Support a national assistance information center, which would be exclusively accessible to those working in Assister Programs. This center would provide ready access to up-to-date interpretations of federal regulation and interstate variation in the non-FFM Marketplaces regarding their interpretation and implementation of particular rules
  • Facilitate regular meetings of state-level assistance programs to encourage more effective learning across states and enhance the diffusion of best practices
  • Fund the development of prototype information management systems for Assister Programs that provide a robust capacity to track clients over time and to assess the full range of assistance that they are receiving.

This issue brief was prepared by Rachel Grob of the University of Wisconsin at Madison, Mark Schlesinger of Yale University, Karen Pollitz of the Kaiser Family Foundation and Lori Grubstein of the Robert Wood Johnson Foundation.

The authors express their appreciation to the 80 roundtable participants who gave so generously of their time and expertise in an effort to assure that on-the-ground experiences from the first year of open enrollment would be understood, learned from, and improved upon in subsequent years.

 

 

Introduction Appendix

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