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CONFIDENTIAL DRAFT REPORT the Seedco Health Insurance REPORT ACKNOWLEDGEMENTS CONFIDENTIAL DRAFT The authors would like to thank the staff at Seedco who provided helpful suggestions in how to improve the report: Barbara Gunn, Ben Thomases, Brian Robinson, and Lisa The SeedcoStein. We are thankfulHealth to Phaon Insurance Spurlock on Seedco’s external affairs team for his efforts in producing this publication. We are also thankful to Seedco Board Member NavigatorHoward Chernick Enrollment (Hunter College, CityProcess University of New York) for providing helpful feedback on various drafts of this report. in Georgia, Maryland, New York, and This report would not have been possible without the hard work and dedication of TennesseeSeedco staff and extensive network of Navigator partners in Georgia, Tennessee, Maryland, and New York. PolicyThis Implications report is based on andan independent Opportunities evaluation and was funded by a quality improvement research contract and obtained all Institutional Review Board clearances. for QualityAny views Improvement expressed are solely those of the authors and do not represent positions or policies of the University of Georgia or its Board of Regents. Any errors are the authors’ own. OctoberSeedco 2014 is a national nonprofit organization that advances economic opportunity for people, businesses, and communities in need. Seedco designs and implements innovative programs and services for workers, families and businesses. We advance vibrant community economic development through three lines of work: workforce Project Codevelopment,-investigators: work and family supports, and employer and small business services. In Neale R. additionChumbler, to our PhD direct service work, we analyze, assess and develop best practices to Principal Investigatorinform our work, as well as that of other practitioners, researchers and policy makers. We provide technical assistance to federal, state and local governments; funders; and nonprofit agencies. Donald Rubin, PhD Co-PrincipalTo downloadInvestigator a copy of this report, please visit www.seedco.org. ©2014, Seedco, New York, NY Amber R. Huff, PhD Mauricio Garcia, MPA Colleen Cherry, PhD Miranda Hill, MPH Rebecca Walcott, MPH Koichiro Otani, PhD 0 CONTENTS EXECUTIVE SUMMARY ................................................................................................ 3 BACKGROUND ..................................................................................................................... 3 CONTEXT OF THE EVALUATION ................................................................................................ 4 GOALS AND METHODS OF EVALUATION ..................................................................................... 4 SELECTED RESULTS AND CONCLUSIONS ...................................................................................... 6 SELECTED RECOMMENDATIONS BY THEME ............................................................................... 10 1. INTRODUCTION ..................................................................................................... 12 1.1 OVERVIEW .................................................................................................................. 12 1.2 STUDY GOALS & OBJECTIVES ........................................................................................... 13 1.3 OVERVIEW OF STUDY DESIGN .......................................................................................... 13 1.4 NOTES ON THE STUDY DESIGN AND ON THE VALUE OF MULTI-METHOD EVALUATIONS ................. 14 2. STUDY DESIGN: OBJECTIVES, SITES, AND METHODS ............................................... 16 2.1 STUDY OBJECTIVES, POLICY- AND PRACTICE-RELEVANT THEMES .............................................. 16 2.2 THE SEEDCO-UGA COLLABORATION ................................................................................ 16 2.3 RESEARCH SITES: POLICY CONTEXTS, MARKETPLACE CHARACTERISTICS, AND NAVIGATOR TRAINING IN GEORGIA, MARYLAND, NEW YORK, AND TENNESSEE ................................................................ 17 2.4 DATA TRANSFER AND DATA MANAGEMENT ........................................................................ 21 2.5 PARTICIPANT SAMPLING AND DATA COLLECTION ................................................................. 22 2.6 DATA ANALYSIS ............................................................................................................ 23 3. RESULTS: ANALYSES OF SURVEYS AND INTERVIEWS .............................................. 26 3.1 ANALYSES OF SALESFORCE SURVEYS ................................................................................. 26 Descriptive analyses .................................................................................................. 26 Results of bivariate analyses ..................................................................................... 32 Results of multivariate analyses ............................................................................... 44 3.2 ANALYSIS OF INTERVIEWS ............................................................................................... 56 Qualitative analysis of Consumer interview data ..................................................... 56 Qualitative analysis of Navigator interview data ..................................................... 62 4. DISCUSSION AND CONCLUSIONS ........................................................................... 72 4.1 WHAT FACTORS ARE ASSOCIATED WITH SUCCESSES AND DISPARITIES IN THE NAVIGATED HEALTH INSURANCE ENROLLMENT EXPERIENCE? WHICH POPULATIONS EXPERIENCED THE MOST SUCCESSFUL RATES OF ENROLLMENT? ...................................................................................................... 72 4.2 WHAT FACTORS ARE ASSOCIATED WITH SUCCESSES AND DISPARITIES IN ENROLLMENT IN PRIVATE PLANS? ............................................................................................................................ 75 4.3 WHAT IS THE IMPACT OF FACILITATED ENROLLMENT ON ENROLLMENT IN MEDICAID AND OTHER FORMS OF PUBLIC COVERAGE? .............................................................................................. 79 4.4 TO WHAT EXTENT ARE SO-CALLED “YOUNG INVINCIBLES” (CONSUMERS AGED 18-34 YEARS) REPRESENTED AMONG ENROLLEES? ........................................................................................ 80 4.5 WHAT SPECIFIC BARRIERS AND FRUSTRATIONS DO PEOPLE EXPERIENCE IN THE NAVIGATED ENROLLMENT PROCESS? ...................................................................................................... 81 1 4.6 WHAT NAVIGATOR PRACTICES AND RESOURCES EFFECTIVELY MITIGATE BARRIERS AND PROBLEMS IN THE CONTEXT OF FACILITATED ENROLLMENT? ........................................................................... 85 4.7 NAVIGATING “THE GAP”: HOW DO NAVIGATORS ASSIST CONSUMERS WHO ARE FOUND TO BE INELIGIBLE FOR BOTH THE MARKETPLACE AND FOR MEDICAID? .................................................... 86 4.8 WHAT DO CONSUMERS AND NAVIGATORS CONSIDER THE CHARACTERISTICS OF EFFECTIVE COMMUNICATION IN THE CONTEXT OF NAVIGATION? ............................................................... 86 4.9 IS CONSUMER HEALTH (AND HEALTH INSURANCE) LITERACY ASSOCIATED WITH OUTCOMES OF FACILITATED ENROLLMENT? .................................................................................................. 87 4.10 RELATIONSHIPS AMONG MARKETPLACE CHARACTERISTICS, INSURANCE POLICY OPTIONS, AND CONSUMERS’ CHOICES ABOUT HEALTH INSURANCE ENROLLMENT ................................................. 88 5. RECOMMENDATIONS ............................................................................................ 91 REFERENCES ............................................................................................................. 96 APPENDICES TO THE REPORT .................................................................................... 98 APPENDIX A: TABLES REFERENCED IN TEXT ............................................................................ 101 APPENDIX B: DATA COLLECTION INSTRUMENTS USED WITH CONSUMERS ..................................... 173 APPENDIX C: DATA COLLECTION INSTRUMENTS USED WITH NAVIGATORS .................................... 176 2 EXECUTIVE SUMMARY BACKGROUND The Patient Protection and Affordable Care Act (ACA) put in place reforms that improve access to quality, affordable health coverage. One of the provisions of the ACA was the creation of new Health Insurance Exchanges, or Marketplaces, to provide a one-stop- shop for Consumers to compare plans, apply for subsidies or public insurance, and enroll in health coverage. The ACA also required each Marketplace to fund a Navigator function to provide in-person outreach, education and enrollment assistance. In 2013, Seedco was awarded funding to lead Navigator consortia in 4 states, Georgia, Maryland, New York, and Tennessee, overseeing Navigator training and program implementation. Seedco is a national nonprofit organization, founded in 1987, with a mission to advance economic opportunity for people, communities and businesses in need. Seedco operates programs in workforce development and benefits outreach and enrollment; and provides technical assistance services for small businesses and nonprofits. Seedco Navigators operate in two states that opted to create their own insurance Marketplaces and that expanded Medicaid eligibility: New York and Maryland. Seedco Navigators also operate in two states that utilize the federally facilitated Marketplace and that opted out of Medicaid eligibility expansion:
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