Implications of Navigator Funding Changes on People with HIV: Navigator Perspectives

The Affordable Care Act (ACA) requires healthcare marketplaces to establish “Navigator” programs to assist individuals with outreach, education, and enrollment in insurance coverage. For states using the federal marketplace (currently 34) the Centers for Medicare and Medicaid Services (CMS) provides navigator funding and manages the program. However, recent funding cuts to the program have meant that grantees have had to assess and, in some cases curb, the services they provide.¹ We examined the potential impact of these funding cuts on people with HIV, a population that has experienced significant gains in insurance coverage under the ACA, with, in many cases, the help of navigators. Several of the federal navigator grantees were AIDS Service Organizations (ASOs) and/or organizations that identified people with HIV as a population they would specifically work with. This issue brief analyzes funding data and findings from stakeholder interviews with these navigator grantees to assess their role in serving people with HIV as well as the potential impact of cuts going forward.

Background

Federally funded navigator organizations are currently operating under a three-year grant, 2015-2017. While earlier this year, CMS announced that $60 million would be available for the third and final year of navigator funding, an amount comparable to each of the first two years under the grant, it later released awards amounting to a $26 million or 41% cut, with several organizations losing funding altogether. CMS explained that year three funding would be “based on [grantee] ability to meet their enrollment goals during the previous year” but did not detail the specific metrics to be used to calculate the award.² A recent Kaiser Family Foundation report found that in many cases services offered by navigator programs will be disrupted, including by cutting services to certain populations and geographic regions and curtailing the types of assistance they provide. They also found that as confusion around the continuation of the ACA “coupled with a shortened open enrollment period, increases demand for the consumer education and in-person enrollment assistance Navigators provide. At a time when more help may be needed, the funding reductions are likely to reduce the level of in-person help available to consumers during this fall’s open enrollment and throughout the 2018 coverage year.”

We sought to examine the impact of proposed cuts on people with HIV and the organizations that serve them. People with HIV face unique medical needs and vulnerabilities, and were more likely to be uninsured prior to the ACA compared to the population overall.³ As such, the availability of enrollment assistance was particularly important for this population. Aware of this, some navigator groups specifically identified people with HIV as a target population for assistance under their grant (11 out of 103, or 11%).  To assess the impact of navigator funding cuts on these entities, we analyzed changes in funding levels and conducted interviews with key stakeholders.

Methods

We examined the CMS notification of 2016 navigator grant awards, which included grant application summaries, to identify organizations that specifically targeted their enrollment assistance to people with HIV either directly or indirectly through sub-grantees.⁴  We included grantees in the following three categories:

• Grantees that are AIDS Service Organizations (ASO);
• Grantees that identified an AIDS Service Organization as a sub-grantee; and/or
• Grantees that specifically identified serving people with HIV as a target population

Using this 3 pronged test, we identified 11 “HIV navigator entities” out of 103 grantees overall (11%). Based on funding data released by a third party, we examined changes in their 2017 awards, compared to 2016.⁵ In addition, we conducted interviews with representatives at 11 navigator organizations, including both named grantees and sub-grantees. Most of the 11 were primary grantees (9); the remaining 2 were sub-grantees. Organizations represented all regions of the U.S., except for the Northeast but were most likely to be located in the South . All participants were asked to discuss: why they decided to include people with HIV as a target population (and for ASOs, why they sought a navigator grant); the role that navigators played for people with HIV; their reaction to the cuts; the impact the cut would likely have on their organization; and the impact the cut would likely have on people with HIV. Interviews were conducted in September and October 2017.