But navigators say they do more than simply help people fill out applications. They are required by the federal government to also respond to consumers' questions about health insurance, help them understand their coverage, enroll them in Medicaid, refer them to other services, and even verify their immigration status at times, Quenga said. Her full-time navigator staff members are paid about $30,000.
Often, people spend an hour with a navigator, and then go home to talk with a spouse before finishing the insurance application online. When that happens, navigators don't get to count that application toward their total enrollment goal. Quenga said her staff worked with as many as 79,000 consumers during the last open-enrollment period, but enrolled only 1,900 of those in person.
Had she known that the Palmetto Project's funding would be based off the goals navigators set themselves, Quenga said she would have lowered the bar. "It's very frustrating given the amount of time we spend with consumers and how personally committed to this work the staff are," Quenga said.
The upcoming fifth open-enrollment period is likely to be a difficult one. In addition to the funding cuts for ads and navigators, this year's open enrollment in states that use the federally operated HealthCare.gov exchange has been shortened to end on Dec. 15. It typically stretches until Jan. 31.
Consumer choice has dwindled since the last open enrollment. Many insurers, such as major marketplace player Anthem, have scaled back their participation on the exchanges because of financial losses and uncertainty over whether the federal government will fund crucial cost-sharing reduction subsidies and enforce the individual insurance mandate.
"A lot of people are going to be looking for new carriers, including those previously assisted by navigators," said Michael Levin, CEO of Vericred, a healthcare data services company. He added that most of the consumers who went to navigators for help were those that needed it most and didn't have a way to enroll on their own.
It's unclear if the navigators will be able to assist as many people on smaller budgets. There are other types of enrollment helpers, including certified application counselor organizations, which could include community health centers or healthcare providers that perform many of the same functions as navigators but do not receive funding from the CMS.
Brokers also help customers enroll in the marketplace plans. But because many insurers have reduced or stopped paying brokers' commissions for individual insurance products, some brokers have put their resources in other product lines, Levin said.
The navigator and outreach funding cuts are predicted to hold down enrollment. "People are concerned that enrollment could decline as a result of these two actions," said Karen Pollitz, a senior fellow at the Kaiser Family Foundation, adding that it will also hurt the individual market's risk pool. Premiums go up when the risk pool worsens.
California's state-run exchange, Covered California, on Sept. 13 predicted that 1 million fewer Americans would enroll in the exchanges as a result of the funding cuts, and that premiums would increase 2.5% for those consumers who do enroll. California's ACA marketing budget of $111 million for 2018 dwarfs what the federal government plans to spend on the 39 states that use the federally operated marketplace.
Without the right help, fewer consumers might enroll in exchange plans, but others may sign up for plans that don't fully cover their needs, said Dr. Stephen Klasko, CEO of the Philadelphia-based Jefferson Health system. Either way, the uninsured and under-insured will still show up at the hospital, and hospitals will end up having to absorb more uncompensated care.
"If the goal is to increase access to people, then there's no question that we should fund the navigator program," Klasko said. "It makes absolutely no sense in my mind (to cut funding) unless you've got an alternative strategy." 1