Diamond Wooten, at left, prepares to sign up for her first individual insurance policy at Farish Street Baptist Church Friday, December 7, 2018.

Diamond Wooten has gone without health insurance for two years. She hasn’t had any major health scares and was able to get basic care at Jackson State University’s campus clinic as an undergraduate.

During the final weeks of the Affordable Care Act open enrollment period, Wooten, 22, is proactively looking for her first personal health insurance policy because she wants better access to primary and preventive health care. 

On her fixed graduate student income, she needs a low-cost plan with a flexible network, but says the options are confusing. Between private brokers warning about premiums soon to “skyrocket” and misleadingly labeled “Obamacare” policies online that are not a part of the federally regulated health care marketplace, Wooten wanted someone to walk her through her options.

That’s where health insurance “navigators” come in.

Wooten started a Healthcare.gov application on her own, then realized she needed help understanding terms that were new to a first-time insurance customer — copay, deductible, premium and tax credit — and she knew her time was running out. For the second year in a row, the enrollment period runs only six weeks from Nov. 1 to Dec. 15.

“I was just looking at it all and like, ‘Huh?’,” she said. “I needed someone to tell me which would be better, between higher deductibles and premiums.”

The ACA law requires marketplaces to set up navigator programs to walk people through insurance options and the nuances of the otherwise complex legislation. Like in Wooten’s experience, the uncertainty between politicians’ repeal-and-replace rhetoric, reduced funding to support the insurance marketplace and a nixed individual mandate penalty have fueled confusion among consumers. Navigators aim to allay fears by providing one-on-one assistance — or as navigators here say, offering “hope and light where there was darkness.”

Fluctuations among monthly premium prices and the number of insurance providers on the marketplace have added to confusion among people seeking help, navigators say.

Premiums for this enrollment period and 2019 coverage are holding steady over last year, although the average increase for a “silver plan,” which generally offers middle-tier premiums and deductibles, jumped by almost 60 percent in 2017 when all but one insurer left the Mississippi marketplace. Ambetter is still the only marketplace insurer, making Mississippi one of five states with just one option on the exchange. Across the U.S., states are expected to have an average of four insurers in 2019.

Recently, Centers for Medicare and Medicaid Services required navigators to focus on recruiting people without insurance, pivoting away from their  broader focus of cultivating relationships with small employers, self-employed people and both uninsured and under-insured consumers. The program ideally intended for navigators to be an established presence in a community that people — particularly those without traditional health insurance options — can rely on for health insurance, tax and eligibility questions.

Wooten heard about the navigator program through her family, and made an appointment with navigator Marian Talley at Farish Street Baptist Church in Jackson. On top of helping people enroll in coverage, navigators can advise consumers on how subsidies will affect their taxes. Next year will be Wooten’s first time filing taxes on her own.

Diamond Wooten, a graduate student Jackson State University, left, gets help from Marian Talley with her first individual insurance policy at Farish Street Baptist Church Friday, December 7, 2018.

Without Talley’s help, Wooten said she would have gone without health insurance again, but instead found a policy with an affordable premium and deductible.

Wooten is the type of consumer that Get Covered Mississippi, one of two federally funded navigator programs in the state, targets — people without insurance.

But this year, navigators are doing more with less. Since 2016, the U.S. Centers for Medicare and Medicaid Services have cut Mississippi’s navigator funds by 79 percent.

Mississippi is better off than most states when it comes to the number of navigator programs. Though funds have been cut— from $907,579 between two programs to $187,849 — there is still at least one navigator in every county, unlike three states that have none and most states that leverage one navigator across as many counties as possible. Seven counties in the south Delta have access to two navigator programs between mobile units and sub-grantee organizations, according to a Kaiser Family Foundation analysis.

In addition to further reduced navigator funds this year, last year the Trump Administration cut the enrollment period in half to six weeks, reduced advertising by 85 percent, and nixed the tax penalty that previously incentivized compliance with the individual mandate, which requires people to have health insurance.

Unlike the national narrative of fewer navigators leading to long waits or hard to access assistance, navigators in Mississippi say the reduced advertising has hurt more than anything because it exacerbates the uphill battle of educating people about what the ACA is, and what their insurance and subsidy options are — and that the nixed tax penalty for going without insurance doesn’t mean that the marketplace exchange is gone.

“Some people don’t think about it until they need it, so it’s all about education,” said Shannin Jones, a Get Covered Mississippi navigator. Though provider competition is non-existent on Mississippi’s exchange this year with just one insurer, Jones says her job is about helping people learn how to access health care. “One option is better than nothing,” she said. “And it’s sad that people are missing out on this avenue to afford insurance and access care without having to go to the ER.”

Premiums are steady from last year and enrollment data show enrollment is only down by 2 percent from this time last year in Mississippi, while national enrollment is lagging 11 percent behind last year.

Navigators say people who’ve previously enrolled in the marketplace know to go back online and renew their coverage, and re-enrollees usually comprise the biggest proportion of overall enrollment numbers. The struggle in matching last year’s 84,000 enrollment threshold, will be reaching uninsured people, who are often the hardest to reach.

Kathryn Rehner

To reach those uninsured and vulnerable groups usually left out of outreach programs, it takes community buy-in and a sustainable presence, says Kathryn Rehner, who ran the navigation program through University of Southern Mississippi for three years, before funding cuts last year forced the program to shut down.

The Mississippi Health Access Collaborative used their grant to exclusively focus on southern counties, where outreach programs are often ignored, Rehner said. They focused on meeting people where they are, and not expecting people to come to them.

“Something that was done a lot was community health centers enroll the people that come through and that’s great, but you have the same people circulating,” she said. “We wanted to do and create something that was broader than that and that reached parts of the community where people weren’t getting information or weren’t necessarily interacting with those traditional spheres.”

Get Covered Mississippi works under Oak Hill Baptist Church in Hernando, and has had a navigation grant since the first cycle in 2013. Their funds have been cut by 84 percent since 2016, but program director Lottie Minor says their biggest hurdle this enrollment period has been combating misinformation due to reduced advertising and marketing budgets.

Consumer needs vary across the state, Minor said. “The state is so different from county to county — in some areas it’s going to be education, just because the people are already further down the totem pole in terms of knowledge, so we have to work a little harder to educate them,” she said. “In other areas, I think it may be those individuals who simply get caught in the gap, and there’s nothing we can do about that. Obviously by Mississippi not being a Medicaid expansion state, that’s something that we deal with.”

Get Covered Mississippi largely relies on word-of-mouth and connections within their ministry to reach new consumers. They haven’t had to cut the number of navigators from the forty they have helping with enrollment across the state, but rely more heavily on volunteers, Minor said.

The other navigation program, Jackson-based My Brother’s Keeper, has five navigators focusing on the southwest corner of the state this enrollment period — their first year as a grantee — and travels the rural corner of the state with a mobile health clinic, hoping to educate communities on the ACA, enrollment options and health care in general.

T’Juan Rucker, prevention program manager and ACA navigation program lead for My Brother’s Keeper, talks on a the phone at the Walgreens in Vicksburg on Thursday, December 6, 2018 to someone who is interested in signing up for health insurance.

“It’s been a challenge,” said T’Juan Rucker, who manages My Brother’s Keeper navigation program and says that the misinformation and confusion surrounding policy and administration changes makes their job harder.

“A lot of people think Obamacare went away with Obama,” he said. “It’s out there but people don’t know what the ACA is and without the mass marketing, it’s like you’re selling snake oil.” Without more systematic support, Rucker says it will be a struggle to reach the uninsured “new consumer” that navigator programs are supposed to reach.

Last year, renewed coverage accounted for 63 percent of all enrollment, which means the bulk of enrollment was from people who were already familiar with the system. Nixing the tax penalty for going without insurance makes it harder too, Rucker says. “No penalty means no call to action or sense of urgency.” And the shortened enrollment period, he says, “it’s playing with folks’ lives.”

Rucker is starting from scratch to build trust in the southwest corner of the state, but had just one month before to build the groundwork and enroll as many people as possible by Dec. 15.

At a sign-up event at a Vicksburg Walgreens this month, Rucker talked to a few seniors about their Medicare options, but his ACA enrollment efforts were left to phone calls instead of in-person interest. He had more traction at the next event and admits, it takes time, energy and continued presence to build rapport with a new area — especially the part of the state he’s focusing on where computer and health literacy tend to be low and the uninsured rate is high. “They’re the hardest to find and the hardest to convince of the importance of insurance.”

Roy Mitchell, executive director of Mississippi Health Advocacy Program, agrees and says it’s too soon to know what the final enrollment outcome will look like, but he is skeptical and says no-show enrollment events are to be expected with all the policy fluctuation.

“I’m not surprised. These kinds of things require outreach and to compare last year to this year, I don’t think it’s a fair comparison because the sabotage efforts began in earnest last September,” Mitchell said. “There’s been systematic and continuous sabotage and that’s the results, when you have sign-up events and nobody’s there.”

During the six-week enrollment period, navigators have to move quickly, but also spend time to create rapport with communities, navigator Rucker says, to be able to reach low-income people in rural areas that are often reluctant, but need the services. “Some of these individuals are balancing eating or health coverage,” he said. “You prioritize what hits first and hunger hits first.”

Mississippians who re-enrolled through the marketplace last year got the best deal on premium prices, when 97 percent of consumers received some marketplace financial assistance — the highest percentage in the country — either between a tax credit or a cost-sharing reduction, with their average premium costing $66.

But the 97 percent receiving financial help only accounts for those who enroll in coverage, and does not capture those priced out of the marketplace because their income is too low. Without Medicaid expansion, of the 350,000 uninsured across the state, about 100,000 fall in the coverage gap and have no realistic options for insurance.

Organizers on the ground helping people enroll in coverage say the biggest effect of reduced funds and advertising is likely on groups health advocates try hardest to reach — those without insurance, like grad student Wooten.

Since the ACA’s inception, navigators have provided much of the education, outreach and support to help the law and marketplace function as intended, Rehner says. And studies show that while navigators might not always account for a large proportion of overall enrollment, the one-on-one assistance is crucial in reaching disenfranchised consumers and impact uninsured people’s enrollment decisions

Rucker agrees. “You got to have boots on the ground. Air strikes don’t work.”

“Most of the people we were signing up were people who were at the poverty level … these are people who really need the support and they need the encouragement, and that’s not something that they will have anymore,” Rehner said, referring to USM’s navigation program losing funding. “Your health care is so personal to you and it’s key to have somebody sit with you and tell you it’s going to be OK and to walk you through it and to tell you you are eligible, or to tell you, “I can help you with this, you don’t have to do it alone.”

USM laid the groundwork on retaining enrollment through community outreach and education, but lost the grant after funding cuts. My Brother’s Keeper hopes to continue the work that USM started, but their focus is on more targeted areas and they have about one-tenth of the budget to stretch.

Mississippi Commissioner of Insurance Mike Chaney speaks during the Neshoba County Fair Wednesday, August 1, 2018.

Mike Chaney, Mississippi’s insurance commissioner, says around 70,000 people have enrolled so far this year. Last count from CMS, tallied just over 35,000 sign-ups during the first month of open enrollment. Last year, 83,649 people enrolled, down from 88,483 the year prior. 

Navigators on the ground are hopeful that their efforts to reach uninsured Mississippians during the last week of enrollment will pay off, but worry that there’s not enough political buy-in to reach everyone that might need help.

Between the shortened enrollment period — now just six weeks — and the drastically cut marketing and navigation funds, navigators have to do more with less time and money to reach people, on top of battling misinformation, says Rucker.

“You got 45 days to make sure no stone is unturned about making sure the public knows our services are here,” he said. “To really effect change in the insurance disparity … you have to touch people in rural areas and know how they think and talk. Every day counts.”

For help enrolling visit Healthcare.gov or call 1-800-318-2596, or local navigators http://mbkinc.org/ and http://www.getcoveredms.org/.

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Erica Hensley, a native of Atlanta, has been working as an investigative reporter focusing on public health for Mississippi Today since May 2018. She is a Knight Foundation fellow for our newsroom’s collaboration with local TV station WLBT and curates The Inform[H]er, our monthly women and girls’ newsletter. She is the 2019 recipient of the Doris O'Donnell Innovations in Investigative Journalism Fellowship. Erica received a bachelor’s in print journalism and political science from the University of Southern California Annenberg School for Communication and Journalism and a master’s in health and medical journalism from the University of Georgia Grady College for Journalism and Mass Communication.