The Affordable Care Act (ACA) reforms private and public health insurance in the United States while expanding access to affordable health care for all legal residents who were uninsured or previously excluded because of preexisting conditions. The accessibility to health insurance and enrollment in health insurance plans are the first of many steps on the path to quality health care delivery. Reference Eisenberg and Power1 Although the ACA requires lawful U.S. residents to carry health insurance, roughly 40 million individuals remained uninsured after the first open enrollment period. 2
Efforts to enroll previously uninsured or underinsured populations in health coverage have been handicapped by low health-literacy rates. The National Center for Education Statistics conducted a national assessment of adult literacy and found that 36 percent of American adults ranked in the lowest categories of health literacy; the majority of lower scores comprised the elderly and less educated. Reference White and Dillow3 Further research found that the lowest average health literacy was among adults who did not carry health insurance or who obtained it through government assistance. Reference Kutner, Greenburg, Jin and Paulsen4 An estimated 10.6 million individuals sought consumer assistance when applying for health insurance under the ACA during the first period of open enrollment. Reference Pollitz, Tolbert and Ma5 A Kaiser Family Foundation survey of consumer assister programs found that the majority of consumers who sought assistance— particularly the young—were uninsured and had difficulty understanding basic health insurance terms. Reference Pollitz, Tolbert and Ma5,Reference Wong, Asch, Vinoya, Ford, Baker, Town and Merchant6
The inability to understand alternatives and their trade-offs leads individuals to make suboptimal decisions. Reference Simon7,Reference Payne, Bettman and Johnson8 If individuals choose suboptimal health insurance plans and are dissatisfied with the plans, they are less likely to use the insurance. Reference Aaron and Lambrew9 Due to a principal-agent problem between consumers and insurance brokers, the ACA contains provisions enabling trained individuals (i.e., navigators) to assist consumers for free in an effort to facilitate error-free enrollment in health insurance or Medicaid. The navigator duties are to:
conduct public education activities to raise awareness of the availability of qualified health plans, distribute fair and impartial information concerning enrollment in qualified health plans
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, facilitate enrollment in qualified health plans, provide referrals to any applicable office
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for any enrollee with a grievance, complaint, or question regarding their health plan
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, provide information in a manner that is culturally and linguistically appropriate
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.
10
The navigator’s primary role is assisting consumers with the selection of a health insurance plan in the ACA-mandated marketplace, which is also known as a health insurance exchange. The marketplace is a virtual site that provides qualified health plans (QHPs) to those not eligible for public programs or employer-sponsored coverage. Reference Brandon and Carnes11 States chose what type of health insurance model they wanted to implement. The three types of marketplace models are state-based marketplaces (SBMs), federally facilitated marketplaces (FFMs), and state-partnership marketplaces (SPMs).
SBMs differ from other models because states assumed responsibility for forming and operating a marketplace. Reference Salazar12 This choice meant that states had flexibility in creating and administering their own unique websites for the marketplace and in training and certifying navigators and other consumer assisters. FFMs, the default if a state refused to act, were organized so that the federal government regulated, certified, and trained navigators. Reference Dash, Monahan and Lucia13 All FFMs used the federal marketplace website at www.healthcare.gov. The third type of marketplace, the SPM, “enables states to assume primary responsibility for carrying out certain activities related to plan management, consumer assistance and outreach, or both.” 14 Partnership states that chose to be consumer assistance partnerships assumed control of navigator regulation; however, during the first open enrollment period, all SPMs chose to function in a plan-management capacity and therefore, like FFMs, ceded navigator training and certification operations to the federal government.
SBMs reported greater success in enrollment efforts than did FFMs. Reference Polsky, Weiner, Colameco and Becker15 Enrollment was measured by the number of individuals who selected health insurance plans since information about who paid for said plans was not publically available. While SBMs often had greater funding for consumer assistance, there were other factors that could have influenced enrollment efforts. Reference Polsky, Weiner, Colameco and Becker15
There are many variables that can influence innovative state policy decisions. Reference Walker16,Reference Volden17 Adopting a marketplace and choosing whether or not to expand Medicaid were the ACA policy decisions that split Democrats and Republicans at both the federal and state levels. Reference Jacobs and Skocpol18 Although many conservative states like North Carolina implemented FFMs, one study on Medicaid expansion cautioned researchers that partisanship is only one possible factor that may have influenced state choice. Reference Jacobs and Callaghan19 Because policy creates politics, and, because politicians are interested in reelection, they care about the policy opinions of their constituents and interest groups. Reference Lowi20,Reference Mayhew21,Reference Berry and Berry22 Since states were not able to opt out of having a marketplace, one way states could voice dissent would be to adopt state-level policies to subvert FFM efforts.
By the start of open enrollment in 2013, several FFM states had adopted legislation barring compliance with the ACA unless approved by the legislature. In particular, North Carolina state law forbade state agencies from assisting in ACA enrollment efforts. 23 Policies governing navigator programs affect many people (salient) and require a great deal of technical expertise to implement (complex). According to Gormley, highly salient and highly complex policy issues ought to be managed in the “operating room” by professional bureaucrats. Reference Gormley24 However, in North Carolina, instead of experienced bureaucrats with sufficient resources implementing the navigator programs at the state level, the work was often left to nonprofit organizations and private contractors. By describing the problems that I witnessed as a volunteer navigator. I demonstrate, in this perspective piece, how those overseeing enrollment efforts influenced navigator training and assistance efforts and, ultimately, consumer decisions.
Navigator training and assistance
Navigator training and assistance efforts were influenced by the type of marketplace selected by state legislatures. In my training, I noted problems with planning and resources. In terms of assistance, navigator discretion allowed for creativity but also disparate treatment of consumers.
Training
There were four navigator organizations in the FFM of North Carolina that received federal funding during the first enrollment period. Three of these organizations served specific populations, but the North Carolina Community Care Network (NCCCN), a consortium comprised of more than 100 organizations, served the entire state. 25 The NCCCN provided for only 40 full-time employee navigators to reach the more than one million uninsured North Carolinians. 26,27 Volunteer navigators were thus a valuable resource in augmenting the limited federal support.
As a volunteer navigator for an organization in North Carolina, I was trained using FFM training materials in October 2013. The group under which I served did not begin training volunteers until the day prior to the first day of open enrollment. This may have been attributed to the fact that the Center for Consumer Information and Insurance Oversight did not notify navigator grant award recipients that they would be funded until six weeks prior to open enrollment. Reference Jost28 Six weeks is a short amount of time to hire and train paid employees, particularly when the 217-page FFM navigator training manual was made available only a month prior to open enrollment. 29 Since training required approximately twenty to thirty hours to complete online modules, I was not able to begin meeting with consumers the day the marketplace opened.
The online training component was a website separate from healthcare.gov and consisted of thirteen modules, each with a reading section and a test. The reading section included questions every three to four slides, but if I answered them incorrectly, I could continue through to the test. To successfully complete a test, navigators needed a score of 80 percent or above. While one could take each test multiple times, the questions were constantly varied, which seemed to encourage a basic understanding of the material in each section. After successfully completing the navigator training, I received a certificate from the U.S. Department of Health and Human Services (HHS) that stated my name, a unique identifying number, and the organization with which I was affiliated. The email I received from HHS further stated that I had to meet state requirements before being able to meet with consumers; there were no additional requirements that I needed to meet in North Carolina. The certificate would allow me to serve as a navigator from October 22, 2013, until August 14, 2014. After this time period, I would have to recertify in order to continue serving in this capacity.
The most frustrating aspect of the training was that I did not have access to the actual website that I would be using as a navigator. Without the chance to gain familiarity with the most important tool of a navigator, I did not feel adequately prepared to begin meeting with consumers. I was told that I could create my own account and see what consumers experience when they attempt to sign up, but the heavy website traffic on healthcare.gov and its other problems in year one made that solution infeasible. I wanted the opportunity to practice with various website features, such as comparing plans, uploading supporting documents, knowing where to go to access formularies and in-network data for the plans from which North Carolina consumers could choose. Lamentably, no such training program or simulation was available through my organization. However, I was permitted to shadow other navigators to learn what the website looked like and how best to utilize its features, which gave me more confidence in meeting with consumers on my own. The various levels of understanding via training influenced the level of assistance a navigator would provide.
Assistance
The organization for which I volunteered participated in a consortium that held “big tent” meetings, providing a way to solicit best practices from other North Carolina private and nonprofit organizations in the absence of bureaucratic expertise. The consortium also had a statewide scheduling system. Having one telephone number that individuals across the state could call helped mitigate the distance that a consumer would need to travel to meet with a navigator. This hotline also saved a great deal of time for navigator organizations that could focus their energy on meeting with consumers and community education.
Navigators were required to supply a laptop in order to enroll consumers in the marketplace. Navigators could also elect whether or not to provide consumers with their personal phone numbers in the event that the consumer wanted to follow up. Due to privacy concerns, navigators were not allowed to keep any personally identifiable information (PII) on consumers and were encouraged to clear their browser history after meeting with consumers. PII, according to the Navigator standard operating procedure (SOP) manual, included tax information, social security number (SSN), email addresses, etc. 29
When I met with a consumer, the first thing I had to do was create an account for the individual using his/her name, email address, and password. If the consumer did not have an email address, I would help him/her create one. Once the account was created, the individual would have to provide additional personal information that would then be matched against his/her credit history by Experian, a credit reporting company. 30 Experian would generate questions to confirm a consumer’s identity. If the information was not verified, the individual would need to provide additional documentation to Experian in order to proceed with the application process.
With an account, the individual could begin the application process. One’s information was supposed to be authenticated via the “data hub,” “managed by the U.S. Department of Health and Human Services, [which] facilitates access to information currently held in databases of the Internal Revenue Service, Social Security Administration, and the Department of Homeland Security.” Reference Rasmussen31 During the application process, an individual could be asked to provide additional documentation if the data he/she provided on the application did not match the information that federal agencies had. Until an applicant provided such documentation and that documentation was verified, a consumer was unable to complete the application process and view the plans and/or subsidies for which he/she was eligible.
My experience revealed several areas that needed improvement in navigator training. In addition to the widely publicized problems of gaining access to healthcare.gov, there were difficulties associated with immigrant applications, the amount of discretion afforded to navigators, and comparing health insurance plans to one another. These problems could effectively be addressed by creating a more robust navigator training program, thus creating a more efficient enrollment experience for consumers.
Legal immigrant struggles
There were several barriers to health insurance enrollment for immigrants and their families. Immigrant status does not preclude one from applying for health insurance or receiving subsidies via the marketplace, an important feature since immigrants are not eligible to apply for Medicaid coverage until after they have lived legally in the United States for at least five years. 32 However, some immigrants were unable to create accounts to begin the application because their accounts could not be verified by Experian. The National Immigration Law Center (NILC) indicates that many immigrants are “credit invisible” and that “individuals with thin or no credit files are often unable to provide one of the limited types of supporting documents required, such as a property deed, property title, or a driver’s license, leaving them unable to access Marketplace coverage online.” Reference Padilla33
Once an immigrant was able to create an account, he/she would then proceed to the application process. However, there were problems in this stage of enrollment as well. If immigrant applicants reached a point while completing the application where their information seemed to conflict with federal agency data, they would be asked to upload additional documents before being allowed to view eligible plans and subsidies. The natural-born citizens with whom I worked did not have to verify their identities, but immigrant applicants often were required to provide copies of passports, green cards, and, occasionally, pay stubs or tax returns.
These additional demands for documentation constituted major barriers in the enrollment process; the immigrants with whom I worked were unable to continue their application and to scout out the plans for which they would be eligible during the initial visit. Because of this interruption, I was not able to explain the many different options to these individuals and help them consider their needs while they waited for documents to be processed. Often immigrants had to schedule a second visit when they would actually consider substantive questions pertaining to their choice of health insurance. Immigrant households are often poorer than native-born households and less likely to own a vehicle. Reference Webster and Bishaw34 A great deal of literature describes how lack of transportation can influence access to care. Reference Syed, Gerber and Sharp35,Reference Zullig, Jackson, Provenzale, Griffin, Phelan and van Ryn36,Reference Ide, Curry and Drobnies37,Reference Wallace, Hughes-Cromwick, Mull and Khasnabis38 Therefore, it is reasonable to assume that a lack of transportation could have hindered some immigrant families in scheduling subsequent visits with a navigator. Many such frustrated consumers may have abandoned the effort to secure coverage or have ventured onto healthcare.gov without assistance and selected a suboptimal plan.
Furthermore, immigrant applications often took longer to complete than nonimmigrant applications. Navigator training could have prepared navigators for longer sessions and dealing with particular difficulties when enrolling immigrant populations. In addition, the training could have demonstrated the importance of helping immigrants understand how to use their plans, and, if necessary, find language concordant health care providers, two factors that can influence health care outcomes. Reference Escarce and Kapur39,40
Navigator discretion
All of the navigators in the organization for which I volunteered received the same training, but after training, navigators functioned similarly to “street-level bureaucrats
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[having] wide discretion over the dispensation of benefits or the allocation of public sanctions.”
Reference Lipsky and Hill41
One area of discretion was in how navigators managed special income cases in North Carolina. The ACA assumed that all states would expand Medicaid and thus stipulated that those eligible for expanded Medicaid did not qualify for advanced premium tax credits. However, in 2012 the Supreme Court ruled that Congress could not constitutionally compel states to expand Medicaid by threatening existing Medicaid funds. States like North Carolina were able to opt out of Medicaid expansion without losing federal Medicaid dollars. In states that did not expand Medicaid, consumers who earned zero income or between 44 and 100 percent of the Federal Poverty Level (FPL) generally did not qualify for Medicaid and were also ineligible for advanced premium tax credits via the marketplace.
Reference Garfield, Damico, Stephens and Rouhani42
These individuals fell into a coverage gap that left them ineligible for assistance and unable to pay premiums. I overheard fellow navigators discuss how to help consumers who fell into this gap. Navigators could help those who did not qualify for Medicaid come up with alternative income sources that they could report to make them eligible. For those whose income exceeded the upper limit to qualify for Medicaid according to state law but who earned too little to be eligible for subsidies according to federal law, navigators helped think of ways in which additional money might be earned in the following year so as to trigger eligibility for marketplace subsidies.
The consequence of this “help” was to identify income that at best was often aspirational. Because advanced premium tax credits were based on potential earnings for the year in which the consumer was applying, the consumer needed to understand that he/she would have to earn the amount projected by the navigator in order to maintain subsidies. Also, if the consumer’s income projections were incorrect, he/she would be responsible to repay, via income taxes, either a portion or the entire amount of subsidies that he/she received as a result of misrepresenting his/her income. During the 2015 enrollment, one North Carolina broker was reported to have profited by enrolling hundreds of low-income and homeless individuals into Medicaid, asserting that these individuals earned more than $11,700 via “panhandling” and “street hustling.” Reference Helms43 Regrettably, these plans rendered many individuals ineligible for the free services that they were receiving when uninsured. Reference Helms43
Navigators also had discretion in the questions they asked consumers. Training provided navigators with suggested greetings; however, there was no evaluation to ensure that all consumers received the same treatment. In addition, there was no checklist to ensure that the navigator considered all relevant variables in helping the consumer think about his/her actual needs. In one of my meetings soon after beginning service, I failed to ask the consumer whether he/she had a physician preference in order to make certain that he/she chose a plan that had negotiated for the physician to be in-network. Without navigators asking such questions, an individual with low health literacy can easily enroll in a plan that does not meet the basic health quality standard of preserving continuity of care.
Apples to oranges
I also witnessed much confusion comparing health insurance plans. While healthcare.gov allowed gross comparisons of health insurance plans, consumers often had more detailed questions that were not answered by such side-by-side screens (see Appendix A). Two insurance companies, Coventry Health Care (Coventry) and Blue Cross Blue Shield (BCBS), sold insurance in the North Carolina marketplace in year one. BCBS offered plans via the exchange in all 100 North Carolina counties while Coventry provided plans in only thirty-nine North Carolina counties, mostly those surrounding large metropolitan areas. Together, these two insurers offered up to thirty-one different health insurance plans in some rating adjustment areas. The large number of choices likely added confusion to the decision-making process. Reference Shugan44 To ameliorate confusion, the federal government required health insurance companies to follow a template when creating summaries of benefits and coverage for each plan (see Appendix B).
This summary template was designed to aid the consumer in drawing comparisons between multiple plans. But the summary did not include many important details. For information about covered services, covered medications, and in-network providers, the consumer and I often had to visit each health insurance provider’s website or call the provider directly. This process was quite time-consuming when considering multiple plans by multiple providers—even more so if the navigator had failed to determine consumer needs through proper questioning prior to presenting the array of choices to the consumer.
North Carolina did not use professional expertise to implement navigator programs, which resulted in insufficient training. Such deficiencies in training influenced how navigators served consumers. As a result, navigators focused on solving the problem of enrollment, but not the real problem of consumer satisfaction with enrollment.
Redefining the problem
While the ACA seeks to expand health insurance, restrain costs, and reform health care delivery, most evaluations of the ACA involve only analyses of the expansion of health insurance. Reference Hamel, Blumenthal, Abrams and Nuzum45 Navigator programs are thus geared to augment the number of individuals with coverage, but not necessarily to enroll them in plans that meet the individuals’ needs. In a recent nationwide survey, 44 percent of assister programs reported that consumers contacted them during the post-enrollment period because they did not know how to use their health insurance; 37 percent met with consumers who felt that they had chosen the wrong plan or reported that their provider was not in-network. Reference Hamel, Blumenthal, Abrams and Nuzum45
Consumers often selected the least expensive option: silver plans. Although the bronze plan had the lowest premium of all “metal” plans, the silver plans tended to be cheaper. Silver plans are the only plans that can be coupled with both advanced premium tax credits and cost-sharing reduction subsidies. 46 If consumers bought plans based on price alone, they may have chosen an insufficient plan to meet their needs. Insufficient plans could leave consumers with less satisfaction. Reference Botti47 Less satisfaction with a health insurance plan could lead to reduced access to care. Reference Aaron and Lambrew9 Individuals with more health care access often exhibit improved outcomes. Reference Aday and Andersen48,Reference Andersen, Davidson, Andersen, Rice and Kominski49,Reference Franks, Clancy and Gold50,Reference Lurie, Ward, Shapiro and Brook51 Thus, navigator programs that improve training to address consumer understanding are more likely to achieve ACA objectives. Two primary types of decisions that are made when dealing with health insurance are complex decisions and risky decisions; therefore, it is important to consider what aids are most useful to consumers in these scenarios.
Complexity
Under the ACA, the government is trying to encourage enrollment among the uninsured, a group that has some of the lowest health literacy rates in the country. Reference Kutner, Greenburg, Jin and Paulsen4 Faced with complex decisions, or choices that they do not fully understand, the rational decision-maker will make thoughtful decisions with limited knowledge, known as satisficing. Reference Simon52 Optimal choices would be made if the decision maker understood all choices and tradeoffs. 53 Due to limitations on cognitive ability, information, or time, an individual who is confronted with too many options may avoid making a decision, blindly maintain the status quo, or arbitrarily elevate one choice over others in order to terminate cognitive turmoil. 54,55,Reference Akerlof and Dickens56,Reference Iyengar and Kamenica57,Reference Iyengar and Lepper58 An example of how complex decisions can arise in health insurance comes from Medicare Part D enrollment that began in 2006. Using bounded rationality theory, some studies indicated how fewer choices could improve Medicare Part D, especially since elderly respondents stated that the program was too difficult to navigate. Reference Hanoch, Rice, Cummings and Wood59,Reference Hanoch, Miron-Shatz, Cole, Himmelstein and Federman60 Thus, evidence suggests that navigators should filter plans in order to pare down the range of choices to a manageable number of feasible alternatives.
Administrators of the North Carolina FFM were fearful about allowing navigators to do anything beyond explaining the moving parts of health insurance to consumers. I was instructed during training that I was not to suggest health insurance plans to any consumer. This warning was based on statute which instructs navigators to “provide information and services in a fair, accurate and impartial manner” and, according to the code of federal regulations, to “provide information to consumers about the full range of QHP options and insurance affordability programs
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for which they are eligible.”
61,62
In reality, however, navigators cannot abide by these restrictions and also provide appropriate choices that would meet consumer objectives.
By requiring background checks – making certain that I was not working for an insurance company – the organization for which I volunteered ensured that I had no conflict of interest. Navigators without any conflicts of interest should be able to present all of the plans to the consumer in an unbiased manner that allows the client to view all appropriate options; then, based on individualized follow up questions, navigators could guide the client towards a narrower range of choices. Such a process allows the navigator to remain impartial, because he/she is basing the filter on the expressed needs of the consumer instead of his/her own needs or perceptions. The very word navigator implies more than someone who passively explains insurance terminology. On a ship a navigator does not determine the destination, but is responsible for advising the captain about the best route to reach a destination or goal. ACA navigators should function in the same way to help each individual consumer achieve the individual’s objectives.
Risk
Uncertainty pertains to a situation in which the decision maker has limited knowledge about the outcomes of a choice. Reference Damghani, Taghavifard and Moghaddam63 The odds that an event will occur or not is probability. Reference Kahneman and Tversky64 “Risk implies a degree of uncertainty and an inability to fully control the outcomes or consequences of such an action.” 65 In purchasing health coverage, one lacks complete knowledge about his/her future needs for health care or the probability of those needs arising. This element of uncertainty can lead individuals to purchase health insurance plans based on their current evaluation of gains and losses, or their reference point. 66 Many who have previously been uninsured often believe that the lowest premium purchase is the best for them, and fail to consider future needs.
The navigator could help the consumer consider future needs by asking about past health care expenditures. A good analogy comes from cellular phone plans. When an individual is trying to determine how many minutes to purchase on a plan, he/she may be afraid to purchase too few minutes and have to pay a higher fee for going over her/his allowance. On the other hand, he/she does not want to waste money purchasing minutes that he/she will not use. This risk is often mitigated by examining the client’s history and making a decision based on past trends. By asking consumers about past health care use, navigators can help consumers find plans that reflect their anticipated needs.
Suggestions to improve navigator training
By revisiting the fundamental objective of navigators and recognizing the need for limiting consumer choices to meaningful, historically based choices, navigator training should focus its efforts on helping consumers make the best decisions for themselves and their families. Providing practice sessions before meeting with consumers that teach trainees how to assess consumer needs would develop the skill of filtering choices for consumers. Navigator programs should systematically collect feedback from consumers to determine areas for further improvement. While the vast majority (92 percent) of assister programs expressed a desire for more in-depth training, some states had more enrollment success than others. 67 By considering the creative implementation strategies in these laboratories of democracy, navigator training and service can be improved.
One way to provide improved training could be via a website. The Kentucky Health Benefit Exchange created a self-service portal that provided navigators “kynectors” with hands-on experience using different features of the state’s marketplace website. If navigator programs are unable to provide website practice, supplying trainees with screen shots of the actual website and practice opportunities would at least give navigators some understanding of how to aid consumers.
A number of other approaches to navigator training to better assess consumer needs and match them to available plans could be tested. The Massachusetts Health Connector website has a decision support toolset that asks questions to determine an individual’s past medical expenses and then limits choices to those plans that would cover similar expenses. Even without a website tool, navigators could use medical expenditure checklists as a way to limit the number of options to those that best meet consumer needs. For example, an individual who reports infrequent visits to the doctor can be best served by a bronze-plan insurance level with the greatest average patient cost-sharing. Another way to determine plans pertinent to a consumer’s specific situation is by asking questions about particular medical needs. The navigator should inquire about particular medications that the consumer requires in order to secure needed drug coverage; similarly, the consumer’s choice of a particular primary care physician or specialist needs to be included in all relevant plans’ provider networks.
As part of the needs assessment, navigators should also be trained to ask certain questions that would provide them with insight into a consumer’s previous medical needs. In so doing, the navigator could also ask if the consumer believes that earlier health care use was based on a special case or whether it is expected to continue. This extra step could encourage consumers to anticipate future needs instead of only focusing on current health needs.
Evaluations of ongoing navigator services can guide administrative efforts to improve training, so collecting consumer feedback is necessary for quality improvement of navigator training. Unlike the FFM for which I volunteered that did not collect consumer feedback, consumers in California’s SBM could see star ratings of health insurance plans pertaining to medical appointments, customer service, and quality of care. Reference Gorman68 Covered California also conducted an online survey of consumers to better understand how the website might be improved. The results show that 70 percent of respondents found the enrollment process “easy to complete.” Reference Aliferis69 Despite this generally positive finding, surveys could provide navigator programs with ways to further improve navigator services.
Conclusion: A note of caution
Enrollment as a measure of navigator success is only one indication of the ACA’s success; it cannot be the only or even the leading determinant of success. 70 If the objective of the navigator were to maximize enrollment, future training efforts and evaluations would only focus on the number of individuals who enroll. This review of the North Carolina navigator program has revealed deficiencies that can be remedied by improvements in consumer decision-making. Improvements should focus on improving aid to consumers in choosing satisfactory health insurance coverage in the marketplaces because satisfaction can lead to improved health access and outcomes. Reference Aday and Andersen48,Reference Andersen, Davidson, Andersen, Rice and Kominski49,Reference Franks, Clancy and Gold50,Reference Lurie, Ward, Shapiro and Brook51,71,72,73,74 Refocusing navigator training to support matching consumers with appropriate plans would contribute significantly towards helping the ACA achieve its overall objectives.
Appendix A. Side-by-side comparison of plans on healthcare.gov
Appendix B. Template of summary of benefits and coverage in year one (6 pages)
