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Tough navigating: ND Navigator Project hit with massive funding reduction

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Deb Nelson, president of DLN Consulting, helped hundreds of people looking for health insurance at this office in northern Dickinson. (Grady McGregor / The Dickinson Press)2 / 3
Until recent budget cuts, DLN Consulting was a subcontractor of the North Dakota Navigator Project. DLN will remain open, focusing efforts on other projects. (Grady McGregor / The Dickinson Press)3 / 3

Steep federal budget cuts for programs that help people navigate the Affordable Care Act, better known as Obamacare, are expected to hit rural states like North Dakota the hardest, advocates say.

DLN Consulting of Dickinson has offered free advice for the last three years across southwest North Dakota to help people understand ACA. It's a service that will no longer be offered because of federal budget cuts.

DLN Consulting is a subcontractor of the North Dakota Navigator Project, which was notified by the U.S. Department of Health and Human Services on Sept. 13 that funding would be reduced from $300,000 in 2016 to $12,000 this year, a 96 percent cut. Over a dozen navigator positions in the state's eight navigator project regions will be eliminated. Other subcontractors of the ND Navigator Project include Family Voices of ND in Edgeley, N.D. and North Dakota Federation of Families for Children's Mental Health in Bismarck.

In addition to the ND Navigator Project, two other organizations in North Dakota receive federal navigator funding, Family HealthCare of Fargo and Great Plains Tribal Chairmen's Health Board.

Family HealthCare, which serves residents in the Fargo area, received about $186,000 in navigator funds, the same amount it received in 2016.

Dennis Delpizzo, a media contact for Centers for Medicare and Medicaid Services, confirmed that the Great Plains Tribal Chairmen's Health Board received a $10,000 dollar navigator grant this year, a steep cut this year from its $150,214 funding total in 2016.

Political navigating

Nationally, funds for "navigator" programs were cut from $62.5 million to about $36 million. North Dakota faced some of the harshest cuts.

Sen. Heidi Heitkamp, D-N.D. said she is alarmed by the cuts because they will "take away critical health care resources for families across our state."

Some congressional Republicans however disagree, saying cuts could bring efficiencies to a program that is no longer important.

"All this chaos and confusion was created by a poorly designed program in the first place," said U.S. Rep. Kevin Cramer, R-N.D. "Now that we are several years into it, there really should be much less if any need for these counselors to help people navigate through it. It seems to be a very inefficient system for distributing a very inefficient health care program."

Sen. John Hoeven, R-N.D. said he thinks the cuts will make the program more accountable and cost-effective.

"Navigators received over $62.5 million in federal grants nationwide and enrolled only 81,426 individuals," he said.

Those who manage the North Dakota navigator programs disagree.

What are navigators?

Deb Nelson, president of Dickinson's DLN Consulting, has worked as a health care "navigator" for several years.

Through educational events, in-person meetings and other outreach initiatives, she and her three DLN navigators have reached thousands of people across eight counties in southwestern North Dakota and helped many of them receive health insurance through the Obamacare exchanges.

One navigator case Nelson worked on sticks out.

"I had a farm couple sitting in my office and they never had insurance, ever," she said. "The wife needed surgery and the husband was diabetic."

Nelson walked them through the complicated process of finding a plan through North Dakota's health insurance exchange market. The couple eventually found a plan they could afford and covered their ailments, made possible through coverage of pre-existing conditions in the Affordable Care Act.

Nelson said as soon as she told the couple they would have affordable health insurance, the husband "burst into tears."

Neil Sharpe, director of the North Dakota Navigator Project, said the cuts will essentially leave him as the state's only statewide navigator, and all of his navigators in North Dakota's eight major cities will lose funding.

Sharpe said the job of North Dakota navigators is threefold: outreach and education to tell people about the ACA, assisting people to enroll in the health insurance marketplace and helping with enrollment in the expanded Medicaid program written into the ACA and approved by the state Legislature.

More than 21,000 people enrolled in North Dakota's individual health insurance marketplace last year and close to the same number received coverage through Medicaid expansion, according to the website

Sharpe said a significant portion of these enrollees were helped by a navigator.

"Either navigators dealt with them, heard them at some event, called them as they were pulling up their application online, or just asked how does (Obamacare) work," Sharpe said.

Sharpe's navigators contacted more than 6,000 people in 2016 and helped enroll about 600 in the insurance marketplace.

Brad Gibbens, deputy director of the University of North Dakota's Center for Rural Health, has studied the health industry in North Dakota for years and believes navigators play an important role in the state's healthcare system.

Without help from navigators, Nelson fears people will struggle to re-enroll, miss opportunities to save money and even fail to be insured.

"We have a couple of people who don't have computers and don't understand working on computers, they don't trust phones, so we aren't quite sure what they are going to do now," Nelson said. "If (the government) can figure out a good way of having people get insurance, then you don't need a navigator, but our experience says that many rural farm people in western North Dakota don't understand how to get through the Obamacare system."

North Dakota markets

HHS released a statement on Aug. 31 saying in order to ensure accountability among navigators in the upcoming year "grantees will receive funding based on their ability to meet their enrollment goals during the previous year." Nelson insisted her team, and North Dakota navigators in general, met 100 percent of its goals and she doesn't understand why its grant was so severely targeted.

Many see cuts to navigator grants in general as part of a broader effort to sabotage and undermine Obamacare marketplaces. Along with cutting navigator funding, the Trump administration announced a 90 percent cut to Obamacare advertising and slashed the insurance enrollment period from three months to six weeks.

Gibbens said taking away these Obamacare resources could negatively impact North Dakota's insurance exchange market.

"It's an indirect connection," Gibbens said. "But if we cut back on the number of navigators and (half) the enrollment period, there will be less people who will go in and buy insurance. I could see that leading to premium increases."

Cramer said he is concerned that the navigator cuts may disproportionately target rural areas, and that he would dig into navigator funding issues with HHS within the week.

Ben Hanson, a Democrat from West Fargo who plans to run for the U.S. House, said he is concerned that Native Americans and poor people will suffer the most.

"These cuts are cruel and appear to be haphazardly applied across the country," Hanson said. "Rural states — like North Dakota and the 67 percent cut we're facing — will be the hardest hit."

What now?

If the U.S. Senate passes the Graham-Cassidy proposal to repeal and replace Obamacare next week, fundamental changes to the nation's health care system may render navigator services obsolete.

But if the current system remains in place, if even just for 2017 enrollment period, residents of Dickinson and other areas that lose local navigator services will still have several options in getting help to navigate Obamacare insurance exchanges.

Chief Marketing Officer Pat Bellmore for Blue Cross Blue Shield North Dakota said that their agents will continue to aid North Dakotans in navigating the federal marketplace.

Nelson also said her firm will still do some navigator work on a pro-bono basis and Sharpe will encourage people to contact Fargo Family HealthCare, which has retained navigator funding.

Reed Reyman, president of CHI St. Alexius in Dickinson, said he also has staff members who are dedicated to helping patients find health insurance plans. The staff members, known as medical eligibility credentialing specialists or MECS, will help answer insurance questions, such on Medicaid eligibility or what the best insurance plan is for them and their family.

People are free to come in to talk with a specialist at any time at no cost. Even if the ACA goes away, Reyman said they plan to keep their MECS person. At one time they were seeing 200 to 300 people a month, but that number has since dropped to about 100 to 150 people a month.

"There's so many variables and policies that until people actually use them, they're really not sure how they work," he said.