The first numbers on the body count from the Republican sabotage of the Affordable Care Act are just now coming in. Last week, an analysis from Harvard's Theda Skocpol revealed that states that both set up their own health care exchanges and embraced the ACA's expansion of Medicaid are racing toward their enrollment goals, while the reddest of red states which refused to do either are barely moving the needle for their uninsured populations. Now, a George Washington University study shows that states that also passed laws limiting the ability of health care "navigators" to advise customers have severely compromised their residents' ability to gain access to health care.
As the case of Missouri shows, that subterfuge of the work of the community groups, health care organizations and other non-profits isn't just tragic, it's ironic. After all, the entire Obamacare navigator program is based on the exact same approach Medicare has used since 1990 to assist, inform and enroll millions of American seniors. (The Bush administration spent millions on navigators as part of its launch of the Medicare Part D prescription drug program.) And as it turns out, the very groups Show Me State Republicans are trying to stop from helping residents get health insurance under the Affordable Care Act are the same ones receiving federal funding as Medicare navigators.

In August, the Department of Health and Human Services (HHS) announced $67 million in grants to Obamacare navigators nationwide. In Missouri, the two major recipients were Missouri Alliance of Area Agencies on Aging ($750,000) and Primaris Business Health Care Solutions ($1,045,624). These funds were then subcontracted to a host of regional groups and non-profits whose staff and volunteers provide outreach, customer service and enrollment assistance to Missourians seeking health insurance.
Both the Missouri Alliance of Area Agencies on Aging and Primaris are well known to Missouri residents and politicians alike. As the Primaris website explains:

For 30 years, Primaris has played an integral role in improving healthcare for Missouri's one million Medicare beneficiaries and beyond.
Founded in 1983 by the Missouri State Medical Association and the Missouri Association of Osteopathic Physicians and Surgeons, Primaris' team of experts assists Missouri's healthcare providers with quality improvement, medical case review, electronic data reporting and health information technology.
Located in Columbia, MO, Primaris is the official Medicare Quality Improvement Organization (QIO) for Missouri. Primaris has held this contract since its founding - the latest three-year contract was awarded to the firm in 2011...
Primaris also provides insurance counseling services for Missourians on Medicare as well as for Missourians wishing to enroll in the Health Insurance Marketplace. Both programs help people understand their benefits and options so they can make informed decisions about their healthcare.

You read that right. The same organizations getting federal dollars to help roll-out the Affordable Care Act in Missouri are the same ones that have been getting millions for years from the State Health Insurance Assistance Program (SHIP).

Writing in the National Journal, Catherine Hollander of the National Journal explained that the use of navigators by the Department of Health and Human Services is nothing new under the sun:

But the navigator program has a precedent, one that suggests the concerns may be overblown: the State Health Insurance Assistance Program, which was enacted through the Omnibus Budget Reconciliation Act of 1990 to offer free counseling to Medicare beneficiaries. SHIP counselors were the model for Obamacare's navigators. "The notion that this is some unheard of ... incursion into people's lives is about as far from reality as it could be," says Sara Rosenbaum, a professor at George Washington University's School of Public Health and Health Services. "This is exactly what Medicare SHIPs do all the time."
SHIP staff members played a key outreach role after Congress passed the Medicare Prescription Drug, Improvement, and Modernization Act of 2003. The legislation introduced prescription-drug benefits--Part D, which was a complicated addition to the coverage offered under Medicare available through enrollment in private plans. In the spring of 2005, just half a year before open enrollment began, 66 percent of seniors polled by the Kaiser Family Foundation said they didn't think they had enough information to understand how the benefit would affect them. Enter SHIPs.

Enter SHIPs, indeed. In August 2008, Laura Summer and Jennifer Thompson of the Georgetown University Health Policy Institute authored an evaluation of the Medicare Part D outreach program for President Bush's HHS titled "Best Practices to Improve Take-Up Rates in Health Insurance Programs." Based in part on a survey of 660 counselors, program managers, and others who worked with beneficiaries, Summer and Thompson found:

Based on a careful analysis of all of the articles reviewed, two predominant findings emerge regarding efforts to promote successful take-up in health insurance programs. The first is that individuals are more likely to enroll in insurance programs and maintain their coverage when extensive personal assistance, geared to the needs of the individual, is available. The second major finding is that simpler enrollment and renewal processes increase the likelihood that individuals will obtain and retain coverage. Studies of publicity campaigns find much weaker evidence of effectiveness. In gauging the success of assistance efforts, the amount and type of assistance provided appears to be relevant as is the source of assistance. Individuals are more likely to seek and accept help from organizations and individuals that they trust and that provide culturally or linguistically appropriate assistance.

Mike Leavitt, President Bush's HHS Secretary during the disastrously bungled rollout of the Medicare Rx benefit agreed with the crucial role of Medicare navigators. As he put it in a July Washington Post op-ed:

Before the program was implemented, only 21 percent of seniors had a favorable opinion of it, and 66 percent didn't understand what the reform would mean for them.
So we spent 18 months devising and implementing a campaign to explain the prescription drug benefit, prepare seniors as well as partners -- such as community groups, churches, pharmacies, insurance plans and state and local governments -- and then sign people up. A national bus tour supported each phase. The summer before enrollment (the same period that the ACA is in now) we logged more than 600,000 miles and visited 48 states. As secretary, I made 119 stops in 98 cities. I learned that with a program like the ACA, you can't count on Washington to sell it. You have to reach people where they live, work, pray and play.

As it turned out, the Bush administration was trying to reach eligible seniors where they lived, worked, prayed and played by partnering with many of the very same organizations Obama HHS Secretary Kathleen Sebelius is turning to now.

In Missouri, the non-profit SHIP entity running the Medicare outreach program is called "Community Leaders Assisting the Insured of Missouri" or CLAIM. For Medicare counseling and enrollment help, CLAIM contracted to Primaris, which in turn funds partners like the APPLE Project, Interfaith Community Services and Ozark Action, Inc., just to name a few. And all of those Missouri Medicare navigators are now Missouri Obamacare navigators as well.

Nevertheless, Missouri like eight other Republican states which refused to expand Medicaid to cover hundreds of thousands of its uninsured has also erected draconian legal barriers to Affordable Care Act navigators, barriers that make their work virtually impossible. Among other things, the Missouri law ("Health Insurance Marketplace Innovation Act of 2013") bars navigators from offering "advice concerning the benefits, terms, and features of a particular health plan." In December, several community groups and individuals brought suit to block the law. As Jane Perkins, legal director at North Carolina-based National Health Law Program and one of five attorneys representing those challenging the state law, explained:

"Missouri's law goes the unnecessary step to block the ability of consumer assisters to serve their intended function under the [federal law] which is to help consumers navigate the new marketplace and get enrolled in a qualified health insurance plan.
Missouri is not only contravening the federal law, it is undermining and chilling enrollment efforts throughout the state."

(Last fall, a federal judge in Tennessee agreed, blocking that state's "emergency rule," which would have fined healthcare navigators for helping people find insurance under the Affordable Care Act.)
In the meantime, Missouri Republicans are not content to wait for that legal process to play itself out. Last month state Sen. Kurt Schaefer (R-MO) proposed Senate Bill 498 requiring licensed navigators "to be bonded for at least $100,000 to protect consumers and would give consumers the ability to collect up to $50,000 if their data are misused or given to an entity that is not entitled to the information."
Jeremy Milarsky, program director at Primaris Health Business Solutions, seemed concerned and confused by the GOP proposal. As well he should. His organization has been getting federal funds to help Missouri residents learn about and obtain both private and public insurance, coverage partially or completely subsidized by Uncle Sam. Of course, that was just fine for Missouri Republicans when George W. Bush sat in the White House and the recipients were senior citizens who vote.
But that was then and this is now. Now, a Democrat is in the Oval Office and the recipients are younger than 65. So, in Missouri and as in other red states, that means the navigators must be stopped.
This piece first appeared at Dailykos.)