In a little more than two weeks, the doors will open for enrollment in the Affordable Care Act marketplace.
What’s behind those doors is anybody’s guess — especially in Iowa.
With the state still waiting for approval of a "stopgap plan" that would revamp the marketplace in Iowa, there are plenty of unanswered questions about what the six-week enrollment period is going to look like.
An added complication this year: The federally funded experts who have answered questions and helped people enroll the last few years have seen their resources dramatically cut.
In Iowa, the Trump administration cut funding for the navigator program this year by 63 percent.
In Illinois, funds were reduced by 31 percent.
There still will be people on hand to help — just not as many.
Planned Parenthood of the Heartland, which had operated a navigator program in 78 counties in Iowa, announced last month it was shutting it down.
Meanwhile, Genesis Health System, which has been a navigator in Iowa and Illinois, will only have one person in its program, said Michele Cullen, community health manager for the hospital.
Genesis saw its navigator funding cut from nearly $200,000 last year to just $20,000, according figures published by the Kaiser Family Foundation.
“We’re going to try to do the best that we can with what we’ve been given,” Cullen said.
A third navigator program in Iowa, run by Visiting Nurse Services of Iowa, also is operating. It saw a much smaller cut, about 15 percent, said Karen Sullivan, the organization’s navigator manager.
The program will operate in 22 counties, though not in the Quad-City area. A few years ago, it had been in 43 counties, but reduced its reach when it saw reduced funding during the Obama administration.
Cullen says that navigators and other counselors don’t just help during the enrollment period. They also answer questions year round.
People can sign up for Medicaid all year round, and many people who sign up for private insurance in the marketplace have never had coverage and often have questions throughout the year.
“I’m most concerned about education to these people,” Cullen said.
Jennifer Busch, a seasoned Genesis navigator, is now working 32 hours a week instead of her regular 40. She’ll add another day when enrollment begins.
Officials say that she will continue to take appointments and be out in the community during the enrollment period. But she’ll be by herself. Last year, there were two people in the program.
Critics of the Trump administration say this year’s cuts to the navigator program, along with reductions to advertising and an enrollment window that's half what it was last year, are all aimed at gutting the Affordable Care Act.
However, the administration has said reductions in the program were made based on performance.
Cullen said that Genesis’s program typically helps just under 1,000 people each year, and that she was under the impression goals were being met.
Despite the cuts, there still will be help enrolling. The federally funded navigators aren’t the only ones out there offering assistance. Insurance agents can help. So, too, can certified counselors who aren’t federally funded but, like Busch, they have been working to help enroll people since the marketplace began taking applicants in the fall of 2013.
Linaka Kain, a regional manager for UnityPoint Health who oversees enrollment counseling and patient financial coordinators, said she added another person when she saw the navigator cuts.
"We ramped up ours to prepare for any carryover," she said. Kain said the program helped about 1,500 people with enrollment last year.
Community Health Care Inc. also helps with enrollment. It is not in the federally funded navigator program, either, so it will continue to operate as usual, said Mateo Tiry-Ortiz, outreach and enrollment coordinator.
This year's enrollment period has an added layer of uncertainty in Iowa this year. The state has asked the Trump administration to approve a temporary stopgap plan that would entail the use of a single, standardized insurance plan that would be sold by participating insurers, a new system of premium tax credits and a reinsurance plan for high cost customers.
The state submitted the request as insurers were dropping out of the marketplace for 2018. Only one, Medica of Minnesota, remains.
So far, with a little more than two weeks to go before the enrollment window opens, no answer has been given as to whether the plan will be approved. If it is, the state's largest insurer, Wellmark Blue Cross and Blue Shield, has said it will participate.
State officials have said they expect to hear whether their waiver is granted by Nov. 1. But it's still not clear what the answer might be.
“People are always asking me what’s going to happen, and I have no answer to that,” Busch says.
Tiry-Ortiz says the uncertainty is not ideal. But he adds this wouldn’t be the first time a curve ball was thrown at them.
“At least for me, I’m used to the changes. It’s been that way the last four years,” he said.
Sullivan, from Visiting Nurse Services, says that it is proceeding as if the stopgap plan will not be approved. If it is, she says, they will have to adjust.