Oklahoma bucked expectations as enrollment on the federal health-care marketplace climbed to a record level for the upcoming year.

Federal data released Wednesday showed about 150,000 Oklahomans signed up for health care coverage during the 45-day Affordable Care Act enrollment period that ended Saturday. That’s nearly 7 percent higher than last year.

The increase was a relief to health-care providers and advocates who worried that Oklahoma could see an enrollment drop for the second consecutive year.

But the growth may not apply to all areas.

Large swaths of rural Oklahoma were left without a tool that proponents say can help improve Oklahoma’s chronically higher uninsured rate.

A pair of Trump administration moves over the past two years slashed funding for the so-called navigator program, intended to help people enroll, from $62 million in 2016 to $10 million for the 34 states, including Oklahoma, that use the federal health exchange under the Affordable Care Act.

The navigator program is designed to promote the exchange and provide one-on-one help for consumers to sign up for plans and understand their coverage options.

The Uninsured in Oklahoma

Oklahoma’s uninsured rate has consistently trended several points higher than that of the nation, but it dropped from 17.7 percent in 2013 – the last year before the Affordable Care Act marketplace opened – to 14.2 percent in 2017. Last year’s rate, however, was up slightly from 2016, when the rate was 13.8 percent, according to the latest Census Bureau numbers.

Health care experts and local community assistance groups say there is concern that that these rural areas, which has some of lowest insurance health coverage rates in a state known for its large percentage of uninsured, won’t see as much of a boost – if any – as the rest of the state.

“There was a lot of confusion this year (in rural corners of the state),” said Tamara Lockhart, a community assistance specialist with the Northeast Oklahoma Community Action Agency. “Without the funding, there is no way to drive out and reach these people.”

County-level data won’t be released for several months. But health-care experts and community groups worry that rural areas, which have some of the of lowest health insurance coverage rates, won’t get the needed boost in enrollment.

For Oklahoma, Trump’s budget cut meant funding was slashed by 78 percent over the past two years – dropping from $1.2 million in 2016 to $251,000 this year.

As a result, this was the first year since the Affordable Care Act was implemented that navigators weren’t able to serve the entire state. Dozens of counties – mostly in rural northeast and southwest Oklahoma – were left without access to the federally funded outreach and assistance program.

Josh Peck, who served as the healthcare.gov’s chief marketing officer during the Obama administration and currently works for nonprofit Get America Covered, said this could heighten coverage disparities between rural and urban areas.

“Navigators make sure people who have a harder time enrolling, like rural or minority populations, because signing up for health insurance is still very complicated,” he said. “I wouldn’t be surprised in the final analysis that we see a shift of where people are enrolled.”

What the Numbers Mean

Oklahoma was one of the outliers among the 39 states that use the federal insurance exchange.

Across those states, overall ACA enrollment fell by 367,000, or 4 percent. But Oklahoma was one of just five states that saw an increase.

Peck said a number of complex factors ultimately determine enrollment in a given area

In Oklahoma, the addition of another health insurer and lower premiums for many plans were likely some of the reasons for the enrollment increase, he said.

At the same time, like other states, Oklahoma faced many factors that might have prevented enrollment from rising more, Peck said.

Among those were the Republican-led Congress’ move last year to eliminate the “individual mandate,” which called for a tax penalty for going uninsured; cutting funds for ACA advertising, and slashing the navigator grants.

He argues the Trump administration’s moves were done deliberately to sabotage the ACA and likely kept millions off the plans nationwide.

“What specific number? We don’t have the answer to that,” he said. “But we think it should be substantially higher.”

However, Centers of Medicare and Medicaid Administrator Seema Verma said enrollment totals from the 39 states, which were higher than projected, are a sign that the Trump administration’s policies are working. In a statement, she added that “while enrollment remained steady through HealthCare.gov, many Americans don’t qualify for subsidies on HealthCare.gov and remain priced out of the insurance market.”

Navigator Deserts 

Lockhart, who worked as a navigator last year but couldn’t this year because of lack of funding, said her experience with rural residents this year indicated not enough was done to provide assistance and get the word out.

She said residents in the counties that lost navigator coverage, including Delaware County, where her group is based, still have options for help if they can’t enroll by themselves over the phone or at healthcare.gov. Those include contacting private insurance brokers, nonprofits or federally designated “assisters,” who are typically employed by a local health care provider.

But these groups can’t always conduct the proactive outreach that navigators offer, such as holding in-person sign-up events in rural areas, Lockhart said.

She added that without navigators’ help, rural counties might not see the same level of enrollment growth as counties where the help was provided.

“These people don’t have gas money to travel,” she said, “and many don’t have internet or know how to find help.”

Is the Help Needed?

There is debate on whether the Navigator program is effective and worth the millions of dollars in federal funding it has received nationally each year.

In announcing the latest round of budget cuts in July, the federal Centers said in a press release that navigators have become less necessary as people have become more familiar with the exchange.

Oklahoma Insurance Commissioner John Doak testified before Congress last year that the navigator program should be eliminated because it “has disrupted the longstanding vital role of agents and brokers in the marketing and sale of health insurance.”

But several national health-care groups have endorsed the program’s effectiveness, and some congressional Democrats have accused Trump of trying to sabotage the Affordable Care Act by cutting the navigator program.

Jennifer Tolbert, director of state health reform for the San Francisco-based Kaiser Family Foundation, said the program is worth the investment.

She said boosting the number of people covered is important to create a stable marketplace and keep premiums down for everyone. On an individual level, she said, a navigator can help determine whether someone receives health care coverage or a premium subsidy.

“At the end of the day, this is an intensive process and endeavor,” she said, emphasizing that funding cuts impact people who need assistance.

Taylor Lott, a navigator with the Latino Community Development Agency, said it can take up to an hour to help walk someone through the sign-up process.

She challenged the view that most people already know about the Affordable Care Act’s enrollment period and how to sign up, saying confusion and misconceptions remain. As an example, she cited the challenge of entering income from multiple jobs or self-employment to determine if one is eligible. In her coverage area of Oklahoma City, there was a high demand for assistance and only four full-time navigators to provide it, she said.

“Yes, people can sign up online,” she said. “But a big part of our job is to let people know what they are qualified for.”

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