Analysis Health Systems

Pennsylvania Considers Navigator Bill That Could Sabotage Affordable Care Act Enrollment

Tara Murtha

Pennsylvania lawmakers have proposed legislation that experts say would hinder the ACA enrollment process and would be illegal under new federal regulations that are likely to pass in the near future.

On top of refusing to expand Medicaid, Pennsylvania lawmakers have proposed legislation that experts say would sabotage the Affordable Care Act (ACA) by hindering the enrollment process, and which would be illegal under new federal regulations that are likely to pass in the near future.

Last week, President Obama announced that his administration reached its goal of enrolling more than 7 million citizens into private insurance plans through the ACA—a triumph for the administration, since high enrollment is key to the health-care law’s success.

Given the confusion among the general public about health-care reform, and the glitch-filled Healthcare.gov website, enrollment goals were reached in large part due to the work of navigators—individuals hired to help citizens figure out whether they qualify for a tax subsidy and assist them in signing up for a plan.

In states that let the federal government run their exchange, Department of Health and Human Services awarded $67 million in grants to 105 organizations. In Pennsylvania, five organizations were granted a total of $2.7 million to hire navigators. Navigators undergo 20 hours of training, and must be certified by the Centers for Medicare & Medicaid Services before working with the public.

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The initial enrollment success may be why Republican lawmakers in Pennsylvania are proposing legislation that experts—and the federal government—say will hinder navigators’ ability to enroll citizens in the future.

In a sponsorship memo circulated in December, Sen. John Eichelberger Jr. (R-Blair) and his 14 Republican co-sponsors of the “Navigator Accessibility and Regulation Act” stated they were concerned that navigators were going to give consumers erroneous information about plans, incorrectly tabulate their income while trying to figure out if the consumer qualifies for a subsidy, and violate consumers’ privacy.

The bill would require that navigators be certified by the state, pass a criminal background check, get fingerprinted, and pay unspecified fees. Since the federal government runs Pennsylvania’s exchange, the federal government already trains and certifies navigators; the proposed state-run regulations would be in addition to that.

According to the memo, the new regulations are necessary to “address consumer protection concerns resulting from the implementation of the Affordable Care Act.”

This reasonable-sounding explanation obscures the fact that the legislation is a pet project of special interests. What’s more, the phrase “consumer protection” is misleading in this context: Policy experts say that the legislation, especially when implemented in a state like Pennsylvania that rejected Medicaid expansion, actually harms the consumer.

The navigator program has been wildly successful, and experts say there’s no evidence of mass fraud perpetrated by navigators.

Pennsylvania Insurance Commissioner Michael Consedine recently admitted that “he has not seen abuses in the navigator position.”

U.S. Rep. Joe Pitts (R-PA), who supports the bill, has pointed to California, where more than 40 navigators were discovered to be convicted criminals. Some of the navigator organizations already run background checks for navigators, and generally speaking that’s not the part of the bill they oppose.

As ever when examining legislation that appears to be an answer in search of a problem, there are several “regulations” that would actually serve as restrictions. In this case, a “conflict of interest” clause would effectively disqualify Pennsylvania’s most effective navigator organization from continuing to help people sign up for health insurance.

From the bill:

It is a conflict of interest for any entity which provides health care services, or affiliate thereof, to serve as a navigator in this Commonwealth.

However, the Pennsylvania Association of Community Health Centers (PACHC), the lead navigator organization in the state, was chosen in large part because as the operator of 200 health centers situated in medically underserved areas, it is uniquely positioned to reach Pennsylvanians who stand to benefit the most from the Affordable Care Act.

PACHC did exactly that by hosting lectures in libraries and rural VFW halls, as well as sit-down sessions where navigators spent an average of one to two hours with citizens looking for help.

All in all, PACHC oversees 201 “enrollment assisters” that provide enrollment assistance in 170 sites across 43 counties, meet with nearly 20,000 consumers, and assist with enrollment of up to 10,000 individuals. (“Enrollment assister” is an umbrella term that includes navigators and certified application counselors who perform essentially the same function, but navigators are federally funded, while certified application counselors are not.)

Jim Willshier, director of public policy and partnership for PACHC, recently testified about the proposed regulations in front of the Pennsylvania Senate. He argued that the conflict of interest clause would mean his organization would have to stop providing enrollment assistance. Further, he pointed out that navigators who still qualified would be forbidden from providing “information or services related to health benefit plans or other products not offered in the exchange.”

A significant segment of the individuals who seek out navigators for assistance don’t earn enough money to qualify for a tax subsidy to purchase a private plan. Although formal data is not yet in, two of Pennsylvania’s five navigator organizations told Rewire that some 40 percent of the people who met with their navigators fell into the Medicaid funding gap that was created when Gov. Corbett refused to expand Medicaid. In other words, the people the navigators are meeting with are the very people who would most benefit from learning if they qualify for any other programs.

What that means is that if a navigator sat down with a citizen who didn’t make enough money to qualify for a tax subsidy to offset the cost of purchasing a private insurance plan on the exchange, but qualified for another program such as Medical Assistance or had children who qualified for the Children’s Health Insurance Program (CHIP), the navigator would be forbidden by law from telling the consumer about those options.

In other words, the proposed legislation is a gag order.

The navigator aspect of the Affordable Care Act unnerved some insurance professionals and lobbyists from the beginning of discussions about the health-care law.

According to the Center for Public Integrity, special-interest business groups “worked to kill or amend the navigator provision.” When the navigator program stayed in the ACA, those groups fought for and won a provision that enabled insurance salespeople to become navigators. Then they “turned their attention to the states,” urging business-friendly state legislators to “enact a licensing framework and regulatory regime for navigators.”

Many of them did just that.

Today, Pennsylvania is one of at least nine states that chooses to let the federal government run their online health insurance marketplace but now wants to be able to create and enact regulations of the navigators.

It’s becoming clear, however, that these state regulations conflict with federal regulations, with lawsuits filed in two states. In January, a federal judge enjoined Missouri’s navigator regulation law, ruling that the state couldn’t create additional regulation for navigators since the state opted out of running the exchange.

USA Today reported that “the court said imposing those restrictions was pre-emptive because it created an obstacle to implementing the Affordable Care Act.”

The same article also notes that the Missouri ruling could be used as a foundation for other lawsuits.

Those lawsuits may not even be necessary, though. In response to state laws, the federal government has proposed a new set of regulations striking down provisions that create obstacles to implementing the Affordable Care Act. The proposed federal regulations are currently in public comment period, which ends later this month, and experts are confident they will pass.

Pennsylvania’s “Navigator Accessibility and Regulation Act” contains at least eight provisions that would be struck down by the new regulations, according to Tricia Brooks, senior fellow at the Center for Children and Families and a research assistant professor at the Georgetown University Health Policy Institute.

“We, stakeholders, people who follow [these policies], know that some of these laws have interfered with what navigators are doing, what they need to do for consumers,” Brooks told Rewire. “It’s been highly politicized.”

Brooks notes that the concept of hiring people in the community to help citizens navigate complex systems is not new, and has never required state-based regulations. This model has been used, for example, to help people enroll children in CHIP programs.

“This is just an industry protecting their own interest, and unfortunately I think what they’re doing is a disservice to consumers,” said Brooks.

If Pennsylvania’s navigator bill is not knocked down by the forthcoming federal regulations, evidence shows the result of the provisions for consumers would be disastrous.

In January, the George Washington University School of Public Health and Health Services published a report exploring the effect such regulations have had on enrollment in states that, like Pennsylvania, rejected Medicaid expansion.

From the report:

In states with restrictive policies toward ACA implementation (defined as both opting out of the Medicaid adult expansion and adopting Navigator laws), health centers are confronting a significantly greater outreach and enrollment challenges.

The success of the Affordable Care Act has always hinged in enrollment goals. In short, the study concluded that navigator laws “did exactly the opposite of what they were purported to do” by hindering enrollment.

Sara Rosenbaum, the senior author for the study, summarized the conclusion for USA Today. “If anyone has any doubt, this should put it to rest,” she said. “The navigator laws combined with opting out of Medicaid really stopped outreach in its tracks.”

CORRECTION: A quote by Tricia Brooks has been updated slightly for clarity, at Brooks’ request.

Commentary Sexual Health

Parents, Educators Can Support Pediatricians in Providing Comprehensive Sexuality Education

Nicole Cushman

While medical systems will need to evolve to address the challenges preventing pediatricians from sharing medically accurate and age-appropriate information about sexuality with their patients, there are several things I recommend parents and educators do to reinforce AAP’s guidance.

Last week, the American Academy of Pediatrics (AAP) released a clinical report outlining guidance for pediatricians on providing sexuality education to the children and adolescents in their care. As one of the most influential medical associations in the country, AAP brings, with this report, added weight to longstanding calls for comprehensive sex education.

The report offers guidance for clinicians on incorporating conversations about sexual and reproductive health into routine medical visits and summarizes the research supporting comprehensive sexuality education. It acknowledges the crucial role pediatricians play in supporting their patients’ healthy development, making them key stakeholders in the promotion of young people’s sexual health. Ultimately, the report could bolster efforts by parents and educators to increase access to comprehensive sexuality education and better equip young people to grow into sexually healthy adults.

But, while the guidance provides persuasive, evidence-backed encouragement for pediatricians to speak with parents and children and normalize sexual development, the report does not acknowledge some of the practical challenges to implementing such recommendations—for pediatricians as well as parents and school staff. Articulating these real-world challenges (and strategies for overcoming them) is essential to ensuring the report does not wind up yet another publication collecting proverbial dust on bookshelves.

The AAP report does lay the groundwork for pediatricians to initiate conversations including medically accurate and age-appropriate information about sexuality, and there is plenty in the guidelines to be enthusiastic about. Specifically, the report acknowledges something sexuality educators have long known—that a simple anatomy lesson is not sufficient. According to the AAP, sexuality education should address interpersonal relationships, body image, sexual orientation, gender identity, and reproductive rights as part of a comprehensive conversation about sexual health.

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The report further acknowledges that young people with disabilities, chronic health conditions, and other special needs also need age- and developmentally appropriate sex education, and it suggests resources for providing care to LGBTQ young people. Importantly, the AAP rejects abstinence-only approaches as ineffective and endorses comprehensive sexuality education.

It is clear that such guidance is sorely needed. Previous studies have shown that pediatricians have not been successful at having conversations with their patients about sexuality. One study found that one in three adolescents did not receive any information about sexuality from their pediatrician during health maintenance visits, and those conversations that did occur lasted less than 40 seconds, on average. Another analysis showed that, among sexually experienced adolescents, only a quarter of girls and one-fifth of boys had received information from a health-care provider about sexually transmitted infections or HIV in the last year. 

There are a number of factors at play preventing pediatricians from having these conversations. Beyond parental pushback and anti-choice resistance to comprehensive sex education, which Martha Kempner has covered in depth for Rewire, doctor visits are often limited in time and are not usually scheduled to allow for the kind of discussion needed to build a doctor-patient relationship that would be conducive to providing sexuality education. Doctors also may not get needed in-depth training to initiate and sustain these important, ongoing conversations with patients and their families.

The report notes that children and adolescents prefer a pediatrician who is nonjudgmental and comfortable discussing sexuality, answering questions and addressing concerns, but these interpersonal skills must be developed and honed through clinical training and practice. In order to fully implement the AAP’s recommendations, medical school curricula and residency training programs would need to devote time to building new doctors’ comfort with issues surrounding sexuality, interpersonal skills for navigating tough conversations, and knowledge and skills necessary for providing LGBTQ-friendly care.

As AAP explains in the report, sex education should come from many sources—schools, communities, medical offices, and homes. It lays out what can be a powerful partnership between parents, doctors, and educators in providing the age-appropriate and truly comprehensive sexuality education that young people need and deserve. While medical systems will need to evolve to address the challenges outlined above, there are several things I recommend parents and educators do to reinforce AAP’s guidance.

Parents and Caregivers: 

  • When selecting a pediatrician for your child, ask potential doctors about their approach to sexuality education. Make sure your doctor knows that you want your child to receive comprehensive, medically accurate information about a range of issues pertaining to sexuality and sexual health.
  • Talk with your child at home about sex and sexuality. Before a doctor’s visit, help your child prepare by encouraging them to think about any questions they may have for the doctor about their body, sexual feelings, or personal safety. After the visit, check in with your child to make sure their questions were answered.
  • Find out how your child’s school approaches sexuality education. Make sure school administrators, teachers, and school board members know that you support age-appropriate, comprehensive sex education that will complement the information provided by you and your child’s pediatrician.

School Staff and Educators: 

  • Maintain a referral list of pediatricians for parents to consult. When screening doctors for inclusion on the list, ask them how they approach sexuality education with patients and their families.
  • Involve supportive pediatricians in sex education curriculum review committees. Medical professionals can provide important perspective on what constitutes medically accurate, age- and developmentally-appropriate content when selecting or adapting curriculum materials for sex education classes.
  • Adopt sex-education policies and curricula that are comprehensive and inclusive of all young people, regardless of sexual orientation or gender identity. Ensure that teachers receive the training and support they need to provide high-quality sex education to their students.

The AAP clinical report provides an important step toward ensuring that young people receive sexuality education that supports their healthy sexual development. If adopted widely by pediatricians—in partnership with parents and schools—the report’s recommendations could contribute to a sea change in providing young people with the care and support they need.

Analysis Politics

The 2016 Republican Platform Is Riddled With Conservative Abortion Myths

Ally Boguhn

Anti-choice activists and leaders have embraced the Republican platform, which relies on a series of falsehoods about reproductive health care.

Republicans voted to ratify their 2016 platform this week, codifying what many deem one of the most extreme platforms ever accepted by the party.

“Platforms are traditionally written by and for the party faithful and largely ignored by everyone else,” wrote the New York Times‘ editorial board Monday. “But this year, the Republicans are putting out an agenda that demands notice.”

“It is as though, rather than trying to reconcile Mr. Trump’s heretical views with conservative orthodoxy, the writers of the platform simply opted to go with the most extreme version of every position,” it continued. “Tailored to Mr. Trump’s impulsive bluster, this document lays bare just how much the G.O.P. is driven by a regressive, extremist inner core.”

Tucked away in the 66-page document accepted by Republicans as their official guide to “the Party’s principles and policies” are countless resolutions that seem to back up the Times‘ assertion that the platform is “the most extreme” ever put forth by the party, including: rolling back marriage equalitydeclaring pornography a “public health crisis”; and codifying the Hyde Amendment to permanently block federal funding for abortion.

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Anti-choice activists and leaders have embraced the platform, which the Susan B. Anthony List deemed the “Most Pro-life Platform Ever” in a press release upon the GOP’s Monday vote at the convention. “The Republican platform has always been strong when it comes to protecting unborn children, their mothers, and the conscience rights of pro-life Americans,” said the organization’s president, Marjorie Dannenfelser, in a statement. “The platform ratified today takes that stand from good to great.”  

Operation Rescue, an organization known for its radical tactics and links to violence, similarly declared the platform a “victory,” noting its inclusion of so-called personhood language, which could ban abortion and many forms of contraception. “We are celebrating today on the streets of Cleveland. We got everything we have asked for in the party platform,” said Troy Newman, president of Operation Rescue, in a statement posted to the group’s website.

But what stands out most in the Republicans’ document is the series of falsehoods and myths relied upon to push their conservative agenda. Here are just a few of the most egregious pieces of misinformation about abortion to be found within the pages of the 2016 platform:

Myth #1: Planned Parenthood Profits From Fetal Tissue Donations

Featured in multiple sections of the Republican platform is the tired and repeatedly debunked claim that Planned Parenthood profits from fetal tissue donations. In the subsection on “protecting human life,” the platform says:

We oppose the use of public funds to perform or promote abortion or to fund organizations, like Planned Parenthood, so long as they provide or refer for elective abortions or sell fetal body parts rather than provide healthcare. We urge all states and Congress to make it a crime to acquire, transfer, or sell fetal tissues from elective abortions for research, and we call on Congress to enact a ban on any sale of fetal body parts. In the meantime, we call on Congress to ban the practice of misleading women on so-called fetal harvesting consent forms, a fact revealed by a 2015 investigation. We will not fund or subsidize healthcare that includes abortion coverage.

Later in the document, under a section titled “Preserving Medicare and Medicaid,” the platform again asserts that abortion providers are selling “the body parts of aborted children”—presumably again referring to the controversy surrounding Planned Parenthood:

We respect the states’ authority and flexibility to exclude abortion providers from federal programs such as Medicaid and other healthcare and family planning programs so long as they continue to perform or refer for elective abortions or sell the body parts of aborted children.

The platform appears to reference the widely discredited videos produced by anti-choice organization Center for Medical Progress (CMP) as part of its smear campaign against Planned Parenthood. The videos were deceptively edited, as Rewire has extensively reported. CMP’s leader David Daleiden is currently under federal indictment for tampering with government documents in connection with obtaining the footage. Republicans have nonetheless steadfastly clung to the group’s claims in an effort to block access to reproductive health care.

Since CMP began releasing its videos last year, 13 state and three congressional inquiries into allegations based on the videos have turned up no evidence of wrongdoing on behalf of Planned Parenthood.

Dawn Laguens, executive vice president of Planned Parenthood Action Fund—which has endorsed Hillary Clinton—called the Republicans’ inclusion of CMP’s allegation in their platform “despicable” in a statement to the Huffington Post. “This isn’t just an attack on Planned Parenthood health centers,” said Laguens. “It’s an attack on the millions of patients who rely on Planned Parenthood each year for basic health care. It’s an attack on the brave doctors and nurses who have been facing down violent rhetoric and threats just to provide people with cancer screenings, birth control, and well-woman exams.”

Myth #2: The Supreme Court Struck Down “Commonsense” Laws About “Basic Health and Safety” in Whole Woman’s Health v. Hellerstedt

In the section focusing on the party’s opposition to abortion, the GOP’s platform also reaffirms their commitment to targeted regulation of abortion providers (TRAP) laws. According to the platform:

We salute the many states that now protect women and girls through laws requiring informed consent, parental consent, waiting periods, and clinic regulation. We condemn the Supreme Court’s activist decision in Whole Woman’s Health v. Hellerstedt striking down commonsense Texas laws providing for basic health and safety standards in abortion clinics.

The idea that TRAP laws, such as those struck down by the recent Supreme Court decision in Whole Woman’s Health, are solely for protecting women and keeping them safe is just as common among conservatives as it is false. However, as Rewire explained when Paul Ryan agreed with a nearly identical claim last week about Texas’ clinic regulations, “the provisions of the law in question were not about keeping anybody safe”:

As Justice Stephen Breyer noted in the opinion declaring them unconstitutional, “When directly asked at oral argument whether Texas knew of a single instance in which the new requirement would have helped even one woman obtain better treatment, Texas admitted that there was no evidence in the record of such a case.”

All the provisions actually did, according to Breyer on behalf of the Court majority, was put “a substantial obstacle in the path of women seeking a previability abortion,” and “constitute an undue burden on abortion access.”

Myth #3: 20-Week Abortion Bans Are Justified By “Current Medical Research” Suggesting That Is When a Fetus Can Feel Pain

The platform went on to point to Republicans’ Pain-Capable Unborn Child Protection Act, a piece of anti-choice legislation already passed in several states that, if approved in Congress, would create a federal ban on abortion after 20 weeks based on junk science claiming fetuses can feel pain at that point in pregnancy:

Over a dozen states have passed Pain-Capable Unborn Child Protection Acts prohibiting abortion after twenty weeks, the point at which current medical research shows that unborn babies can feel excruciating pain during abortions, and we call on Congress to enact the federal version.

Major medical groups and experts, however, agree that a fetus has not developed to the point where it can feel pain until the third trimester. According to a 2013 letter from the American Congress of Obstetricians and Gynecologists, “A rigorous 2005 scientific review of evidence published in the Journal of the American Medical Association (JAMA) concluded that fetal perception of pain is unlikely before the third trimester,” which begins around the 28th week of pregnancy. A 2010 review of the scientific evidence on the issue conducted by the British Royal College of Obstetricians and Gynaecologists similarly found “that the fetus cannot experience pain in any sense prior” to 24 weeks’ gestation.

Doctors who testify otherwise often have a history of anti-choice activism. For example, a letter read aloud during a debate over West Virginia’s ultimately failed 20-week abortion ban was drafted by Dr. Byron Calhoun, who was caught lying about the number of abortion-related complications he saw in Charleston.

Myth #4: Abortion “Endangers the Health and Well-being of Women”

In an apparent effort to criticize the Affordable Care Act for promoting “the notion of abortion as healthcare,” the platform baselessly claimed that abortion “endangers the health and well-being” of those who receive care:

Through Obamacare, the current Administration has promoted the notion of abortion as healthcare. We, however, affirm the dignity of women by protecting the sanctity of human life. Numerous studies have shown that abortion endangers the health and well-being of women, and we stand firmly against it.

Scientific evidence overwhelmingly supports the conclusion that abortion is safe. Research shows that a first-trimester abortion carries less than 0.05 percent risk of major complications, according to the Guttmacher Institute, and “pose[s] virtually no long-term risk of problems such as infertility, ectopic pregnancy, spontaneous abortion (miscarriage) or birth defect, and little or no risk of preterm or low-birth-weight deliveries.”

There is similarly no evidence to back up the GOP’s claim that abortion endangers the well-being of women. A 2008 study from the American Psychological Association’s Task Force on Mental Health and Abortion, an expansive analysis on current research regarding the issue, found that while those who have an abortion may experience a variety of feelings, “no evidence sufficient to support the claim that an observed association between abortion history and mental health was caused by the abortion per se, as opposed to other factors.”

As is the case for many of the anti-abortion myths perpetuated within the platform, many of the so-called experts who claim there is a link between abortion and mental illness are discredited anti-choice activists.

Myth #5: Mifepristone, a Drug Used for Medical Abortions, Is “Dangerous”

Both anti-choice activists and conservative Republicans have been vocal opponents of the Food and Drug Administration (FDA’s) March update to the regulations for mifepristone, a drug also known as Mifeprex and RU-486 that is used in medication abortions. However, in this year’s platform, the GOP goes a step further to claim that both the drug and its general approval by the FDA are “dangerous”:

We believe the FDA’s approval of Mifeprex, a dangerous abortifacient formerly known as RU-486, threatens women’s health, as does the agency’s endorsement of over-the-counter sales of powerful contraceptives without a physician’s recommendation. We support cutting federal and state funding for entities that endanger women’s health by performing abortions in a manner inconsistent with federal or state law.

Studies, however, have overwhelmingly found mifepristone to be safe. In fact, the Association of Reproductive Health Professionals says mifepristone “is safer than acetaminophen,” aspirin, and Viagra. When the FDA conducted a 2011 post-market study of those who have used the drug since it was approved by the agency, they found that more than 1.5 million women in the U.S. had used it to end a pregnancy, only 2,200 of whom had experienced an “adverse event” after.

The platform also appears to reference the FDA’s approval of making emergency contraception such as Plan B available over the counter, claiming that it too is a threat to women’s health. However, studies show that emergency contraception is safe and effective at preventing pregnancy. According to the World Health Organization, side effects are “uncommon and generally mild.”