October 1st is getting very close which means the most visible part of the Affordable Care Act is about to go live.  The health insurance exchanges in all 50 states will be up and running and this will allow those without insurance and those who want to shop to compare prices to buy insurance through these online marketplaces.  It should be very exciting as it will, perhaps for the first time, allow individuals and small businesses to purchase healthcare insurance in a fully transparent and affordable manner.  If it works, it should be like buying airline tickets and hotel rooms through the websites that show all discounts and all prices from competitive companies. That is the promise.

One of the most important, and yet one of the least talked about, parts of the exchanges is the role of the navigators.  These navigators, as approved in the ACA, are meant to be live people who will help those shopping for insurance coverage maneuver their way through the process.  This role is critical and in many ways could be viewed as the grease that allows the machine to run properly.  The navigators will help people fully understand the costs and the benefits of the various different level plans that will appear on the exchanges.  Is is better to go for a gold plan that covers more or a bronze plan that is perhaps more affordable?  Perhaps the most confusing issue will be the amount of subsidy each person will qualify for from the government based on their income level.  This will require some significant explanation as it will impact the amount and type of insurance that will be purchased.

This is all well and good and makes a lot of sense except for the fact that so little is known about these navigators.  Who are these people?  What is their training?  How are they or how will they be qualified to do this work?  Take a look at this piece in last week’s New York Times to get a feel for some of the issues.  Due to the fact that so many states are allowing the federal government to run their exchanges, there has not been enough money set aside to pay for these navigators.  It seems a lot of these workers will come from nonprofit agencies which is good and bad.  This may allow the money to go a little further as the nonprofits may be able to reach more people through their existing structures but there will also be overhead costs.  Why is this all starting so late?  How will these folks be trained?  Will they be able to add all the value as envisioned by the bill or not?  It really does seem to be one of the points of concern for the ACA implementation.

Think back, if you are old enough, to when companies began to offer choices to employees around their health insurance benefits.  There was a tremendous amount of discussion, company meetings, individual sheets printed on the different options and a plethora of trained experts to help employees understand the options.  There were a ton of “navigators” at each company that helped explain the options, paperwork and the cost of each choice.  Even today a lot of effort goes into the annual enrollment process and for most people this is merely a formality of continuing the same coverage.  This may give some picture as to what a mess this could be if the navigator concept doesn’t work.

Perhaps the biggest questions are who will fill the gaps and how?  Will this be done through television ads or through Internet explanations?  Will insurance companies with plans on the exchanges step in to help and will their bias hurt the system?  Will those opposed to the ACA initiate a program to confuse the process and make matters even worse?  Could the pharmaceutical companies, who have such a large stake in an orderly healthcare system, step in some way?  I hope we are not going to all stand back and allow people to struggle with these life and death decisions all on their own.