Physicians

Could Med Students Help Win the Enrollment War?

State health exchanges are facing many challenges in the recent scramble to enroll their residents in the healthcare marketplace. Among the numerous obstacles, including online systemic glitches (Washington state botched the tax-credit calculation while Maryland’s appears to be having just general technical incompetence) and complete lack of knowledge (according to a recent Gallup poll, 71% of uninsured Americans have no clue what the exchanges are), a critical challenge is the quick generation of a new healthcare workforce, namely enrollment counselors and navigators.

According to the Center for Medicare and Medicaid Services, enrollment navigators are supposed to help people enroll, whether through online or paper applications, determine individual eligibility for various subsidies and assistance programs, and generally educate the public regarding the new health exchanges. Certified application counselors differ slightly from navigators, taking a less involved role in the process, but still serving as assistants to people who need help completing their application.

However, in many states, including Florida (1 navigator per 100,000 uninsured citizens as of October 1st), Georgia (only 4 people were certified to be counselors when the exchanges went live) and California (official numbers will be released on November 14th, but current estimates suggest less than 20% of future counselors are fully certified yet), there is a huge workforce shortage which is both reducing the rate of enrollment and contributing to people’s doubts about the Affordable Care Act in general.

Part of the problem is that many states, for several months now, have purposely made it more difficult for people to become certified enrollment employees; Ohio and Missouri are  widely cited as two of those. They have also instituted regulations on what information counselors can and cannot give patients and have tried to implement large fines, such as in Tennessee, which luckily ruled to temporarily restrain these penalties, for those who may unknowingly breach part of the contract.

As a medical student hoping to be more involved in influencing patient care, but unable to do so at a clinical level just yet, the opportunity to serve as an enrollment counselor or navigator is more than timely.

In my home state of California, training and certification to become a Certified Enrollment Counselor is not easy, but it’s doable. The process involves 20 hours of in-person courses, a number of online modules, and a background check. However, the cost of training is compensated—$58 per completed application, to be exact.


A recent study showed that many uninsured patients do not even have basic knowledge of insurance terminology, let alone a strategy of how to go about securing an insurance plan from the exchanges. As students, even helping to improve health literacy and teaching workshops at local clinics on basic insurance concepts would be a significant community service contribution. A group of medical and public health students at my school, UCLA, and USC are forming a collaborative to serve as certified enrollment counselors.

This experience will allow the next generation of medical leaders in our state to hear first-hand the challenges that patients face in terms of practical considerations that are often left out of medical school curricula, including financial limitations that restrict patient decision-making.  In today’s healthcare system, health professionals are not the only ones to have a direct impact on healthcare outcomes for millions of Americans—the opportunity for students awaits.

Abraar Karan is a Yale graduate and MD candidate at UCLA. He blogs at Swasthya Mundial.

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  3. I would be concerned about advocating for ACA, thinking it in the best interest of your patients now or ever, when, there is some very serious doubt that it is a viable piece of legislation, and it could very well be repealed. Its flaws are so wide and deep because of flawed goals and unanticipated consequences. By being a medical professional navigator, you would have an aura of competence that no other navigator could possible have. Wouldn’t you feel just awful if you helped a citizen sign up for something that is truly harmful to them, the country and our beloved profession?

  4. Joel, I understand your frustrations with the government. The fact is, the ACA is now law. As students, we are still focused on what is best for our patients today and tomorrow.

  5. Hi Paul,
    Your point is definitely valid– I do think, however, that we have a lot to learn about patient challenges with regards to healthcare access. Understanding these issues when we are young and relatively unbiased will be important when we are policy advocates in the future.

  6. Hi Joe,
    We are working with public health students as well. This was really meant to advocate for all students, not just med students. As you probably know, authors don’t choose the post title.

    As for the reimbursement method– we aren’t doing this for the money. I’m all for value-based payment, but our job is to connect people to navigators– hopefully there won’t be too much variation on how we do this (but who knows)

    All in all, I think medical students would benefit a lot from engaging with people and understanding the difficulties they are facing with regard to healthcare access.

  7. Hello Paul,

    Thank you for your comments and insight. I am a little biased because I’m one of the medical students involved in organizing this effort. So far we have 145 student members between UCLA and USC medical and MPH students. While I think your concerns about not being able to work in medical school are valid I don’t think it’s as black and white as you describe. First, these medical students are largely first and second year students and the way our curriculum is set up we actually do have some time undertake this endeavors adequately particularly in the first and second years. Second, this isn’t a full time job per se because due to the fact that we have so many members we are able to divide the work up pretty evenly so as not to put too much strain on any student. Finally, this is purely on a volunteer basis and students are encouraged to make sure their studies are coming first.

    On another note I think what we have the ability to learn here has the potential to be more important than many of our classes that we take in our first two years of medical school. I am ignorant in this regard being only a second year medical student but it is my understanding that the majority of clinical medicine is learned through experience in the clinic, which for us at UCLA starts mainly in our third year. Of course the basic science and pathophysiology are important but again using this as a proxy to evaluate what makes a good physician is obviously flawed and when compared to the impact we can make (as well as the educational component this opportunity presents) I think most (who are not politically biased against something that was upheld by the Supreme Court and is now law) would agree. History has shown us what happens when physicians, medical students and other health care professionals sit idly on the sidelines and do not get involved in policy decisions and implementation that, especially from an underserved population perspective, often affect our patients more than the medicine we provide to them mainly because it affects and influences what that medicine is.

  8. Medical school is a full-time endeavor and then some. No medical student I have known over 4 decades (I was a professor) has had time to work. If this student were to commit to help folks with ACA, he would have to sacrifice precious time needed to study and learn the craft of medicine, or not do a good job as a facilitator. Whatever you do, you should do with 100% effort.

  9. Why not dispatch hundreds of Government vehicles/vans-

    – Call them “OBAMACAREMOBILES” –

    -to US communities to sign up people who can’t use or navigate the broken website?

  10. I applaud Abraar for wanting to take an active role in helping patients navigate the complexity of the healthcare system – at the end of the day, this is one of our most important jobs as physicians. The IOM, AAMC, and ACGME have all identified the importance of training “systems thinking” physicians and Abraar is on the leading edge.

    Sure, students have a lot on their plates, but understanding the mechanics of patient affordability is no less important than understanding genetics.

    Navigators, particularly those who are well informed, can play a critical role in addressing the gaps in public understanding that Abraar has identified. Engaged medical students can provide both credibility and “boots on the ground” in the same way they did to remove the influence of pharmaceutical companies from academic medical centers and in the same way they are already doing in conjunction with Costs of Care to “teaching value” (www.TeachingValue.org)

    Abraar, the next step is to translate your ambition into action – serve as a navigator and encourage your colleagues to do the same. Then get back to us on what this experience has taught you and what you feel you were able to contribute.

  11. “A recent study showed that many uninsured patients do not even have basic knowledge of insurance terminology, let alone a strategy of how to go about securing an insurance plan from the exchanges.”

    Insurance and their for-free marketing government exchanges are not the solution.

  12. Talking about taking advantage of “slave labor”!

    As if med students don’t have enough on their plates to learn how to diagnose and treat people, now the government is going to coerce them into selling this travesty??

    Memo to any med students reading here, ask the apologists and defenders of this ilk legislation why, to my knowledge at least, less than 50% of practicing doctors in the US (and I am being charitable with that figure) support PPACA.

    So why should you help the government when the government is more than likely to NOT help you once you finish your training.

    Oh, those damn insignificant truths, always getting in the way.

    Oh, and also, google this little gem revealed today: “sexually suggestive Obamacare ad & Fox News”

    Bet all the women students will just love this type of publicity for this legislation. Read it and weep, folks!!!

  13. Which makes absolutely no sense at all. Why Congress and the Administration, in all their wisdom, believe a community group can help people “navigate” the insurance marketplace better than a broker is one of the biggest farces of this whole thing.

    And it is a farce at its core.

  14. There are several tens of thousands of LIfe/Health agents around the country who could facilitate enrollment. They happen to be fully versed in health insurance and had to pass licensing exams to prove it. Alas, they are specifically prohibited from acting as navigators. Too bad, so sad. All that talent, utterly wasted.

  15. Fee for service navigators are completely different from FFS physicians mainly because this service can only be preformed once per patient per insurance cycle (re-enrolling patients is also reimbursed at a much lower rate). There are many other reasons which I won’t go into but that comparison doesn’t make sense to me.

    Second, the ACA is no longer political. It is the law. Regardless if you agree with it or not it is law and the fact of the matter is connecting patients to care involves getting them insurance.

    SR it is sad that some facilitators are not well informed but I would hope that this will improve as they gain more experience.

    Finally this whole notion that medical students should solely concentrate on their studies is one that people never fail to mention when they get the chance. I completely understand the need to focus on your studies but at the same it doesn’t take that much time to get involved in these efforts relative to their contribution. It is estimated that 1 in every 1000 uninsured patients die prematurely from simply lacking insurance. With the estimated 2 million uninsured people in LA county that are eligible for the MediCal expansion or exchange subsidies we can help avoid 2,000 preventable deaths. Is this not worth sacrificing some of our time now. Furthermore to imply that this will make students a worse doctor in the future is misguided and maybe our definition of what makes someone a “good doctor” should be reevaluated, because the amount you learned in medical school is definitely not a good proxy.

  16. The answer would seem to me that navigators should know considerably more about the insurance system than the people they are trying to help.

    Pouring millions into community groups with no expertise in health insurance seems like another way to waste money without actually help patients to, you know, enroll (even if they could get beyond the technical challenges).

  17. While I appreciate your desire to be more involved, I think you’re overreaching.

    First, having had several conversations with ‘facilitators’, I am shocked at their relative uselessness. True, I am both a physician, a business person, and someone fairly knowledgeable about this whole process, so maybe my bar is a little higher than the general public….but no, I’m not buying that argument. Any time I pressed for information, I got back a series of fairly rote, unsophisticated answers. This is the problem with the whole let’s give you 20hours of education and then you’re ready to be let loose upon the world. It’s a little like getting a call center operator reading from a handbook – it’s just not how to make something work well.

    In addition, part of the reason the ‘facilitators’ aren’t as knowledgeable as I think they should be is that the whole system is unbelievably convoluted right now. Some of the best answers I’ve gotten is from ehealthinsurance. Their staff at least have a macro view of how things are working and are some of the most educated and informed people I have spoken with yet – and even they have a fair amount of variability in quality (ie their small business group staff is much more sophisticated than their individual insurance folks).

    And, lastly, I agree with Paul – I think it’s great that you want to do more, but as someone who has many friends who completed Medical School and went on to various business areas in healthcare, I will say this – decide if you want to practice medicine. If you do, by all means, you can have side interests (you already blog and read). But by the time you are taking care of me or your other patients, I want you to be a good and knowledgeable physician. I care much less whether you’re a health policy expert.

  18. As a medical student, you need to concentrate on your studies. That information learned, as you know, is cumulative, and it will likely benefit the patients you will treat in your residency and in practice. Although your concerns for the healthcare of the folks is admirable, you would be best served to avoid being embroiled in the politics of national health insurance at this point in your career. Later, when you have more experience in the real world, if you want to advocate for something, that would be fine. (from a physician)

  19. Abraar –

    You pose an interesting question.You’d think the administration would be encouraging healthcare providers to talk with patients – possibly even give them incentives to help enroll folks at the healthcare system’s main point of contact (you know, those doctor office front desk things with all the busy people filing out forms and answering phones). At the very least they should provide tools and information for doctors to help counsel patient …

  20. Abraar- serious question:

    I am going to assume you oppose fee-for-service medicine.

    Why would you support fee-for-service navigator fees? Why not pay navigators for some value based metrics?

    Also, why would medical students be more equipped than non-medical students to provide appropriate information and advice re: signing up for insurance?

    Today, good brokers provide invaluable services to individuals (preACA) and small businesses on this issue… and big business outsources the extremely complex process to independent firms that can do analysis and give advice?

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