The Role of External Support in Health Insurance Decision-Making Under the Affordable Care Act
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Health insurance decision-making in the United States is a challenging process plagued by complex eligibility guidelines, unfamiliar product choices, increasing financial burdens, and an ever-changing regulatory environment. The Affordable Care Act (ACA) attempted to increase access to healthcare, in part by alleviating some of the barriers to gaining health insurance coverage. However, complexities persist in health insurance decision-making and enrollment and as a result, many Americans remain uninsured. Further, under a new administration in 2017 we can expect to see yet another revised health insurance landscape for individuals to navigate. This study broadens this growing body of knowledge on the role and mechanisms by which both ACA Navigators and Health Insurance Brokers provide external decision making support in health insurance enrollment and offerings. The key contributions include: the development of a large new primary dataset on ACA Navigators in Illinois and the types of Outreach work they conduct; leverages this complete set of multi-year data by combining it with longitudinal census data to determine Navigator's association with declining uninsurance rates at the community zip code level; and, finally adds the usage of a mixed methods approach to better understand these results and the underlying mechanisms by which health insurance decision support workforces like Navigators and Health Insurance Brokers harness their social capital to improve the uptake of new policy decisions intended to expand insurance coverage. This framework examines the links in the relationship between two core theories often used separately to explain phenomenon in health promotion - Social Capital Theory (Coleman, 1988) and Diffusion of Innovations (Rogers, 1995). The core aims of this study are: 1. Describe the ACA Navigator program funding (nationally), workforce distribution, and outreach activities (Illinois), measured by a newly constructed Navigator Outreach Activity Index. 2. Evaluate the association of the ACA Navigator program funding, workforce distribution and outreach activities with the rate of uninsurance in Illinois and nationally from 2013-2015. 3. Describe and compare a health insurance broker's (the historic health insurance outreach and enrollment workforce) approach to policy and product innovations to that of ACA Navigators. We find that navigator programs are associated with related geographic decreases in uninsurance rates, and it is observed at an even greater magnitude among key sub-populations of interest. Further, we find that both navigators and brokers leverage the three core dimensions of social capital (Cognitive, Relational and Structural) but each, in a way that magnifies their own unique strengths. Further, it appears that to some extent, this ability to leverage social capital on behalf of a client, has a potentially positive relationship with the desired end result - health insurance enrollment by the uninsured in the case of the ACA Navigator; and adoption of employee health promotion and wellness programs by small employers in the case of health insurance brokers.