Financial Instability of Federal Navigator Program Challenges Organizations to Help Uninsured Enroll in Health Insurance Coverage.

Under the Affordable Care Act, the federal Health Insurance Navigator Program aims to reduce the rate of uninsured in the United States. Under this program, navigators help people obtain insurance coverage through federally facilitated Marketplaces. However, the program's financial instability and substantial budget cuts created a severe shortage of navigator assistance for the uninsured and underserved. The COVID-19 pandemic added further pressure to the already-strained program. Our study examined how unstable and unpredictable federal funding and the COVID-19 pandemic affected organizations' navigator work in the federal program in 2020. The results study show (1) that navigator organizations provide vital, year-round resources; (2) that organizations feel pushed to direct scarce resources to grant management and cut service provision; and (3) that there are policy changes that can support navigator organizations in the future. Increased and ongoing federal investment is needed to support this vital health workforce and expand enrollment assistance for underserved communities.

"This work that we're doing is bigger than ourselves": A qualitative study with community-based birth doulas in the United States.

CONTEXT: Community-based birth doulas support pregnant women, transgender men, and gender non-binary individuals during the perinatal period and provide essential services and expertise that address health inequities, often taking on additional roles to fill systemic gaps in perinatal care in the United States (US). Despite the benefits that community-based birth doulas provide, there is little research exploring the work-related conditions and stressors community-based doulas experience. To address this gap, we examined the work experiences, related stressors, and stress management strategies of individual community-based birth doulas. METHODS: In this qualitative, descriptive study we conducted 18 interviews in March through June 2021 with individuals who self-identified as community-based doulas working in underserved communities in the US. We analyzed the interviews for themes, which we defined and finalized through team consensus. RESULTS: The doulas reported engaging in specific strategies in their work to address perinatal inequities. They also described facing several work-related stressors, including witnessing discrimination against clients, experiencing discrimination in medical environments, and struggling with financial instability. To mitigate these stressors and job-related challenges, interviewees reported they relied on doula peer support and reconnected with their motivations for the work. CONCLUSIONS: Community-based doulas provide essential services and expertise which address inequities and systemic gaps in perinatal care. However, as they work to improve perinatal health, doulas themselves are providing equity work amidst an inequitable system and with insufficient political or financial support. Increased compensation and systemic support which acknowledges the breadth of services provided is needed to strengthen and sustain this critical part of the perinatal workforce.

Addressing Systemic Racism in Birth Doula Services to Reduce Health Inequities in the United States.

Purpose: Birth doulas support pregnant people during the perinatal period. Evidence of doulas' positive impacts on pregnancy and birth outcomes, particularly among underserved populations, supports expanding access. However, health workforce-related barriers challenge the development of robust doula services in the United States. This study examined the various approaches organizations have taken to train, recruit, and employ doulas as well as their perspectives on what system-level changes are needed to redress health inequities in underserved communities and expand access to birth doula services. Methods: In addition to literature and policy reviews, we conducted 16 semistructured interviews from March to August 2020 with key informants from organizations involved in training, certifying, advocating for, and employing doulas, and informants involved in state policy making. We analyzed data using qualitative analysis software to identify cross-cutting themes. Results: The landscape of organizations involved in doula training and certification is diverse. In discussing their training and curriculum, interviewees from large organizations and community-based organizations (CBOs) stressed the importance of incorporating a focus on structural racism in maternal health into training curricula. CBOs specifically offered three areas of systems-level change that can help equitably grow doula services: the importance of addressing structural racism, changing the balance of power in decision making and policy making, and a cautious approach to Medicaid reimbursement. Conclusion: This study provides evidence of how doula organizations move the field toward better serving the specific needs of underserved populations. It recognizes the expertise of CBOs in developing policy to expand doula services to communities in need. The information from this study highlights the complexities of facilitating consistency across doula training and certification requirements and implementing a sustainable funding mechanism while also meeting communities' unique needs.

Lack of Consistent Investment in Federal Insurance Navigator Program Undermines Navigators' Equity Work in Vulnerable Communities.

CONTEXT: Navigators in the federal Insurance Navigator Program ("Navigator Program"), who are employed by organizations in states with Federally Facilitated Marketplaces, provide enrollment assistance, outreach, and education to individuals who are eligible for health insurance coverage. Such work is central to public health efforts to address inequities but continues to be poorly understood and undervalued. More information is needed to understand the components of navigators' equity work and how decreases in program funding have affected their service provision. OBJECTIVE: To examine navigators' labor at a granular level to better understand and highlight the equity work they do, the training and skills required for this work, and the Navigator Program-based challenges they face. DESIGN: This was a descriptive qualitative study using data collected from interviews conducted in February-May 2021. We used a thematic analysis approach to develop major themes and subthemes. SETTING: This was a national study. PARTICIPANTS: We conducted 18 semistructured interviews with 24 directors, navigators, and other professionals at organizations funded as federally certified Navigator Programs. MAIN OUTCOME MEASURES: Components of navigators' work; required training and skills; and challenges faced in accomplishing the work. RESULTS: We identified 3 major themes: (1) navigators' health equity work goes beyond required responsibilities; (2) equity skills are built on the job; and (3) financial instabilities challenge navigators' health equity work. CONCLUSION: Navigators bring specialized and essential skills and services to underserved communities. They are trusted sources of information, advocates, resource connectors, and, most significantly, health equity workers. However, the Navigator Program fails to support navigators' work and the communities they serve in the long term. To facilitate organizations' capacities to train, keep, and support navigators in this health equity work and to guarantee long-term enrollment assistance for underserved communities, efforts to stabilize funding are needed.

Health Workforce Challenges Impact the Development of Robust Doula Services for Underserved and Marginalized Populations in the United States.

Evidence of doulas' positive impacts on maternal health outcomes, particularly among underserved populations, supports expanding access. Health workforce-related barriers challenge the development of robust doula services in the United States. We investigated organizations' barriers regarding training, recruitment, and employment of doulas. We conducted literature and policy reviews and 16 semi-structured interviews with key informants who contribute to state policymaking and from organizations involved in training, certifying, advocating for, and employing doulas. Our study shows barriers to more robust doula services, including varying roles and practices, prohibitive costs of training and certification, and insufficient funding. This study underscores the importance of doulas in providing support to clients from underserved populations. Health workforce-related challenges remain, especially for community-based organizations seeking to serve underserved communities.