Angela Baker-Hill knew she needed to sign up for health insurance again when lab results over the summer showed that her kidney disease had progressed slightly.
Baker-Hill had stopped carrying insurance as she battled with other rising costs, including housing, food and transportation. But with her kidney condition worsening and high blood pressure, Baker-Hill realized that having insurance would be cheaper then foregoing it.
"I can't afford to pay out of pocket," Baker-Hill said in an interview. "Last time I came (to the clinic), I didn't have insurance, even the doctor visit ... was like $200 something."
With that in mind, Baker-Hill visited a southeast Raleigh healthcare clinic on a Saturday in early January seeking assistance to sign up for insurance through the Affordable Care Act's Marketplace. Baker-Hill, who works in housekeeping at a local senior facility, has had insurance through the marketplace before.
This year, though, there are a litany of changes to the coverage, including to Biden-era enhanced premium tax credits that brought the cost of healthcare plans down for millions of enrollees. Navigators, who offer free assistance to help people traverse those changes, are facing challenges of their own amid significant federal funding cuts.
Donna Rasmussen, a certified navigator with the N.C. Navigator Consortium, met Baker-Hill inside an exam room. Rasmussen perched behind a small desk while Baker-Hill sat in a chair near wall-mounted exam equipment like a blood pressure cuff.
Navigators 'definitely felt a strain'
Rasmussen is one of 177 navigators working in North Carolina this year, down from 235 last year. That decline is almost entirely in paid, full-time navigators at the Navigator Consortium or its six partner agencies, a consequence of a 90% cut to federal funding for navigators the Trump Administration enacted in early 2025.
For North Carolina, that meant funding dropped from $7.5 million to $750,000. The Consortium was able to secure about $2.4 million in philanthropic funding ahead of this year's open enrollment period, but navigators statewide have still needed to take on heavier workloads or shift how they operate.
All of that is taking place at the same time that the expiration of the enhanced premium tax credits are causing significant anxiety among people seeking coverage.
"We're simultaneously seeing an increase in appointments from consumers because of all the changes and things that they're hearing in the media, combined with our decreased capacity. So we've definitely felt a strain," Hollis Smith, deputy director of the N.C. Navigator Consortium, said in an interview.
The Navigator Consortium has seen a 22% increase in calls during this year's open enrollment period compared to last year, Smith said.
There are 84 navigators who are on staff at either the consortium or its partner agencies, and they've seen a 33% increase in appointments during this open enrollment period compared to the 149 navigators who were on staff last year.
Ciara Zachary, an assistant professor at UNC-Chapel Hill's Gillings School of Public Health, said navigators play a key role in helping clients ensure that they're eligible for coverage under the Affordable Care Act and then steering through the multitude of options that are often available.
"Navigators are there to spend time with you. It's not just a quick 15-minute phone call. They can spend hours and have multiple appointments with the same client just to make sure that they're making the best choice," Zachary said.
Navigators also do outreach to places like rural communities, places where English isn't necessarily the most common language or churches, efforts that Zachary worried could be rolled back due to the funding cuts.
At Charlotte Legal Advocacy, the Consortium's partner in Mecklenburg County, there are three full-time navigators this year. Last year, the organization had 12 navigators.
That has meant certified navigators are taking five or six appointments per day instead of three or four, said Natalie Marles, the Center's navigator program manager. And everyone worked six days weeks between November 1 and December 15.
Marles also said that the center tried to shorten appointments to an hour long instead of 90 minutes.
"We were doing like an hour appointment so we can see more people. But it's been stressful, it's been frustrating because a lot of people are getting mad because the prices are not what they expected," Marles said.
Karina Barnes has volunteered as a navigator with Charlotte Legal Advocacy over the last two open enrollment periods. Typically, Barnes takes appointments from 9 a.m. to 4 p.m. on Mondays and then does follow-up paperwork on Wednesdays.
This year's open enrollment has been significantly more complicated, Barnes said in an interview, in part because she and other navigators are needing to keep up with changes to the Affordable Care Act, largely enacted in last year's House Resolution 1.
"A lot of these appointments that I've had are way more complicated... if people qualify, how they qualify, is it going to get sent to Medicaid, and then obviously questions about affordability and things like that," Barnes said.
In some cases, Barnes said, she had clients who had started an application only to enter their income in such a way that sent the application over to Medicaid — typically a consequence of entering income earned in a given month instead of estimating annual income.
In those instances, she said, the navigators need to get state health officials to send a letter saying that the person actually qualifies for coverage through the Affordable Care Act in order to start the application again.
"Sometimes they ask the same question three different ways in the same application, so it can be a little unnerving to go through it when you're new to it. ... It's kind of like a Choose-Your-Own Adventure book," Barnes said.
Picking a plan
Baker-Hill quickly ran into one of those roadblocks when she tried to sign up for healthcare, with the Marketplace unable to verify her identity even though she'd had coverage through it several years before.
Rasmussen quickly laid out their options, saying they could try to verify her identity with Experian over the phone, upload her identity documents and wait for them to be verified or just go ahead and apply over the phone.
With just days left in the January open enrollment period, Rasmussen suggested they do everything over the phone and then return to the documents after the plan was secured.
"We can upload a copy of your identity document, but it'll take a few days for them to approve that and since we're running up until the end of the deadline I want to make sure we get you in on time," Rasmussen said.
Experian was also unable to verify Baker-Hill's identify.
"Everything should be in there," Baker-Hill said, turning to her wallet moments later and pulling out her insurance card for the ACA plan she used to have to demonstrate why.
Rasmussen decided the best course of action was to call the Marketplace to sign up. But first they needed to pick an insurance plan.
Baker-Hill provided basic information like her age, income, current ZIP code and whether insurance is available through her employer. (It wasn't.) With that in hand, Rasmussen was able to verify that Baker-Hill is eligible for a $947 monthly tax credit.
As they started to turn to plans, Baker-Hill wanted to know if silver plans are specifically for people who are her age.
Rasmussen explained that it has to do with how much a consumer pays out of pocket, saying, "The silver plans are specifically for people within a certain income range and it gives you kind of extra savings, but it's not related to your age."
They started by looking at the silver plans, but the cheapest one available to Baker-Hill was $217.95 a month.
"That's too much for you?" Rasmussen asked. In response, Baker-Hill's eyes widened before she nodded.
Next, they dropped down to the bronze plans. Quickly, the conversation turned to the same plan that Baker-Hill had previously.
It provided dental and vision coverage in addition to healthcare. It offered generic prescriptions for $3, an important benefit for Baker-Hill. And it cost $57.38 a month with the subsidy, which seemed manageable in her already stretched budget.
After confirming that Baker-Hill's doctors are in-network with that particular plan, Rasmussen and Baker-Hill called the Marketplace. On the other end of the line, a call center employee asked Baker-Hill a slew of questions, which Baker-Hill answered with Rasmussen listening closely to ensure that everything was accurate.
About 23 minutes later, Baker-Hill had successfully enrolled in coverage. She would need to pay the first month's premium and verify her identity, but she'd achieved the hardest part.
In the waiting room afterward, Baker-Hill expressed relief that she'd still be able to afford the prescriptions she needs to take and can visit the doctor.
"I have coverage that I can afford, you see what I'm saying? Now, it might not be the best coverage, but it's something that I can afford and I can feel comfortable that I'm getting some help," Baker-Hill said.
