Social Work and Implementation of theAffordable Care Act
Christina M. Andrews, Julie S. Darnell, Timothy D. McBride, and Sarah Gehlert
The Affordable Care Act (ACA) (full title:The Patient Protection and AffordableCare Act) (P.L. 111-148) will generate
sweeping changes in the financing, organization,and accessibility of health and social services in theUnited States. The expansion of Medicaid and theestablishment of state health insurance exchanges(HIEs) will vastly expand insurance access in theUnited States, with an estimated 30 million Ameri-cans gaining coverage (Banthin et al., 2012). Theemphasis on integrated models of care, includingpatient-centered medical homes and accountablecare organizations, introduces new opportunitiesto improve care coordination, reduce unnecessaryservice use, and make health care more cost-effective. Realizing these changes relies on thework of many health care professions. In this edi-torial, we make a case for how the social work pro-fession can forge a leadership role in implementingthis historic legislation.
SOCIALWORK EXPERTISE AND THE ACABecause the ACA is so bold and ambitious, it isimportant to consider how the unique skills andknowledge bases of social work and other healthcare professions align with its objectives and goals.An integrated approach is needed to maximize theACA’s potential to improve the health of the pop-ulation.
Four central qualities of the social work profes-sion make it uniquely suited to advance a numberof the objectives and goals of the ACA. First, socialwork situates individuals in the social contexts inwhich they live. Social workers understand thatindividuals are part of social networks, neighbor-hoods, and communities that influence their healthchoices and participation in health care. Under-standing these social relationships provides us with
insight into health behaviors and health outcomesthat is necessary to achieve population health goals.
Social workers likewise understand the relation-ship between health, education, employment, andother systems that form the nexus from whichresources can be drawn to protect, maintain, andrestore health. Social workers are familiar with thecomplex and overlapping systems that must benegotiated to ensure that the social, psychological,and economic needs of individuals and groups areaddressed in a way that underscores optimal health.For instance, social workers know how to ensurethat patients have what they need from multiplesystems upon discharge, that discharge instructionsare understood, and that resources are in place toensure that those instructions can be followed.This knowledge is essential for avoiding unneces-sary readmissions—events subject to financialpenalties under the ACA.
In a related sense, social work is guided by anevidence base that is informed by rigorous researchwithin communities and collective wisdomgleaned from over a century of social work prac-tice. Of importance is social workers’ research tounderstand how mental health and physical healthinteract to enhance or impede functioning andpatients’ participation in health care treatment.Social workers devise plans based on knowledge ofhow the two interact and can help to ensure thatthe communication occurs that underlies optimal,sustained functioning and wellness. Evidence-based social work practice begins where individualsand groups are, in a way that is sensitive to culturalbeliefs and health literacy. This orientation helps toensure that recommendations for disease preven-tion and care management are understood and thatpatients and families are able to follow instructionswhen individuals become ill.
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It is important to consider one additional qualityof social work, not because it is directed at thosewho will be covered by the ACA, but because itconsiders those who will not be covered. Approxi-mately 29 million Americans will still lack healthinsurance after the ACA is fully instituted (Banthinet al., 2012). Social workers historically have tar-geted their services to such disenfranchised groups,including those who do not have a stable place insociety, may lack housing and other basic services,and have no or irregular contact with the healthsystem. Through the profession’s ability to partnerwith communities in research, social workers willbe able to work with disenfranchised groups whowill be left uncovered in the post–health reformera because of resident status, unwillingness to takepart in the system, inability to pay, or state choices.The profession can help to promote wellness amongthese groups who will not be covered by the ACAand might otherwise be ignored.
ACAOPPORTUNITIES FOR SOCIALWORKERSWe describe three opportunities presented by theACA that we believe have special import for thesocial work profession: patient navigation, carecoordination, and behavioral health treatment.Although the ACA provides a wide range ofopportunities for social workers, we have high-lighted these particular opportunities in light oftheir fit with the knowledge and skills of socialworkers and their potential to improve healthoutcomes.
Patient NavigationThe ACA’s success depends largely on enrolling alleligible people into plans. Toward this end, theACA will require a single, streamlined applicationfor Medicaid, the Children’s Health Insurance Pro-gram, and HIE premium credits. Although a simple,user-friendly application form is likely to be suffi-cient to facilitate enrollment for most people, therewill be some—particularly vulnerable and under-served populations—who will require more help.Indeed, previous research documents low Medicaidtake-up rates (Sommers et al., 2012), difficultiesencountered by plan enrollees in Massachusetts’sexchange (Sinaiko, Ross-Degnan, Soumerai, Lieu,& Galbraith, 2013) and disenfranchisement of adultseligible for Medicaid (Perry, Mulligan, Artiga, &Stephens, 2012), and HIEs (Trish, Damico,Claxton, Levitt, & Garfield, 2011). Collectively,
they underscore the formidable enrollment chal-lenge ahead.
In response, the ACA has created a new “naviga-tor” program to help consumers enroll in healthinsurance. States are required to establish navigatorprograms through their health benefit exchanges, amarketplace where consumers purchase insurance.The ACA spells out a variety of navigator dutiesthat could be ably carried out by social workers:conducting public education activities to raiseawareness about qualified health plans; distributingfair and impartial information about plan enroll-ment and the options for premium assistance andcost-sharing reductions; assisting consumers inselecting plans; providing referrals to consumerassistance programs; and providing informationthat is culturally and linguistically accessible. Thisopportunity may have slipped below the radarbecause it falls under the broad heading of “con-sumer assistance,” but a closer look suggests that italigns strongly with social work practice.
Social workers’ expertise makes them ideallysuited to carry out these navigator duties. By law,the navigator programs must reach the uninsuredand underinsured—the very populations that socialworkers regularly serve. Social workers also areprepared to provide services that are both linguisti-cally and culturally appropriate. They routinelywork with clients who have low health literacyand are accustomed to devising effective commu-nication strategies that minimize the barrierscaused by low literacy (Boulware et al., 2013;Hendren et al., 2010; Leach & Segal, 2011;Nonzee et al., 2012).
The navigation landscape is still largely unchar-ted, offering social workers an opportunity to layclaim to an enterprise that has been touted as“making or breaking” the experience people havein the new health care marketplace (Scott, 2012).The ACA provides general guidance on the rolesand responsibilities of navigator programs, butstates have considerable flexibility in their design.States are just starting to establish HIEs (NationalConference of State Legislators, 2013), and onlya few have written navigator plans. Both socialwork researchers and advocates must become wellacquainted with the navigator provisions so thatthey can clear a path for social workers to becomenavigators. This can be achieved by providinginput about navigator standards, educationalrequirements, and the scope of navigator duties to
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the exchanges’ advisory boards and the federalCenter for Consumer Information and InsuranceOversight.
Care CoordinationThe ACA includes two major provisions designedto enhance care coordination and improve integra-tion of primary care and behavioral health services.First, it establishes a new Medicaid option to estab-lish patient-centered medical homes (PCMHs) forenrollees with complex health care needs. ThePCMH is an enhanced model of primary care thatprovides accessible, comprehensive, ongoing, andcoordinated patient-centered care that address theneeds of the whole person (Patient-Centered Pri-mary Care Collaborative, 2013). The PCMH aimsto achieve these ends by organizing physician-ledprovider teams that provide continuous and coor-dinated care, emphasize prevention and effectivemanagement of chronic illness, and strive forimproved access and communication. The ACA isexpected to greatly accelerate the proliferation ofPCMHs by providing up to two years of enhancedmatching rates for the services they provide (KaiserFamily Foundation, 2011).
The ACA also establishes accountable care organiza-tions (ACOs), defined as organizations of healthcare providers that are accountable for the quality,cost, and overall care of Medicare beneficiaries.The ACO model is less structured than thePCMH, encouraging providers to develop creativeapproaches to providing more cost-effective, qual-ity care. ACOs that meet specified quality perfor-mance standards will be eligible to receive apercentage of savings incurred if the per benefi-ciary expenses for care are sufficiently low com-pared with cost expectations set by the program.The Centers for Medicare and Medicaid Services(CMS) has established five domains in which ACOsmust achieve high-quality ratings to earn bonuspayments: patient and caregiver experience, carecoordination, safety, preventive health, and healthof at-risk populations and frail older adults.
Social workers are particularly well equipped toassist in the design and implementation of coordi-nated care models. They receive in-depth trainingin identifying and addressing social determinantsof health critical to achieving long-term healthand well-being and to do so within the social andenvironmental contexts in which patients areembedded. Social workers have specialized
knowledge of community and social systems andtraining in case management that is sensitive to cul-tural beliefs and health literacy. Moreover, researchindicates that such models are particularly effectivein meeting the needs of what are known as “highutilizers” of health care and include individualswith complex health needs, such as co-occurringphysical and behavioral health disorders (see Allen,2012; Bachman, 2011;Golden, 2011).
Although there is no question that the profes-sion has much to contribute to the PCMHs andACOs, the extent to which social workers willengage in these activities will depend on the ser-vices social workers can be reimbursed to provide.CMS encourages states to include social workers inintraprofessional health care teams that will staffPCMHs, but each state Medicaid agency will ulti-mately decide whether to do so. Consequently,there is a need for social work researchers andadvocates to work together at the state level toadvocate for the inclusion of social workers asrequired PCMH professionals. Social work partici-pation in ACOs may be more of an uphillbattle. CMS’s final rule on ACOs—issued in late2011—does not include social workers as “ACOprofessionals,” a list that includes only physicians,physician assistants, nurse practitioners, and nursespecialists. Continued advocacy is needed toconvince state and federal Medicaid officials toinclude social workers as reimbursable ACO pro-fessionals.
Behavioral Health TreatmentInsurance coverage provided through the newlyestablished HIEs and Medicaid benchmark planswill be subject to the Mental Health Parity andAddiction Equity Act (MHPAEA). When passedin 2008, MHPAEA requirements were restrictedto health insurance plans for large employers (thosewith more than 50 employees) that already coveredbehavioral health services, requiring them to insurethat their limits on these services were no morerestrictive than that of other health services offeredby the plan. The ACA extends the MHPAEA byrequiring Medicaid benchmark plans and state HIEplans to cover behavioral health services in compli-ance with parity guidelines established by theMHPAEA. Consequently, about 30 million peo-ple will gain coverage for behavioral health servicesthrough the ACA (Buck, 2011).
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These coverage expansions are expected to trig-ger significant growth in demand for behavioralhealth services, and, consequently, a major expan-sion of the behavioral health workforce will beneeded. Medicaid enrollment alone is estimated toincrease by 82 percent among states expected toparticipate in the expansion (Banthin et al., 2012).This is especially important because those newlyeligible for coverage through the Medicaid expan-sion exhibit almost every behavioral health disor-der at higher rates than the general population(Garfield, Lave, & Donohue, 2010). In light ofthese changes, the Bureau of Labor Statistics (2012)projects that employment opportunities for behav-ioral health counselors and social workers willincrease by roughly 30 percent.
Social workers have a long history in behavioralhealth and are already the predominant profession-als providing these services (Bureau of Labor Statis-tics, 2012). Yet to expand this role, the professionmust be responsive to shifts in decision-makingpower resulting from ACA-driven insuranceexpansions. Medicaid is poised to become the pri-mary payer of behavioral health services, and instates that take the expansion option, Medicaidagencies will become the single most powerfuldecision makers in behavioral health. Concomi-tantly, state agencies that have administered themajority of public behavioral health fundingthrough state and federal block grants are likely todecline in importance.
Although the ACA requires all states to includebehavioral health services in their essential benefitspackages, state Medicaid agencies and HIEs willhave broad discretion in determining whichbehavioral health services will be covered and whocan be reimbursed for providing them (Buck,2011). These decisions will greatly influence thesize and scope of the behavioral health workforceexpansion resulting from the ACA and the relativerole of social workers. The majority of these deci-sions have yet to be made and present a narrowbut significant window of opportunity for the pro-fession. It will be critical for social work advocatesand researchers to work together to cultivatestrong ties to state Medicaid agencies and newlyestablished HIEs and to develop an in-depthknowledge of key policy decisions that will influ-ence social workers, including such issues as reim-bursement, covered services, and limitations on
utilization. These tasks will need to be carried outon a state-by-state basis.
AN AGENDA FOR SOCIALWORK RESEARCHThe profession has much to contribute to theimplementation of the ACA. Social workers’understanding of patients’ environmental context,knowledge of social systems, and training inevidence-based practice all make social workersuniquely equipped to serve as patient navigators,care coordinators, and behavioral health counselorspar excellence. Yet, to do so, the profession mustfirst develop a multilevel advocacy strategy focusedon influencing national, state, and local decisionsregarding the implementation of key ACA provi-sions. In particular, it will be critical for socialwork advocates and researchers to demonstrate theeffectiveness of social work practice to key decisionmakers, especially within state Medicaid agenciesand HIEs. If the profession fails to communicatewhy social workers are best suited to advance theACA’s aims to improve enrollment, care coordina-tion, and behavioral health services, these roles arelikely to be filled by other professionals and para-professionals.
Social work scholars can assist in these efforts inseveral ways, including conducting policy analysis toidentify key state-level decision points, researchreviews that document social workers’ effectivenessin carrying out ACA-related activities, and originalresearch relevant to the ACA that places socialworkers in a prominent role. Research that detailshow social workers can work effectively withinintraprofessional health care teams and settings willbe particularly crucial. We believe these aims can beadvanced most effectively by facilitating the start of apractice-based research network (Nutting, Beasley,& Werner, 1999; Westfall, Mold, & Fagnan, 2007).Widely used by other health professionals, practice-based research networks bring together practitionersand researchers for the purpose of advancingresearch. Led by the Society for Social Work andResearch and other key stakeholders, includingNASW and the Council on Social Work Educa-tion, such a network could serve as a national coor-dinating body through which to share resources,coordinate cross-state efforts, and develop a visionfor enhancing the profession’s role in the ACA overtime (McMillen, Lenze, Hawley, & Osborne,2009).
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We believe that the ACA needs social workersto achieve its ambitious agenda. The time hascome for our profession to develop a well-coordinated strategy to communicate the evidencedemonstrating social workers’ effectiveness inadvancing ACA aims and build the infrastructurefor further research on how they can contribute toimplementation of this historical legislation.
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Christina M. Andrews, PhD, is assistant professor, College ofSocial Work, University of South Carolina. Julie S. Darnell,PhD, is assistant professor, School of Public Health, Universityof Illinois at Chicago. Timothy D. McBride, PhD, is profes-sor and Sarah Gehlert, PhD, is E. Desmond Lee Professor ofRacial and Ethnic Diversity, George Warren Brown School ofSocial Work, Washington University in St. Louis. The authorswould like to thank the Society for Social Work Research for itssponsorship of a Briefing on the Hill focusing on this topic onDecember 13, 2012. Address correspondence to ChristinaM. Andrews, College of Social Work, University of SouthCarolina, 323 DeSaussure Hall, Columbia, SC 29208;e-mail: firstname.lastname@example.org.
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