GUEST EDITORIALSocial Work and Implementation of theAffordable Care Ac.docx

GUEST EDITORIAL
Social Work and Implementation of the Affordable 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 Affordable Care Act)
(P.L. 111-148) will generate
sweeping changes in the financing, organization, and accessibility of health and social services in
the United States. The expansion of Medicaid and the establishment of state health insurance
exchanges (HIEs) will vastly expand insurance access in the United States, with an estimated 30
million Ameri- cans gaining coverage (Banthin et al., 2012). The emphasis on integrated models
of care, including patient-centered medical homes and accountable care organizations, introduces
new opportunities to improve care coordination, reduce unnecessary service use, and make
health care more cost- effective. Realizing these changes relies on the work of many health care
professions. In this editorial, we make a case for how the social work profession can forge a
leadership role in implementing this historic legislation.
SOCIALWORK EXPERTISE AND THE ACA Because the ACA is so bold and ambitious, it is
important to consider how the unique skills and knowledge bases of social work and other health
care professions align with its objectives and goals. An integrated approach is needed to
maximize the ACAâ€™s potential to improve the health of the population.
Four central qualities of the social work profession make it uniquely suited to advance a
number of the objectives and goals of the ACA. First, social work situates individuals in the
social contexts in which they live. Social workers understand that individuals are part of social
networks, neighbor- hoods, and communities that influence their health choices and participation
in health care. Under- standing these social relationships provides us with
insight into health behaviors and health outcomes that is necessary to achieve population health
goals.
Social workers likewise understand the relation- ship between health, education, employment,
and other systems that form the nexus from which resources can be drawn to protect, maintain,
and restore health. Social workers are familiar with the complex and overlapping systems that
must be negotiated to ensure that the social, psychological, and economic needs of individuals
and groups are addressed in a way that underscores optimal health. For instance, social workers
know how to ensure that patients have what they need from multiple systems upon discharge,
that discharge instructions are understood, and that resources are in place to ensure that those
instructions can be followed. This knowledge is essential for avoiding unnecessary
readmissionsâ€”events subject to financial penalties under the ACA.
In a related sense, social work is guided by an evidence base that is informed by rigorous
research within communities and collective wisdom gleaned from over a century of social work
practice. Of importance is social workersâ€™ research to understand how mental health and

physical health interact to enhance or impede functioning and patientsâ€™ participation in health
care treatment. Social workers devise plans based on knowledge of how the two interact and can
help to ensure that the communication occurs that underlies optimal, sustained functioning and
wellness. Evidence- based social work practice begins where individuals and groups are, in a
way that is sensitive to cultural beliefs and health literacy. This orientation helps to ensure that
recommendations for disease prevention and care management are understood and that patients
and families are able to follow instructions when individuals become ill.
doi: 10.1093/hsw/hlt002 Â© 2013 National Association of Social Workers 67
It is important to consider one additional quality of social work, not because it is directed at those
who will be covered by the ACA, but because it considers those who will not be covered.
Approxi- mately 29 million Americans will still lack health insurance after the ACA is fully
instituted (Banthin et al., 2012). Social workers historically have tar- geted their services to such
disenfranchised groups, including those who do not have a stable place in society, may lack
housing and other basic services, and have no or irregular contact with the health system.
Through the professionâ€™s ability to partner with communities in research, social workers will
be able to work with disenfranchised groups who will be left uncovered in the postâ€“health
reform era because of resident status, unwillingness to take part in the system, inability to pay, or
state choices. The profession can help to promote wellness among these groups who will not be
covered by the ACA and might otherwise be ignored.
ACAOPPORTUNITIES FOR SOCIALWORKERS We describe three opportunities presented
by the ACA that we believe have special import for the social work profession: patient
navigation, care coordination, and behavioral health treatment. Although the ACA provides a
wide range of opportunities for social workers, we have high- lighted these particular
opportunities in light of their fit with the knowledge and skills of social workers and their
potential to improve health outcomes.
Patient Navigation The ACAâ€™s success depends largely on enrolling all eligible people into
plans. Toward this end, the ACA will require a single, streamlined application for Medicaid, the
Childrenâ€™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, there
will be someâ€”particularly vulnerable and under- served populationsâ€”who will require more
help. Indeed, previous research documents low Medicaid take-up rates (Sommers et al., 2012),
difficulties encountered by plan enrollees in Massachusettsâ€™s exchange (Sinaiko, Ross-
Degnan, Soumerai, Lieu, & Galbraith, 2013) and disenfranchisement of adults eligible 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 â€œnaviga- torâ€• program to help consumers enroll in
health insurance. States are required to establish navigator programs through their health benefit
exchanges, a marketplace where consumers purchase insurance. The ACA spells out a variety of
navigator duties that could be ably carried out by social workers: conducting public education

activities to raise awareness about qualified health plans; distributing fair and impartial
information about plan enrollment and the options for premium assistance and cost-sharing
reductions; assisting consumers in selecting plans; providing referrals to consumer assistance
programs; and providing information that is culturally and linguistically accessible. This
opportunity may have slipped below the radar because it falls under the broad heading of
â€œcon- sumer assistance,â€• but a closer look suggests that it aligns strongly with social work
practice.
Social workersâ€™ expertise makes them ideally suited to carry out these navigator duties. By
law, the navigator programs must reach the uninsured and underinsuredâ€”the very populations
that social workers regularly serve. Social workers also are prepared to provide services that are
both linguistically and culturally appropriate. They routinely work with clients who have low
health literacy and are accustomed to devising effective communication strategies that
minimize the barriers caused 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
lay claim to an enterprise that has been touted as â€œmaking or breakingâ€• the experience
people have in the new health care marketplace (Scott, 2012). The ACA provides general
guidance on the roles and responsibilities of navigator programs, but states have considerable
flexibility in their design. States are just starting to establish HIEs (National Conference of State
Legislators, 2013), and only a few have written navigator plans. Both social work researchers
and advocates must become well acquainted with the navigator provisions so that they can clear
a path for social workers to become navigators. This can be achieved by providing input about
navigator standards, educational requirements, and the scope of navigator duties to
68 Health & Social Work Volume 38, Number 2 May 2013
the exchangesâ€™ advisory boards and the federal Center for Consumer Information and
Insurance Oversight.
Care Coordination The ACA includes two major provisions designed to enhance care
coordination and improve integration of primary care and behavioral health services. First, it
establishes a new Medicaid option to establish patient-centered medical homes (PCMHs) for
enrollees with complex health care needs. The PCMH is an enhanced model of primary care that
provides accessible, comprehensive, ongoing, and coordinated patient-centered care that address
the needs of the whole person (Patient-Centered Pri- mary Care Collaborative, 2013). The
PCMH aims to achieve these ends by organizing physician-led provider teams that provide
continuous and coordinated care, emphasize prevention and effective management of chronic
illness, and strive for improved access and communication. The ACA is expected to greatly
accelerate the proliferation of PCMHs by providing up to two years of enhanced matching rates
for the services they provide (Kaiser Family Foundation, 2011).
The ACA also establishes accountable care organizations (ACOs), defined as organizations of
health care providers that are accountable for the quality, cost, and overall care of Medicare
beneficiaries. The ACO model is less structured than the PCMH, encouraging providers to

develop creative approaches to providing more cost-effective, quality care. ACOs that meet
specified quality perfor- mance standards will be eligible to receive a percentage 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 ACOs must achieve high-quality ratings to earn bonus
payments: patient and caregiver experience, care coordination, safety, preventive health, and
health of at-risk populations and frail older adults.
Social workers are particularly well equipped to assist in the design and implementation of
coordinated care models. They receive in-depth training in identifying and addressing social
determinants of health critical to achieving long-term health and well-being and to do so within
the social and environmental contexts in which patients are embedded. Social workers have
specialized
knowledge of community and social systems and training in case management that is sensitive to
cultural beliefs and health literacy. Moreover, research indicates that such models are
particularly effective in meeting the needs of what are known as â€œhigh utilizersâ€• of health
care and include individuals with complex health needs, such as co-occurring physical and
behavioral health disorders (see Allen, 2012; Bachman, 2011;Golden, 2011).
Although there is no question that the profession has much to contribute to the PCMHs and
ACOs, the extent to which social workers will engage in these activities will depend on the ser-
vices social workers can be reimbursed to provide. CMS encourages states to include social
workers in intraprofessional health care teams that will staff PCMHs, but each state Medicaid
agency will ulti- mately decide whether to do so. Consequently, there is a need for social work
researchers and advocates to work together at the state level to advocate for the inclusion of
social workers as required PCMH professionals. Social work participation in ACOs may be
more of an uphill battle. CMSâ€™s final rule on ACOsâ€”issued in late 2011â€”does not include
social workers as â€œACO professionals,â€• a list that includes only physicians, physician
assistants, nurse practitioners, and nurse specialists. Continued advocacy is needed to convince
state and federal Medicaid officials to include social workers as reimbursable ACO pro-
fessionals.
Behavioral Health Treatment Insurance coverage provided through the newly established HIEs
and Medicaid benchmark plans will be subject to the Mental Health Parity and Addiction Equity
Act (MHPAEA). When passed in 2008, MHPAEA requirements were restricted to health
insurance plans for large employers (those with more than 50 employees) that already covered
behavioral health services, requiring them to insure that their limits on these services were no
more restrictive than that of other health services offered by the plan. The ACA extends the
MHPAEA by requiring Medicaid benchmark plans and state HIE plans to cover behavioral
health services in compli- ance with parity guidelines established by the MHPAEA.
Consequently, about 30 million people will gain coverage for behavioral health services
through the ACA (Buck, 2011).
Andrews et al. / Social Work and Implementation of the Affordable Care Act 69

These coverage expansions are expected to trig- ger significant growth in demand for behavioral
health services, and, consequently, a major expansion of the behavioral health workforce will
be needed. Medicaid enrollment alone is estimated to increase by 82 percent among states
expected to participate in the expansion (Banthin et al., 2012). This is especially important
because those newly eligible for coverage through the Medicaid expansion exhibit almost every
behavioral health disorder at higher rates than the general population (Garfield, Lave, &
Donohue, 2010). In light of these changes, the Bureau of Labor Statistics (2012) projects that
employment opportunities for behavioral health counselors and social workers will increase by
roughly 30 percent.
Social workers have a long history in behavioral health and are already the predominant
professionals providing these services (Bureau of Labor Statis- tics, 2012). Yet to expand this
role, the profession must be responsive to shifts in decision-making power resulting from ACA-
driven insurance expansions. Medicaid is poised to become the primary payer of behavioral
health services, and in states that take the expansion option, Medicaid agencies will become the
single most powerful decision makers in behavioral health. Concomi- tantly, state agencies that
have administered the majority of public behavioral health funding through state and federal
block grants are likely to decline in importance.
Although the ACA requires all states to include behavioral health services in their essential
benefits packages, state Medicaid agencies and HIEs will have broad discretion in determining
which behavioral health services will be covered and who can be reimbursed for providing them
(Buck, 2011). These decisions will greatly influence the size and scope of the behavioral health
workforce expansion resulting from the ACA and the relative role of social workers. The
majority of these decisions have yet to be made and present a narrow but significant window of
opportunity for the profession. It will be critical for social work advocates and researchers to
work together to cultivate strong ties to state Medicaid agencies and newly established HIEs and
to develop an in-depth knowledge of key policy decisions that will influence social workers,
including such issues as reim- bursement, covered services, and limitations on
utilization. These tasks will need to be carried out on a state-by-state basis.
AN AGENDA FOR SOCIALWORK RESEARCH The profession has much to contribute to the
implementation of the ACA. Social workersâ€™ understanding of patientsâ€™ environmental
context, knowledge of social systems, and training in evidence-based practice all make social
workers uniquely equipped to serve as patient navigators, care coordinators, and behavioral
health counselors par excellence. Yet, to do so, the profession must first develop a multilevel
advocacy strategy focused on influencing national, state, and local decisions regarding the
implementation of key ACA provisions. In particular, it will be critical for social work
advocates and researchers to demonstrate the effectiveness of social work practice to key
decision makers, especially within state Medicaid agencies and HIEs. If the profession fails to
communicate why social workers are best suited to advance the ACAâ€™s aims to improve
enrollment, care coordination, and behavioral health services, these roles are likely to be filled
by other professionals and para- professionals.

Social work scholars can assist in these efforts in several ways, including conducting policy
analysis to identify key state-level decision points, research reviews that document social
workersâ€™ effectiveness in carrying out ACA-related activities, and original research relevant
to the ACA that places social workers in a prominent role. Research that details how social
workers can work effectively within intraprofessional health care teams and settings will be
particularly crucial. We believe these aims can be advanced most effectively by facilitating the
start of a practice-based research network (Nutting, Beasley, & Werner, 1999; Westfall, Mold, &
Fagnan, 2007). Widely used by other health professionals, practice- based research networks
bring together practitioners and researchers for the purpose of advancing research. Led by the
Society for Social Work and Research and other key stakeholders, including NASW 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 vision for
enhancing the professionâ€™s role in the ACA over time (McMillen, Lenze, Hawley, &
Osborne, 2009).
70 Health & Social Work Volume 38, Number 2 May 2013
We believe that the ACA needs social workers to achieve its ambitious agenda. The time has
come for our profession to develop a well- coordinated strategy to communicate the evidence
demonstrating social workersâ€™ effectiveness in advancing ACA aims and build the
infrastructure for further research on how they can contribute to implementation of this historical
legislation.
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Christina M. Andrews, PhD, is assistant professor, College of Social Work, University of South
Carolina. Julie S. Darnell, PhD, is assistant professor, School of Public Health, University of
Illinois at Chicago. Timothy D. McBride, PhD, is professor and Sarah Gehlert, PhD, is E.
Desmond Lee Professor of Racial and Ethnic Diversity, George Warren Brown School of Social
Work, Washington University in St. Louis. The authors would like to thank the Society for
Social Work Research for its sponsorship of a Briefing on the Hill focusing on this topic on
December 13, 2012. Address correspondence to Christina M. Andrews, College of Social Work,
University of South Carolina, 323 DeSaussure Hall, Columbia, SC 29208; e-mail:
[emailÂ protected]
Advance Access Publication May 3, 2013
Andrews et al. / Social Work and Implementation of the Affordable Care Act 71
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