The Medicaid program has gone through several amendments and expansions since its inception in the 1960s, most notably with the Affordable Care Act (2010). However, its purpose remains es

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 edi- torial, we make a case for how the social work pro- fession 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 ACA’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 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 unneces- sary readmissions—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 prac- tice. Of importance is social workers’ research to understand how mental health and physical health interact to enhance or impede functioning and patients’ 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 preven- tion and care management are understood and that patients and families are able to follow instructions when individuals become ill.

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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 profession’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 post–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 ACA’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 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, there will be some—particularly vulnerable and under- served populations—who will require more help. Indeed, previous research documents low Medicaid take-up rates (Sommers et al., 2012), difficulties encountered by plan enrollees in Massachusetts’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 “naviga- tor” 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 enroll- ment 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 “con- sumer assistance,” but a closer look suggests that it aligns strongly with social work practice.

Social workers’ expertise makes them ideally suited to carry out these navigator duties. By law, the navigator programs must reach the uninsured and underinsured—the very populations that social workers regularly serve. Social workers also are prepared to provide services that are both linguisti- cally and culturally appropriate. They routinely work with clients who have low health literacy and are accustomed to devising effective commu- nication 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 “making or breaking” 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

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the exchanges’ 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 integra- tion of primary care and behavioral health services. First, it establishes a new Medicaid option to estab- lish 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 coor- dinated 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 organiza- tions (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, qual- ity 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 coordi- nated 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 cul- tural beliefs and health literacy. Moreover, research indicates that such models are particularly effective in meeting the needs of what are known as “high utilizers” 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 profes- sion 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 partici- pation in ACOs may be more of an uphill battle. CMS’s final rule on ACOs—issued in late 2011—does not include social workers as “ACO professionals,” 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 peo- ple will gain coverage for behavioral health services through the ACA (Buck, 2011).

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These coverage expansions are expected to trig- ger significant growth in demand for behavioral health services, and, consequently, a major expan- sion 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 expan- sion exhibit almost every behavioral health disor- der 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 behav- ioral 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 profession- als 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 pri- mary 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 deci- sions have yet to be made and present a narrow but significant window of opportunity for the pro- fession. 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 influ- ence 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 workers’ understanding of patients’ 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 provi- sions. 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 ACA’s aims to improve enrollment, care coordina- tion, 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 workers’ 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 profession’s role in the ACA over time (McMillen, Lenze, Hawley, & Osborne, 2009).

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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 workers’ 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 profes- sor 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: [email protected]

Advance Access Publication May 3, 2013

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