MEDICAID - Assignment Essays

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 essentially the same: to assist people with low income in gaining access to necessary health services. Because the federal program is administered by each state, Medicaid looks different across the country. What are the requirements and procedures for your state?

In this Discussion, you research your own state’s Medicaid policy and consider its effect on a certain population. Make sure to access the Medicaid.gov website, in the Learning Resources, to conduct your research.

Identify a population that is eligible to receive Medicaid benefits, and describe why they are eligible.
Explain your state’s eligibility requirements for this population.
Recommend and defend one change to the Medicaid policy in your state that would benefit the population you presented.

reference

Stern, M.J., & Axinn, J. (2018). Social welfare: A history of American response to need (9th ed.). Pearson Education.
Chapter 7, “War and Prosperity: 140-1968” (pp. 205-243)
Andrews, C. M., Darnell, J. S., McBride, T. D., & Gehlert, S. (2013). Social work and implementation of the Affordable Care Act Links to an external site.. Health & Social Work, 38(2), 67–71.
Medicaid.gov Links to an external site.. (n.d.). Retrieved December 21, 2016, from https://www.medicaid.gov/index.html

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.

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

68 Health & Social Work Volume 38, Number 2 May 2013

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).

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 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).

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 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: candrews@mailbox.sc.edu.

Advance Access Publication May 3, 2013

Andrews et al. / Social Work and Implementation of the Affordable Care Act 71

http://www.bls.gov/ooh/

http://www.ncsl.org/issues-research/health/state-actions-to-implement-the-health-benefit-exch.aspx

http://www.pcpcc.net/about/medical-home

http://www.governing.com/blogs/view/gov-health-exchange-navigators-still-an-unknown-for-most-states.html

http://aspe.hhs.gov/health/reports/2012/MedicaidTakeup/ib.shtml

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