Navigators and Assisters: Two Case Management Roles for Social Workers in the Affordable Care Act

Social workers can help ensure successful implementation of the Patient Protection and Affordable Care Act (PPACA, hereafter ACA) (P.L. 111-148). This became clear to me as I attempted to find my way through the 2,400-page-long ACA, looking for the "low-hanging fruit": places where there was evidence that social work would be effective and there was a natural fit because of social workers' specialized training and professional code of ethics. There are, in fact, many such places in the ACA, particularly where one encounters the terms "case management," "care coordination," and "care management"--terms that occur 39 times. With each such mention is an opportunity for social work to meet the ACA's goal of reducing costs by improving health through a set of activities that the social work profession calls "social work case management." The National Association of Social Workers (1992) defines social work case management as "assess[ing] the needs of the client ... and arrang[ing], coordinat[ing], monitor[ing], evaluat[ing], and advocat[ing] for services" to address the client's needs; Two characteristics set social work case management apart from other kinds of case management. First, social work has a dual focus on the person and the environment. Social work's biopsychosocial focus means that social workers are concerned with the interaction between the body, the mind, and the social system. Second, social workers carry out case management by using a strengths-based approach, which focuses on strengths rather than deficits and views the community as an "oasis of resources" (Etzel-Wise & Howley, 2006). Because of its potential to improve health outcomes and reduce costs, case management has entered a renaissance period. Indeed, we have witnessed a proliferation of various kinds of case management programs in recent years, most notably patient navigator programs (Dohan & Schrag, 2005; Freeman, Muth, & Kerner, 1995; Freund, 2011; Vargas, Ryan, Jackson, Rodriguez, & Freeman, 2008; Wells et al., 2008). The ACA invigorates this trend. In this Viewpoint, I focus on how social workers can positively impact implementation of the ACA by doing what they do well--social work case management--through two new roles envisioned by the ACA: navigators and assisters. These roles are important because they can affect the three major milestones of the ACA: people obtaining coverage for the first time through Medicaid or the exchanges; people making efficient use of their insurance benefits; and, finally, bending the cost curve, a product of achieving the first two milestones. NAVIGATORS The success of the ACA will be measured initially on the basis of its performance on the first milestone: enrolling currently uninsured people in eligible health insurance programs. Previous research suggests that this is not an easy task. A recent report from the Office of the Assistant Secretary for Planning and Evaluation summarizes the evidence of "take-up rates" in Medicaid among adults (Sommers et al., 2012). The take-up rate refers to the percentage of eligible people who actually end up enrolled. Overall, studies show that take-up rotes range from 32 percent to 81 percent, but if one excludes tile studies that are known to produce upwardly biased estimates, the take-up rotes are much mole modest: between 32 percent and 52 percent. These take-up estimates are often much lower than the published take-up projections for the ACA. The take-away message from the take-up literature is that states will face a formidable challenge in enrolling eligible populations. A recent report by the Kaiser Commission on Medicaid and the Uninsured about the experiences of uninsured adults who could gain Medicaid coverage underscores the enrollment challenge before us (Perry, Mulligan, Artiga, & Stephens, 2012). In focus groups conducted across the country, participants were largely unaware of the new law. …