Affordable Care Act
Implementation:
Opportunities and Challenges
For Social Workers
Stacy Collins, MSW
National Association of Social Workers
Presentation to the New York State
Association of Deans of Schools of Social Work
August 20, 2012
Presentation Agenda
• Update on ACA implementation, including
NASW involvement
• Direct and indirect benefits of the ACA for the
social work profession
• Roles for social work in ACA-supported
delivery system models
Benefits of the ACA for Social
Workers
• Support for the vulnerable
populations served by social workers
(i.e. Uninsured/Underinsured)
• Support for the SW Profession
Major outcomes of the June 28th
SCOTUS decision:
 Individual mandate was upheld
 State Insurance Exchanges will be established
 Medicaid expansion will go forward w/o
penalizing states that don’t comply (i.e.,
withholding of all Medicaid funds)
 Absent the penalty, many states now believe
that the Medicaid expansion (coverage for all
people with incomes up to 133% FPL) is
optional.
 Implementation of the law goes forward
How do we get to (near) universal
coverage?
• People receiving coverage through their
employers will continue to receive this coverage
• Everyone under 133% of the Federal Poverty Line
(FPL) - about $15K for an individual - is now
covered by Medicaid*
• Everyone between 133-400% FPL will receive a
federal subsidy to purchase coverage on their
state “health insurance exchange” – a virtual
marketplace for health plans
• Medicare will continue to cover everyone of the
age of 65
Only 15 months away!
Major components of health reform –
Medicaid expansion and state
insurance exchanges – need to be up
and running on
January 1, 2014
ACA implementation:
Major challenges at the state level
A Patchwork of ACA Compliance
Major ACA benefits
for individuals and families
• Dependent coverage to age 26 (2010)
• No lifetime caps (2010) or annual caps (2014)
• PCIP insurance plan (2010) (over 75K enrollees;
bridge program in advance of exchanges)
• Guaranteed Issue; aka: No Pre-existing
condition exclusions (2014)
• No coverage rescissions (2010)*
• Closing the Medicare donut hole (begin 2010)
• No cost-sharing for preventive services (2010)
The definitive - and most reliable
source for all
ACA-related information
Resources on Healthcare.gov
Take Action
Find Insurance Options
Your Insurance Company &
Costs of Coverage
Prevention & Wellness
Compare Care Providers
Get Help Using Insurance
Managing Your Insurance
Understanding Insurance
Free or Low-Cost Care
Medicare & Long-Term Care
Employers & Self-Employed
The Health Care Law and You
Read the Law
Key Features of the Law
Timeline: What’s
Changing & When
Implementation Resources
Many states opposed to ACA are
stalling implementation until
November
campaign outcome
Where does NY stand?
• Governor Cuomo signed Executive Order in
April 2012, to establish the NY Health Benefit
Exchange.
• Governor submitted letter to CMS July 2012
confirming NY’s intent to create an exchange
• Donna Frescatore appointed ED of NY State
Health Benefit Exchange
All plans operating on the
exchanges have to offer a
set of “essential health
benefits”
Essential Health Benefits
• ambulatory patient services
• emergency services
• hospitalization
• maternity and newborn care
• mental health and substance abuse disorder services
• prescription drugs
• rehabilitative and habiliative services and devices
• laboratory services
• preventive and wellness services and chronic disease
management
• pediatric services, including oral and vision care
Essential Health Benefits –
Potential New York Benchmark Plans
 Three largest Federal Employees Health Benefits Program (FEHBP)
– Government Employees Health Association (GEHA)
– Blue Cross Blue Shield Basic (BCBS Basic)
– Blue Cross Blue Shield Standard (BCBS Standard)
 Three largest New York State Employee Plans (NYSHIP)
– Empire Plan
– Capital District Physicians Health Plan HMO
– Independent Health HMO
 Three largest New York Commercial Small Group Products
– Oxford EPO
– Oxford HMO
– Oxford Direct
 Largest New York Commercial Group HMO
– HIP Prime (part of Emblem Health)
Millman analysis - August 2, 2012
Advocacy that all NY social workers
can and should do:
• Advocate for an EHB plan that include robust
mental health and substance abuse services –
get comments in ASAP:
Danielle Holahan at
exchange@health.state.ny.us
• Promote social work appointments to the
state health exchange governing board and
advisory committees
NASW’s ACA support
• Obama Administration ally
• National coalition involvement on all aspects of
ACA implementation
• Input on all regulation affecting the profession
and the populations we serve
• Working with NASW state chapters on
implementation, esp in “reluctant” states
ACA: Direct Benefits for the
Profession
• Loan repayment for mental health providers
working in health professional shortage areas
• Mental and Behavioral Health Education and
Training Grants for SW & psychology schools
(apps were due June 2012)
• Health care workforce development grant $
available to states
ACA: Indirect Benefits
for the Profession
• Support for delivery system models that are
pro-social work:
• Medical home – micro level
• ACO – macro level
ACA:
Indirect Support for Social Work
• Payment and Care
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–
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Enhanced primary care $: Medicare and Medicaid
Medicaid “Health Home” for chronically ill
Bundled payment: hospital/sub-acute 30 days
Community based transition program: complex chronic
Community-based Collaborative Networks
ACOs: Medicare Shared Savings program
• Innovation Center and Pilots/Demonstrations
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Chronic disease teams for high risk beneficiaries
Innovations to improve outcome/lower costs: Value
In-home care for high-need Medicare patients
Medicare authorized to join multi-payer initiatives
The “New and Improved” Medical Home
Focuses on:
Coordinated & integrated Care:
• Care coordination/care management
• Integrated Behavioral health
• Emphasis on patient empowerment/self care
• Attention to the Social Determinants of Health
• Team-based care
AHRQ, 2010
“ The primary care medical home is accountable
for meeting the large majority of each
patient’s physical and mental health care
needs, including prevention and wellness,
acute care, and chronic care. Providing
comprehensive care requires a team of care
providers. This team might include physicians,
advanced practice nurses, physician assistants,
nurses, pharmacists, nutritionists, social
workers, educators, and care coordinators.”
Department of Veterans Affairs, 2010
• “An essential component of patient-centered
primary care practice is inter-professional
teamwork. High-functioning teams require
collaboration between physicians, nurses,
pharmacists, social workers, clinical
psychologists, case managers, medical
assistants, and clinical administrators… ”
Who’s on the Team?
Accountable Care Organizations (ACOs)
Collection of provider-based organizations that:
• manage the health care needs of a defined
population
• Reduce costs and improve health care quality
and patient experiences by aligning incentives
and reducing fragmentation within the care
delivery system.
NCQA, 2012
Where do Social workers fit in?
Within Medical Homes and ACOs
Social work can and should be a key
ingredient
Ample Opportunities for Social
Workers in medical homes/ACOs:
• Care coordination/case management, esp for
those with multiple chronic conditions
• Patient education & wellness coaching
• Behavioral health
• Specialty mental health
• Outreach specialists
• CHW supervisors
“It is important to note that patients and families define the “care
team” more broadly than the clinicians working in the primary care
practice. Care team members also often include pharmacists,
physical therapists, social workers, specialists and mental health
providers, among others.”
Medical Home Example:
Allegiance Health System, MI
• Health coach – LMSW – works as part of primary care
team
• Works with PX identified as having depression
• Has access to EMR
• Monitors clinical outcomes, supports treatment
adherence and provides one-on-one support
• Reports issues back to MD and team
Quotes from Allegiance Health
Clinical Manager
• “Patients often tell physicians what they
want to hear, but they are more likely to
confide in a social worker.”
• “This is a prototype, not a pilot. With a few
adjustments, you could take out depression
and plug in diabetes.”
Small (2 MDs/2 PNPs) pediatric practice –
announcement to patient families
• “As part of our interest in providing
collaborative care for patients and families in
our office, we are excited to announce that we
will be launching our Behavioral Health
Program in November. Ms. ____, PsyD and
Ms. ____,LSW will bring their many years of
experience to our office to see patients and
families for a variety of behavioral,
developmental, emotional, and school
problems. “
The Good News
When the ACA is fully
implemented…..
More than 30 million additional people
will become insured
That translates into significant job growth
potential for social workers
Biggest hurdles
Getting SW students to look at the full range of
career opportunities in health social work
Demonstrating our
Unique value among the
other team members
(RNs, CHWs, volunteers)
Final Thoughts……
Social workers are a natural fit in the
“new” health care delivery models.
But as social workers, if we don’t claim a
stake in these models, others will
gladly fill the void.
Contact Info:
Stacy Collins, MSW
National Association of Social Workers
scollins@naswdc.org