All-Hands-on-Deck: Lessons from ACA Enrollment Assistance in California

Background and Purpose: The Affordable Care Act (ACA) has been shown to have expanded health coverage to more people, however little research has been conducted to identify the mechanisms through which expansion was accomplished, nor on impacts to those who were charged with implementing the law.

I examined how state officials, county workers, insurance agents, and certified enrollment counselors, those implementing the ACA in California, made sense of the law; I analyzed the ways that their roles changed pre- and post-ACA, and assessed their perspectives on the evolving U.S. public-private healthcare system.

H1: Views of front line enrollment assisters go beyond the partisan divide present in public debate.

H2: The enrollment assistance infrastructure built in California facilitated insurance expansion.

H3: Role strain among assisters from public agencies, businesses, and community-based organizations created tensions that impeded meeting expansion goals.

Methods: I conducted a qualitative case study, which includes analysis of the ACA’s design and implementation in California from in-depth interviews and secondary materials. I interviewed 67 healthcare and policy leaders, including representatives of public agencies, businesses, and community-based organizations directly implementing expanded coverage in California. Interview topics included: the law and its consequences; creation of the exchange; new roles and responsibilities; working together; and emerging tensions. Topics and specific questions were tailored to match the expertise of each respondent type.

Themes were drawn from systematic coding of interview transcripts. Secondary materials - conference proceedings, training manuals, and reports – provided background for interview coding validation.

Results: The implementers discussed the law and its impact in terms of three themes: politics, morality, and stigma. The nature of their work changed under a no-wrong-door approach to enrollment. With Covered California, a quasi-state agency, the state’s role transformed from market regulator to market facilitator. With the new effort to help people enroll in subsidized private and public insurance plans, community-based assisters became a salesforce, and insurance agents helped the poor free of charge.

An all-hands-on-deck approach blended public and private roles among stakeholders who previously had more autonomous standing in insurance markets and social benefit provision. This facilitated insurance coverage expansion, especially in the first enrollment period. However, as demand for assistance diminished and grant funding from the federal government was spent, competition among assister organizations began to replace cooperation. Moreover, a shift toward “performance-based compensation” for enrollment assistance created conflicting incentives; while payment increased the motivation of venders to reach out and enroll new insurance applicants it weakened cooperation among the organizations involved in assistance and in so doing diminished the total assistance available to new applicants.

Conclusions and Implications: The unique perspectives and experience of frontline ACA implementers can help policy-makers and community stakeholders shape future reform. The views presented from people and organizations across political lines can help balance heated debate and positively influence policy changes to come. Further, changing roles in healthcare presents opportunities for social work practice interventions and future research into their impact.