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Let’s Consider the Future Role of Public Agency Caseworkers in Connecting Americans to Health Benefits

The views expressed are those of the author and do not necessarily reflect the views of ASPA as an organization.

By Cheryl A. Camillo
October 11, 2017  

It is time to discuss the roles state and local eligibility caseworkers play in conveying health benefits to Americans. Over the past two decades, public agency caseworkers’ roles have narrowed significantly, largely (and ironically) as a result of efforts to facilitate enrollment in the programs they serve. Now, new circumstances warrant reconsideration of their scope and duties.

From the inception of the modern American social welfare system in the mid-1960s until the 1990s, caseworkers generally determined eligibility for multiple means-tested programs, such as Medicaid, cash assistance and Food Stamps (now Supplemental Nutrition Assistance Program, or SNAP, benefits), jointly through a lengthy, intensive process that included a face-to-face interview and manual submission and review of documents. Changes in policy, public management and information systems since the mid-1990s have limited the jobs of many workers to verifying health insurance eligibility information collected through electronic means.


  • Federal welfare reform legislation enacted in 1996 delinked eligibility for Medicaid and cash assistance leading states to bifurcate caseloads;
  • Federal Medicaid policy changes intended to reduce the rate of individuals without health insurance eliminated several burdensome application requirements, such as the need to apply in person;
  • Implementation of the Children’s Health Insurance Program (CHIP) for uninsured kids with family income over the Medicaid limits drew non-governmental organizations into performing outreach and enrollment activities in an effort to reduce stigma associated with public health insurance programs;
  • Technological advances automated some remaining caseworker tasks, such as redetermining eligibility;
  • The establishment, via the Affordable Care Act (ACA), of Health Insurance Marketplaces where individuals can shop for subsidized private health insurance coverage led to further separation of health and social service casework because many states co-located Medicaid and Marketplace functions; and
  • The institution of health insurance navigator and other grant programs to educate individuals about Marketplace coverage options caused many states to channel public insurance outreach through them.

It is states’ reliance on grant-funded navigators that makes it urgent for them to reconsider the role of caseworkers—on August 31, just two months before the start of the 2018 open enrollment period for Health Insurance Marketplaces, the Trump Administration announced it would cut ACA advertising by 90 percent and navigator grants by about 40 percent, leaving states extremely vulnerable to decreases in insurance coverage.

Yet, there are other pressing reasons to reconsider. There is growing evidence that individual health is determined more by income, environment, diet, education level and other factors addressed by social service programs than it is by health care services, which argues for the reintegration of health and social service benefits programs. At the same time, momentum is building for a ‘Medicare for All’ single payer health insurance program run by the federal government, which could mean the elimination of state health insurance programs. Plus, the decline in public sector jobs, especially those that require only a high school diploma or college degree, as is the case with eligibility worker positions, is contributing to the erosion of the U.S. middle class.

Some health and social services integration can be accomplished through inter-agency collaboration, but sustaining collaboration is a notoriously difficult and elusive skillset that is the subject of many articles and workshops. Data exchanges and linkages can also facilitate integration, like they did in states that exercised the ‘express lane eligibility’ option that allowed them to rely on eligibility findings from SNAP and other social services programs to confer Medicaid eligibility, but they would not wholly eliminate the need to communicate with clients before eligibility determinations are finalized. Nor would information systems address post-enrollment questions and problems that the majority of navigators and application assistors in five states reported fielding during the first year of ACA enrollment. Many individuals have low health insurance literacy and need terms and concepts such as “deductible” explained to them. Still other applicants prefer face-to-face contact. In research done to prepare individuals to navigate the post-ACA health insurance system, GMMB found that certain sub-populations, especially Hispanics, preferred to enroll in government offices because they are “official.”

Photo credit: Emile Wamsteker

Photo credit: Emile Wamsteker

Certainly, new approaches will be needed to find and enroll the millions of Americans who are eligible but uninsured.

The discussion should include, at the minimum: federal policymakers; the National Academy for State Health Policy; the National Association of Medicaid Directors; the National Eligibility Workers Association; labor union representatives; the American Public Human Services Association; consumer representatives; and researchers. Topics should include, but not be limited to: public versus non-public funding and personnel; the level of government responsible; the extent of integration with social service programs; the physical locating of caseworkers; automated or in-person tasks; and, the scope of caseworker responsibility. It will be important to remember that public management strategies should evolve as goals and objectives change and feedback dictates.

Author: Cheryl A. Camillo is an assistant professor at the Johnson Shoyama Graduate School of Public Policy. A former public administrator at the U. S Department of Health and Human Services and Maryland Department of Health, she works to bring together scholars and practitioners to solve real-world health policy problems. She can be reached at [email protected] or via Twitter @CherylACamillo.

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