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Nonprofit Management and the Affordable Care Act

The Affordable Care Act (ACA), also known as “Obamacare,” is being implemented through a wide-ranging combination of public and nonprofit organizations. All of these organizations are experiencing challenges in meeting the high-intensity demands of the ACA at the federal, state and local levels.

This article emphasizes the requirements being placed on nonprofit managers today in this complex setting. Some management techniques that are matched to the setting involve the internal operations of existing and new nonprofit organizations. Other matched techniques emphasize external relationships with governmental agencies (public organizations).

The following discussion also contrasts the management requirements placed on nonprofit and public organizations.

(Further background on public administration and the ACA is available on the ASPA National Weblog; the authors are writing a series of blog postings on implementation of the ACA from the public administration perspective.)


At the Federal Level

It is helpful to first look at the ACA activities at the federal level. The most visible public agencies at this level are the Department of Health and Human Services (HHS) and the Internal Revenue Service (IRS). Activities of the HHS are described at both www.hhs.gov and www.healthcare.gov; the latter web page was recently updated with version 2.0 that emphasizes implementation activities. Activities of the IRS have been largely behind the scenes.

For several years after the ACA became law (2010-2012), HHS was primarily involved with the interpreting of statutes, along with the writing and publishing of regulations. These were familiar tasks for managers and staff. No new procedures were required.

However, for 2013, HHS attention has shifted to less familiar task areas associated with implementation of the ACA. As a result, managers are now having to emphasize communications with the public regarding the new Health Benefit Exchanges, which are to be available as state, federal, or partnership organizations for all states. Managers are also having to deal with expanded Medicaid programs, to be available in only some states.

Other HHS tasks have included the development of major web pages and revisions, and setting up call center locations that are expected to soon have 9,000 trained customer service representatives in place (as reported by Robert Pear, “U.S. Unveils Health Care Web Site and Call Center” at www.nytimes.com, June 24, 2013).

Public management efforts have had to shift to methods of outreach based on “navigators” as advisers to the public, new call centers and the recruitment of popular sports figures to speak to the public on behalf of the program. Further requirements have related to technology development (for complex software required to link with the IRS to determine eligibilities for subsidies). And throughout, funding for tasks has been inadequate.

These activities are often not as familiar to managers.

While the activities of public agencies have been developing, nonprofit organizations at the federal level have also become a major aspect of ACA implementation. Management of these nonprofit organizations involves many unique issues.

The new navigator outreach program is being coordinated by a 501(c)(3) nonprofit group called Enroll America. And several nonprofits are serving as online information resources to supplement efforts by the public agencies. For example, the Kaiser Family Foundation is providing extensive background materials on a newly redesigned web page.

These nonprofit groups face their own issues and management requirements.

At the federal level, some nonprofit organizations are functioning as closely-knit supporters of efforts by public agencies. Nonprofit managers must both work to develop new organizations and to modify established organizations to function in new task areas.  However, nonprofit purposes may vary widely. Enroll America is concerned with the enrollment of individuals in a new program, while Kaiser Family Foundation is concerned with providing background information that is often useful for managers.

Both types of nonprofits rely on HHS to serve as a primary resource, and both have concerns about the best use of technology.

Nonprofit managers must consider the recruitment of appropriate staff for the tasks at hand and remain aware of urgent schedules. In addition, close working relationships with public agencies are critical, so priority attention must be directed to inter-organizational communications.

At the federal level, the key management issues for public managers are public communications, communications with nonprofits, technology implementation, delegation of tasks and management of funds.

The key issues for nonprofit managers are maintaining linkages to public agencies, performance of specific tasks as part of larger efforts, technology applications, managing information and customized methods for education and outreach.

Identifiable management skills are required for these nonprofit organizations.


At the State and Local Levels

At the state level, public agencies are typically involved with the development of state or partnership exchanges. They also must deal with implementation of an expanded Medicaid program (or, in the alternative, with the management of issues related to less funding for Medicaid becoming available).

Public agencies must support all state efforts to cope with ACA implementation. Public management strategies tend to vary widely from state to state, depending on the policy decisions that have been made by each state.

At the state and local levels, nonprofit organizations are taking on important roles. Some state exchanges are being set up as private, nonprofit legal entities. Many state hospitals, physician practices, and organized delivery systems are set up as nonprofits. And the navigator program is set up to draw extensively on both public and nonprofit groups for enrollment assistance.

Nonprofit management strategies will determine how effectively the ACA is implemented.

The key issues for public managers are coping with policy decisions made by states and being in a supporting role where needed.

The key issues for nonprofit managers are the ability to function as part of a diverse team and contributions through the performance of coordinated tasks while protecting organizational viability and managing internal effectiveness.

Identifiable management skills are also required for these nonprofit organizations.



Nonprofit organizations are closely integrated into the ACA at all governmental levels. The management requirements of nonprofits are different from, but highly complementary to, those of public organizations.

Success or failure of implementation of the ACA over the next six months depends on how well each type of organization recognizes the ways in which relationships with other organizations must function, develops the necessary internal skills and achieves the desired performance impact.


Authors: Ferd and Cheryl Mitchell

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The American Society for Public Administration is the largest and most prominent professional association for public administration. It is dedicated to advancing the art, science, teaching and practice of public and non-profit administration.

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