Policy implementation under stress: How the Affordable Care Act’s frontline workers cope with the challenges of public service delivery

Public service delivery in the contemporary American state is becoming increasingly challenging. As the implementation of the Affordable Care Act (ACA) shows, new social policies combine high technological and cognitive demands on citizens and government with budget austerity, decentralization and political polarization. Yet, as we argue in this paper, the ACA also shows how frontline workers cope with these challenges by focusing on improving client experiences and policy outcomes. In particular, we consider how non-governmental social-service professionals, critical to contemporary service delivery, cope with high caseloads, legal rigidity, and a lack of policy knowledge on the part of citizens. Variation in coping techniques is consequential; rationing care to deal with large numbers of high-demand clients may lead to poorer service and citizen dissatisfaction. By contrast, techniques like learning and rule bending may actually improve citizens’ experience of policy. To examine patterns of coping in ACA implementation, we present the results of 21 in-depth interviews with navigators, assisters, and Certified Application Counselors in Wisconsin and Minnesota. Across both states, our respondents coped by engaging in instrumental action (learning & collaboration) and rule bending, rather than rationing care, routinizing their work, or rigidly adhering to rules. While these pro-client techniques are both fiscally and organizationally constrained, our interviews reveal that social-service professionals use them even in especially adverse circumstances.