Social Work Grand Challenge
A year ago Heidi L. Allen’s sister died.
“She lived in Idaho, which did not expand Medicaid under the ACA” (Affordable Care Act, also called Obamacare), said Allen, an associate professor of social work at Columbia University in New York whose focus is low-income, uninsured adults.
“Here I study health insurance, and I have a 44-year-old sister dying of cancer who doesn’t have health insurance,” she said. “I felt so helpless to be an expert in this particular area and not be able to help my family. It was horrible. I’ve seen firsthand the consequences people have to this financial barrier.”
And, she said, she is not alone.
“This was my personal tragedy,” Allen (photo left) said. “Four children lost their mother in the United States of America. It is wrong, and it happens every day. Everyone I know has a story like this. I’ve seen tragedy after tragedy.”
“I focus on insurance, and because I study health insurance, it’s my personal passion. I think it’s one of the biggest issues we need to address.”
The American Academy of Social Work and Social Welfare has focused the profession’s attention on the issue by making “Close the Health Gap” one of its 12 Grand Challenges for Social Work.
Now that group, which Allen is a member of, is proceeding amid the uncertainties of an altered political climate that is pushing potentially dramatic changes for millions of Americans who cannot afford to buy insurance on their own.
“We definitely have setbacks with the political climate, but at the same time, the election has banded people together and created a community of people who want to see change,” said challenge co-leader Michael Spencer (photo right). “It’s an opportunity for social work to encourage participation with changing structures.”
While he believes a single-payer system “would solve a lot of problems,” he said, “that’s not where we are starting with this grand challenge.”
“Now we have the ACA, a huge step forward for people and for this country,” said Spencer, BA, MSSW, Ph.D. and the Fedele F. Fauri Collegiate Professor of Social Work at the University of Michigan in Ann Arbor. “It needs more funding. It needs to expand and grow. Those states that chose to expand Medicaid are doing well. We can be idealistic — and we are — but we also believe the fight is before us, and where we’re starting now is with the ACA.”
Gains in Care
The Obamacare Facts website cites a 2012 FamiliesUSA study that states between 2005 and 2010, more than 130,000 Americans died because they lacked health insurance.
“The number of deaths due to a lack of coverage averaged three per hour and the issue plagued every state,” it says. “Other studies have shown those statistics to be high or low, but all studies agree: In America the uninsured are more likely to die than those with insurance.”
A September report by the Henry J. Kaiser Family Foundation states: “The ACA’s major coverage provisions went into effect in January 2014 and have led to significant coverage gains. As of the end of 2015, the number of uninsured non-elderly Americans stood at 28.5 million, a decrease of nearly 13 million since 2013.”
In the following year, more people gained health insurance, according to data from the National Center for Health Statistics released in April. It found 18.2 million fewer adults overall lacked insurance in 2016 than in 2010.
Titled “Changes in Characteristics of Chronically Uninsured Adults,” the bulk of information covers changes for the chronically uninsured — those who lacked insurance for more than one year — from 2010 to September 2016. Those highlights include:
- Among adults ages 18 to 64, the percent of chronically uninsured decreased from 16.8 percent to 7.6 percent.
- In 2010, the percent of chronically uninsured adults who were non-Hispanic white was larger than the percent who were Hispanic. But in the first nine months of 2016, Hispanics comprised the largest group among the chronically uninsured.
- The percent of chronically uninsured adults who lived in the South was higher than in any other region, increasing from 44.6 percent in 2010 to 54.7 percent in the first nine months of 2016.
Inequities’ Broad Impact
It’s extremely important that social workers address this issue, said Allen, BS, MSW, Ph.D.
“There are so many in our population who are truly suffering,” she said. “We’re in one of the richest countries in the world, yet we have people who die because of inadequate health care — particularly people who have a low income, people of color and people who live in rural areas.”
“This is a persistent social problem. We have to rally around improving the health care system because people are dying. Social workers are called by a code of ethics to right societal wrongs, and this is a societal wrong.”
Challenge group member Edwina S. Uehara (photo right), BA, MSW and Ph.D., professor and the inaugural holder of the Ballmer Endowed Deanship in Social Work at the University of Washington School of Social Work in Seattle, agrees, saying the health gap is the differences in health and wellness between groups of people within a society where the differences are defined in terms of social and economic conditions. And it’s avoidable.
“In the U.S. and worldwide, this gap affects the morbidity, mortality and socioeconomic mobility of millions and millions of people,” she said. “The health gap is one of the signature, global grand challenges of our times. It’s a central social justice issue: No one’s health and well-being should be dependent upon one’s race, class, gender, neighborhood or circumstances of birth.”
The challenge group released its Policy Brief No. 2 in September, which outlines its recommendations:
- Focus on settings-based research and interventions to improve the conditions of daily life
- Advance community empowerment and advocacy for sustainable health solutions and prevention
- Cultivate health innovation in primary care and community-based centers
- Promote access to health care and insurance for all
- Foster development of an inter-professional health workforce.
Uehara, a NASW-Washington member, said the goal of making measurable progress within a decade is ambitious.
“Doing so will take an all-out effort: a long-term, multilevel, cross-sector approach,” she said. “It will require reform in health systems and in health financing and policy, as well as an increase in our basic investment in people and local communities.”
“As a society, we have the resources and many of the tools necessary to move the needle. Now we must align those to a renewed sense of political will and collective impact,” Uehara said.
In organizing for this challenge, Spencer said the plan is to take a settings-based approach, develop research and empower communities.
Health is biology as it interacts with environments, he said, so addressing the two settings — community settings and health-care settings — makes sense because “the two broad areas intersect and overlap.”
“Studies have demonstrated that the outcomes of various groups of people are unequal,” Spencer said. “We see the social determinants of health. Just working within health care settings and getting people to manage their health care behaviors is useful, but we also need to go beyond intervention in health care settings to places where people are.”
He said because “the impacts of environments are extremely important,” stimulating research and scholarship in this area can help us find ways to empower communities to get involved so they can find their own solutions.
Group members focusing on the health-setting side are focusing on primary care innovations and in creating new innovations, he said.
Allen said the plan is a comprehensive approach to eradicate inequities.
“Our own unique professional lens makes it clear to us that we have to address things within the health care system and outside the health care system,” she said. “We’re not going to improve people’s health by just addressing the health system and insurance issues.”
“It’s also where you live that contributes to your health. Racism also affects health. We want to organize around addressing those issues.”
One big challenge is this does require changes in so many different policies, structures and institutions, Allen said.
“There’s not just one lever we can pull and inequalities disappear,” she said. “There are huge challenges.”
One is eliminating poverty, which “is extremely difficult,” Allen said. “Racism also is a big social problem.”
“I think the biggest challenge is, you have to get people to care. You have to change people’s hearts and minds. It’s not going to change unless people believe that all people have a human right to health and they decide to tackle racism and poverty.”
Expanding Medicaid is another challenge, she said.
“Last year, I thought Medicaid expansion was a done deal,” Allen said. “Now it’s questionable whether Medicaid expansion will continue. Now I’m thinking what can we do outside of insurance to improve health. How can we engage health care systems around the social determinants of health?”
There have been decades of social research on the social determinants of health, she said.
“Where you live; your ZIP code; your skin color; where you work, play and pray determine how healthy or sick you are,” Allen said. “Health care does not address health. Adequate shelter, income security, eradicating racism — these are the indicators of health, and those need to be addressed to eliminate the disparities.”
Spencer agrees, saying the settings-based approach can help address structural factors that cause poor health by working to provide, and empowering residents to work toward, access to healthy foods and improving neighborhood safety so people can walk or exercise outside.
“The impacts of environments are extremely important,” he said. And they’re often obvious to see.
“Legally, segregation doesn’t exist,” Spencer said. “But we can see areas of the country with visible inequalities where people live — like communities that are exposed to toxic hazards.”
He said an example is a community planning to build a new incinerator. It accepts comments from the public and everyone says “Not in MY backyard.”
“We know what happens in boardrooms. We know who policy makers tend to listen to,” Spencer said. “There’s a psychological impact this has on people who live in a disenfranchised community. They’re not just faced with an environment that doesn’t respect them as human beings, but a society with stereotypes and biases against people who look like them. And it’s historically passed down.”
“Our society has made overt discrimination illegal, but conversations still happen at dinner tables, behind closed doors and in corporate boardrooms. We know what’s said. And it is by far the most challenging.”
Other issues like eye care, dental care and affordable prescription drugs often are not covered by health insurance, which places them out of reach for many low-income people.
“There’s no denying that those disparities exist as well,” Spencer said. “If you can’t get basic care, you can’t get specialty care. One of the easiest class markers to see is someone’s teeth.”
Uehara said health care approaches are increasingly moving toward integrating services that address social needs and social determinants of health “in order to achieve better health outcomes and to address major challenges facing the U.S. health care system.”
“These services include mental health, dental care — but also services addressing social needs, such as housing assistance.”
Social workers have been included in many integrated care models that the ACA encouraged.
And social workers have a fundamental role to play in creating and leading these new efforts at integrated care, Uehara said.
Allen said most people view the health care system as something that makes people healthy.
“Right now, it’s a sick person system,” she said. “I tell my students the medical model is failing patients. The medical model is not producing health.”
“What social workers bring to the table is, we see things through so many different lenses. We have the ability to transfer the medical model to a health model. We honor culture and the role culture plays. We know how oppression hurts people and hurts health. We must approach through understanding, and we must approach communities through their traditions.”
Uehara agrees, saying social work can and must play a very strong role in leading the effort to close the health gap.
“As a profession, we are key to the effective case management and coordination of health services and to the culturally respectful linkage between people, communities and formal health systems.”
“As a discipline, we bring prodigious strength in understanding the complexity of social systems and in developing multilevel interventions necessary for effective systems change. Now, more than ever, efforts to transform health and health care require social work’s expertise, leadership and commitment to justice.”
NASW releases statement opposing repeal of the Affordable Care Act
NASW released a statement on May 4 saying it strongly opposes legislation to repeal the Affordable Care Act “because it would have a devastating impact on the health of our nation’s most vulnerable citizens and make it more difficult to provide affordable health care for poor and low-income Americans.”
The U.S. House of Representatives in May narrowly passed a revised version of the American Health Care Act (AHCA) by a vote of 217-213. The revisions included new amendments that were fashioned to appeal to both conservative and moderate members of the Republican majority, according to the statement.
It says a change that is being referred to as the Upton Amendment — named after the congressman who introduced the new language — adds $8 billion to cover costs for the “risk pool” of persons with pre-existing medical conditions.
In addition, NASW said, “While the changes were successful in garnering sufficient votes to pass AHCA, they did nothing to alleviate the devastating impact of AHCA on the nation’s most vulnerable citizens. In fact, the bill passed today will likely exacerbate the challenge of providing affordable health care for poor and low-income Americans.” (See link below to read full statement.)
NASW also is working in coalitions and with partners, like Families USA and the Coalition on Human Needs, to preserve the gains of the ACA and prevent changes in the Medicaid program.
Republicans in Congress have proposed changing the financing of the Medicaid program to a capped funding model, which would strain state resources, phase out Medicaid expansion and lead to more restrictive eligibility, reduction in covered services and increase the uninsured rate.
NASW encourages members to contact their elected officials and communicate their priorities for health care going forward.