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Law promises good things, faces hurdles

By Rena Malai

Supporters of President Obama’s Affordable Care Act hold signs Affordable Care Act clears high court.

Supporters of President Obama’s Affordable Care Act hold signs outside the U.S. Supreme Court on June 28 as they await the court’s ruling on the constitutionality of the law.

Social workers celebrated on June 28 when the U.S. Supreme Court ruled to uphold President Obama’s Affordable Care Act, which paves the way for more than 30 million uninsured people to have health care coverage.

The landmark ruling also has the potential to create more jobs for social workers. But the law — most of which should be in place by 2014 — still faces hurdles, as many governors have pledged not to implement the ACA in their states.

As advocates and health care providers, social workers are key to ensuring that the law is fully implemented.

“Social workers need to be involved in this on the ground floor. We’re the ones in the trenches seeing people not getting the health care they need,” said Januari Leo, NASW member and public affairs field specialist with Legacy Community Health Services in Houston. “The role of advocacy is really important as so many states may not implement the ACA. People need to get out and vote. We can be the game-changers.”

ACA highlights

The cornerstone of the ACA is the “individual mandate,” the requirement that most Americans and legal residents possess health insurance coverage. Achieving this goal requires a complex mix of federal and state effort. The ACA requires all states to establish health insurance exchanges — competitive marketplaces where individuals and small businesses can buy affordable health plans.

Individuals with incomes between 133 percent and 400 percent of the federal poverty line (FPL) will receive tax credits to purchase plans on the exchanges. The ACA also expands coverage by raising Medicaid eligibility nationwide to 133 percent FPL, with the federal government covering approximately 95 percent of the cost of the expansion. Undermining the expansion effort is the Supreme Court’s denial of the federal penalty (withholding all Medicaid funds) for states that refuse to implement the expansion.

The ACA also includes a variety of consumer protections, one of the most important being the “guaranteed issue provision,” which will end the industry practice of denying coverage based on pre-existing conditions. Other provisions include expansion of dependent coverage for adult children up to age 26, and the elimination of annual and lifetime coverage caps and cost sharing for preventive health services.

Although some fear that the act could result in a loss of employer-based coverage for millions — and possibly an increase in health care costs instead of a reduction — the Obama administration says the ACA is projected to lower the nation’s overall health care spending and future deficits by ensuring that all Americans have access to affordable coverage.

Job implications

The social work field may be positively affected as the terms of the reform play out, said former NASW board member Donna M. Ulteig, a licensed clinical social worker in Madison, Wis. As things unfold, she sees social work jobs expanding in some areas.

"I suspect that mental health agencies and practices will need to hire more social workers,” she said. “More people with mental health needs will have access to mental health coverage without a ban on pre-existing conditions. In addition, Accountable Care Organizations have the ability to use social workers in a variety of ways."

Other areas also could see a boost in social work opportunities, said NASW member Kathy Wood-Dobbins, CEO of Tennessee Primary Care.

“From my perspective working as an advocate for accessible primary health care services for low-income Tennesseans, I see emerging opportunity for social workers in the field of primary care,” Wood-Dobbins said.

She also said she would like to see more integration of behavioral health and primary care services as more people gain access to mental health coverage.

“Some days as many as half of the patients (we) serve present a behavioral health concern, such as substance abuse and addiction, concerns about feeling anxious, or depression,” she said. “Many patients turn to their primary health care providers for relief and are more likely to seek care in a primary health care setting than seeking out a mental health service provider. I would like to see more integration of behavioral health services into the primary care setting, and for social workers to take a lead role contributing to this integration.”

A dancer with the West Virginia Belly Dancers for Single PayerA dancer with the West Virginia Belly Dancers for Single Payer, who oppose the act, performs.

Amelia Mahan, NASW member and the Behavioral Health Care Coordination program manager at North Carolina Community Care Inc., said the social work field should grow if states decide to expand the Medicaid program. This could create jobs in her state, she said, which has a unique mix of urban and rural pockets.

“If they do expand (the Medicaid program), there will be significantly more people on Medicaid. It will be a big expansion — and fast,” Mahan said. “There will be a great need just to have staffing. North Carolina is an interesting state. We have some large urban areas, but a big part is very rural where the access to service is very challenging. It’s hard to get providers out there, but hopefully this will change.”

Leo, of Houston’s Legacy Community Health Services, said big changes are anticipated for social work in Texas as the switch from the Ryan White Program — which provides services for those living with HIV in Texas — to Medicaid goes through. People who have not been able to access services before will now be able to get them, she said, and this will create a natural job expansion for social workers.

“I work with a largely HIV population who are on Ryan White and who have been in the system for 25 plus years,” she said. “The switch to Medicaid is different … social workers will play a huge role in making sure everyone (will) be able to navigate the system. There will be opportunities opening up for social workers to be patient navigators, and to help people apply (for) Medicaid. There will be more people accessing services overall, so there will be a greater need for case managers and people in behavioral health services. There will be more job creation, which is great for social workers trained in these things.”

Ulteig said more social workers will be hired in clinical social work practices that offer therapy services and also potentially in elder-care services.

“The emphasis on getting care for seniors in their homes and the incentives to reduce hospital readmissions call for more hospital discharge planners and additional home and community supports,” she said. “Social workers do this best.”

Challenges ahead

The ACA faces significant opposition. Republican presidential nominee Mitt Romney has vowed to work with Congress to repeal the legislation if he is elected. Of more immediate concern is the opposition to the ACA among Republican governors, many of whom have said they will not implement it in their states. To expand health coverage to the uninsured, particularly in the Medicaid program, state cooperation is needed.

National and state health advocates —including NASW and its chapters — are organizing to support administration efforts and to encourage reluctant states to fully comply with the law.

The complexities of the ACA also leave a lot of questions unanswered to the general public, said Sara S. Bachman, associate professor and research director with the interdisciplinary Ph.D. program in sociology and social work at the Boston University School of Social Work. She encourages social workers to educate themselves on the details.

“Health reform is complex and intricate. When the media or politicians try to sum it up in a sound bite, it’s nearly impossible for all aspects to be understood,” she said. “I think there is still some lack of clarity around the Supreme Court ruling, and it’s important for social workers to get involved in this. Social workers need to find out about Medicaid eligibility requirements, and it’s important for social workers to become educated in the details and understand the implications of health reform. Access information that’s available, and work towards understanding it at the policy level.”

Bachman also pointed out that health reform is a matter of social justice — the foundation of social work.

“Social workers need to advocate for social justice, she said, “and ensuring everyone has access to health care is a social justice issue.”

Wood-Dobbins, who has worked in the health care field since the late 1970s, said it is rewarding to see health care reform finally come to fruition.

“Our current health care system is not sustainable because it costs too much and it leaves too many people without access to care,” she said. “The Affordable Care Act takes us in the right direction. This is where we have needed to go.”

NASW members can access the following Practice Perspectives:

  • “State Health Insurance Exchanges: What Social Workers Need to Know” ( March 2012)
  • “The Affordable Care Act: Implications for Low - and Moderate - Income Women’s Health and Well Being” (Jan. 2012)
  • “Accountable Care Organizations (ACOs): Opportunities for the Social Work Profession” (September 2011)
  • “The Medical Home Model: What Is It And How Do Social Workers Fit In?” (May 2011)

NASW Senior Practice Associate Stacy Collins contributed to this article.

Supreme Court Rules on other cases important to social work

By Paul R. Pace

In addition to upholding the Affordable Care Act, the U.S. Supreme Court in June handed down decisions in two other cases that are important to NASW and social workers.

The high court struck down the majority of Arizona’s immigration policy that critics charged as being excessive.

NASW’s Legal Defense Fund facilitated NASW’s participation in amicus curiae briefs in legal challenges to Arizona’s and Alabama’s immigration laws, United States v. Arizona and Hispanic Interest Coalition v. Bentley. They can be viewed at the LDF Amicus Brief Database.

Even though the court struck down key elements of the Arizona law, it let stand a provision, Section 2(B), that requires police to check a person’s immigration status while enforcing other laws.

Melvin Wilson, manager of the NASW Department of Social Justice and Human Rights, said there is concern that law enforcement officials could abuse the provision by finding probable cause to stop anyone who appears to be Hispanic and require them to “show me your papers.”

This would constitute racial profiling, he said, but added that in the court’s majority opinion, the justices left the door open for further legal challenges if Section 2(B) is used to support racial profiling of undocumented immigrants.

NASW is actively working with coalitions to ensure an end to racial profiling in connection with immigration, Wilson said.

He submitted testimony on behalf of NASW that stated the association’s opposition to racial profiling at an April U.S. Senate hearing on the issue. NASW is on record in support of passage of the End Racial Profiling Act, or ERPA (H.R. 3618/S.1670).

If passed into law, the act would prohibit racial profiling by federal, state and local law enforcement and require federal law enforcement agencies to maintain policies and procedures to eliminate racial profiling.

ERPA is gaining support in Congress. Wilson stated that the Leadership Conference for Human and Civil Rights Racial Profiling Taskforce announced at its July meeting in Washington, D.C., that ERPA had 73 co-sponsors in the House and 16 co-sponsors in the Senate.

“We’re encouraging our members to contact their representatives in Washington to support this bill as we will continue to encourage support for anti-racial profiling measures at the grassroots and state levels as well,” Wilson said.

Another positive result from the Supreme Court ruling is that the majority of justices stipulated the federal government is responsible for setting immigration policy and laws.

“An important message in the ruling is that the court affirmed that federal laws will trump immigration legislation that a given state may attempt to implement,” Wilson said.

Also taking place in June, the U.S. Supreme Court outlawed mandatory life without parole sentences for youths convicted of murder.

In a 5-4 decision, the majority of justices said such laws violate the Eighth Amendment’s ban on cruel and unusual punishment.

The ruling is consistent with the position taken in an amicus brief filed with the high court by the American Psychological Association and joined by NASW.

The ruling combined two cases, Miller v. Florida and Jackson v. Hobbs.

In the brief, it was noted that NASW opposes any legislation or prosecutorial discretion permitting children to be charged and punished under adult standards.

It explained that research supports the theory that juveniles are more vulnerable or susceptible to negative influences and outside pressures, including peer pressure, while at the same time they lack the freedom and autonomy that adults possess to escape such pressures.

In delivering the majority opinion, Supreme Court Justice Elena Kagan wrote, “Mandatory life without parole for a juvenile precludes consideration of his chronological age and its hallmark features — among them, immaturity, impetuosity, and failure to appreciate risks and consequences. It prevents taking into account the family and home environment that surrounds him — and from which he cannot usually extricate himself — no matter how brutal or dysfunctional.”