Abstract
The Patient Protection and Affordable Care Act of 2010 (“Patient Protection and Affordable Care Act,” 2010) is the culmination of a hundred years of wrangling over the government’s role in health care. The fact that the bill passed in the face of intense opposition shows just how dire the situation had become with regard to the health of the nation. Despite spending twice the amount per capita on health care than other similarly resourced countries, the United States has dwelt in the lower rankings on most key health indicators (Davis, Stremikis, Squires, & Schoen, 2014). These poor outcomes are not uniform but instead rest upon deep disparities, meaning that people’s health care is often determined by who they are and where they live. A recent Institute of Medicine report found declining health outcomes for women over the last three decades, with women in the United States being almost twice as likely to die before the age of 50 than women in other peer countries (Institute of Medicine, 2013). The underlying causes of poor health outcomes include lack of health care coverage, disparities both in access and in quality and care, fragmentation, and the inadequate coordination of care. The good news is that the Patient Protection and Affordable Care Act (ACA) has already and will continue to mitigate some of these troubling aspects of the U.S. health care system. But as the product of political compromise, the legislation cannot not fix an inherently broken system, leaving it to perpetuate what is both bad and ugly about U.S. health care.
There are very real and tangible ways that, 5 years after its passage, the ACA has improved people’s lives. One of the most visible ways is by expanding health care coverage: Since its passage, 16.4 million people have health care insurance due to the ACA, which represents an 8.3% increase for Hispanics and 7.3% increase for African Americans (Blumenthal, 2010). Single mothers, a third of whom lacked health care insurance in 2009, will now be able to afford health care (Wu & Eamon, 2013). Moreover, they will no longer pay more for their health care, as the “gender rating,” which has resulted in women paying more for their health care than do men, is now illegal under the ACA. Not only do more people have coverage, they also have more coverage. Women now have improved access to a range of preventive services including mammograms, pap smears, well-baby care, domestic violence screenings, and contraception without co-pays or deductibles. The ACA has also significantly expanded the reach of the 2008 mental health parity law by requiring that mental health and substance abuse services be essential benefits in both private and public plans (Aggarwal & Rowe, 2011).
Maybe a less publicized good, but as important, is how the ACA is changing the orientation of the health care system to better meet the needs of our most medically vulnerable citizens. Due to financial incentives and professional specialization, health care services have treated all health conditions as if they were acute: addressing presenting symptoms in isolation as a discrete condition which can be cured. For people with complex and chronic health problems, this approach both neglects critical underlying problems and generates duplicative and unnecessary procedures. People experiencing chronic illnesses, which often include comorbid behavioral health and physical health conditions, all too often end up being treated in emergency rooms and being subjected to preventable hospitalizations (Gawande, 2011). The bifurcation of behavioral health and physical health services has been particularly damaging, resulting in shockingly high mortality rates among people served in specialized mental health settings and the neglect of mental health needs in primary care settings. Managing a chronic illness takes a very different approach, which involves taking the time to understand a person holistically, their overall health and wellness, and how this is shaped by one’s life and community (Wagner, Austin, & Von Korff, 1996).
To shift the system to a chronic care model, the ACA has increased funds to primary care and promoted innovation in the coordination of services. To have the complete picture of how one care encounter should build upon previous ones and inform future encounters, providers need to be connected, which can be achieved by close communication across systems, being networked, or colocated (Heath, Wise Romero, & Reynolds, 2013). Patient Centered Medical Homes, Health Homes, and Accountable Care Organizations are all mechanisms supported by the ACA that redesign service delivery systems to facilitate coordinated care. At the clinical level, the chronic care model recognizes that the passivity implied by “patient” fails to utilize and develop the many ways in which people effectively manage their wellness. The aim, instead, is to have an “activated” service user who is both informed and empowered about making decisions about her health. This is often termed “person-centered care” but is closely related to the social work value of self-determination. The good news for social workers, therefore, is that this new approach is congruent with social work and that we can make a significant contribution to integrated health care (Stanhope, Videka, Thorning, & McKay, 2015).
Health care reform has been largely driven by escalating costs and the need to demonstrate cost reductions looms large over any new initiative to improve services. However, the Triple Aim which has set the goals for health care reform demands that simultaneous to cutting costs, health care reform must also improve the quality of services and health outcomes at the population level (Berwick, Nolan, & Whittington, 2008). The hope is that this will prevent the rampant cost cutting we witnessed with managed care in the 80s and, also by requiring that health be improved at the population level as opposed to the individual level, will avoid some receiving high-quality care at the cost of others. While good in principle, the Triple Aim loses much in translation as it filters down to the complexity of on-the-ground policies and the underlying assumptions of the U.S. health care system. While the drama of its passage may have suggested radical change, the ACA was in fact an exercise in pragmatism, designed to keep the insurance companies at the table and minimize the change experienced by people who already had insurance coverage. This incremental approach has meant that the consumerist model of health care remains unchallenged.
Unlike in countries with nationalized health care systems, health care is regarded as a commodity in the United States. Health care operates according to a neoliberal paradigm with reform being framed and evaluated according to the logic of competitive market principles (Rylko-Bauer & Farmer, 2002). Building upon the idea of health care as an exchange of goods, the major tool of reform within the ACA has been the use of financial incentives to change provider behavior. Many of the problems of the health care system have been due to rewarding volume rather than quality, with institutions providing care in order to be funded rather than to meet people’s needs (Song & Lee, 2013). Health care reform does not challenge this notion but merely seeks to change the incentives—now providers will be reimbursed for improving outcomes and if they can also demonstrate cost savings, that is, be more efficient, they will be able to share in these savings. As a result, the systems of accountability which monitor, evaluate, and reward providers retain their dominance over the health care system.
Under the ACA, payers will require even more of providers in terms of timely documentation and quality improvement measures. As a result, providers are scrambling to improve their “business model.” What we are already seeing is that those with more administrative and oversight capacity, often larger institutions, are the most able to adapt to new funding streams, leaving smaller providers struggling to survive (Rosenberg, 2013). Despite the aura of objectivity, the very assumption that all valued outcomes can be quantified and amenable to measurement rests upon certain beliefs related to human well-being. For social work, outcomes which we pursue such as nurturing relationships and the attainment of what is personally meaningful are hard to capture with rote measures. Moreover, even if we accept that all outcomes can be quantified, the pragmatics of what it is feasible for institutions to measure and report profoundly delimits the human experience of change and growth. The bad news, therefore, for social workers is that we have no choice but to demonstrate our effectiveness in the rubric of quantifiable outcomes and cost-effectiveness, and in our role as agency leaders, the ability to pursue a business model may well determine our survival.
Finally, an ugly aspect of health care reform lies in what on the surface appears to be a significant breakthrough in our understanding of what constitutes health and well-being. The ACA has embraced the notion of the social determinants of health, which refer to factors that traditionally lie outside the realm of health care such as personal behavior, living and working conditions in homes and communities, and economic and social opportunities and resources (Braveman, Egerter, & Williams, 2011). Social workers have always understood the concept of social determinants, and this maybe where the most opportunities lie for the profession in the ACA. On a microlevel, this means health care dollars can be used for work with families, lifestyle enhancements such as yoga or joining a gym, or education. On a more macro-level, funds can be channeled into community organizations that address housing, employment, and economic development by demonstrating their connection to improving health outcomes. For example, New York State is proposing to redirect Medicaid dollars into capital funds for supportive housing, making the argument that this will decrease hospitalization rates (Doran, Misa, & Shah, 2013). The ability to address structural factors with health care dollars that have traditionally only been available when people suffer the deleterious effects of deprivation seems enlightened and even potentially radical. What we may well see is the health care system increasingly taking on the burden created by a diminishing welfare system and devastating inequality. To talk of health promotion, health disparities and cost savings masks the underlying economic injustices making this rhetoric of change palatable in the current political climate. It also means that you will need a diagnosis to receive help. This signifies the increasing trend toward “medicalization,” the treatment of all social problems as medical, and using medical interventions as the solution (Conrad, 2008). As a result more social workers than ever will be left with the task of fitting the consequences of deprivation and oppression into the box of “medical necessity” to fund their services. With these diagnoses comes a particular narrative and trajectory, sometimes accompanied with stigma and judgement, which obscures basic human needs and the right to a decent life. This will be ugly for the individuals and families in need of assistance and the social work profession, which serves them.