Health care reform and health disparities: implications for social workers.
Article Type: Editorial
Subject: Social workers (Practice)
Health care reform (Demographic aspects)
Health care reform (Social aspects)
Health care disparities (Demographic aspects)
Health care disparities (Social aspects)
Authors: Gorin, Stephen H.
Gehlert, Sarah J.
Washington, Thomas Alex
Pub Date: 11/01/2010
Publication: Name: Health and Social Work Publisher: National Association of Social Workers Audience: Academic; Professional Format: Magazine/Journal Subject: Health; Sociology and social work Copyright: COPYRIGHT 2010 National Association of Social Workers ISSN: 0360-7283
Issue: Date: Nov, 2010 Source Volume: 35 Source Issue: 4
Topic: Event Code: 200 Management dynamics; 290 Public affairs
Geographic: Geographic Scope: United States Geographic Code: 1USA United States
Accession Number: 243525229
Full Text: Health disparities, or "preventable differences in the burden of disease, injury and violence, or opportunities ... experienced by socially disadvantaged racial, ethnic, and other populations groups and communities," remain a serious problem in the United States (Centers for Disease Control and Prevention, 2008). The grim figures are well known to social workers (NASW, 2009). Compared with white Americans, African Americans have shorter life expectancies and higher rates of disease and death. Although Hispanic Americans, particularly those born in other countries, are in better health than nonimmigrant white Americans for at least one generation after immigrating, they lag behind in some measures (Kimbro, Bzostek, Goldman, & Rodriquez, 2008; Russell, 2009; U.S. Department of Health and Human Services [HHS], 2010). Racial and ethnic minorities, including Hispanic Americans, also generally have less access to care than white Americans, and when they get it, it is often inferior (HHS, 2010). Much less is known about disparities from Asian Americans, Arab Americans, and other racial and ethnic groups.

During the presidential campaign, candidates Obama and Biden pledged to "tackle the root causes of health disparities by addressing differences in access to health coverage and promoting prevention and public health" (Obama Biden, n.d.). The Obama administration has also pledged to take steps to address health disparities (Council on Social Work Education, 2010). Yet, what has been done to date? Thus far, one feat has been the enactment of the Patient Protection and Affordable Care Act (PPACA) (EL. 111-148) by Congress in March 2010. This article examines the potential impact of the PPACA on two kinds of health disparities: racial and ethnic disparities and class (as determined or influenced by socioeconomic status) disparities.

PPACA AND RACIAL AND ETHNIC DISPARITIES

A central issue facing many racial and ethnic minorities is lack of access to health care. In 2008, 10.8 percent of non-Hispanic white Americans lacked health insurance, whereas 19.l percent of African Americans and 30.7 percent of Hispanic Americans had no coverage (these figures provide a rough measure of the uninsured population at a point in time, not the entire year) (U.S. Census Bureau, 2009).

If implemented as planned, PPACA will ameliorate this problem by providing tax credits and other subsidies to individuals and families earning less than 400 percent of the poverty line to assist them in buying coverage through the new health exchanges (Kaiser Family Foundation, 2010). Because approximately "80 percent of nonelderly blacks, Hispanics, and American Indians and Alaska Natives" (compared with 57 percent of white Americans) "had incomes below 400 percent of poverty," the new law should help reduce disparities in access (Families USA, 2010). The legislation will also extend Medicaid coverage to children and adults with incomes below 133 percent of the poverty line.

PPACA also should decrease group differences in health by expanding funding for community health centers, which have played a critical role in the effort to stem "the nation's growing flood of uninsured people" (Iglehart, 2010, p. 343). Former president George W. Bush described these centers, which grew out of the antipoverty efforts of the 1960s, as "an integral part of a health care system because they provide care for the low-income, for the newly arrived, and they take pressure off of our hospital emergency rooms" (cited in Iglehart, 2010, p. 343). In 2008, 61 percent of the 20 million people served by community health centers were African American or Hispanic American (National Association of Community Health Centers, 2009). The legislation will provide $11 billion over five years, an "investment" that "will approximately double the number of people seen in health centers" (Wakefield, 2010).

Also, health plans will be required to offer free preventive health and wellness coverage, which many African Americans, Hispanic Americans, and others with high rates of uninsurance often go without (Health Reform for African Americans, n.d.). The new law will also expand access to primary care coverage and accelerate efforts to treat chronic diseases, which should improve the health of individuals from racial and ethnic minority groups. It will emphasize the need for, and promote the development of, a more diverse and culturally competent health workforce (Chunn, 2008). Expanded access may increase the representation of racial, ethnic, and economically disadvantaged minorities in the data collected on health disparities; hence, the data will inform the development of target services.

PPACA AND CLASS DISPARITIES

In 2004, Isaacs and Schroeder described "class" as the "ignored determinant of the nation's health." According to them, although much attention has focused on "racial and ethnic disparities in health care ... the wide differences in health between the haves and the have-nots are largely ignored" (p. 1137). They also acknowledged that class can be "difficult to define," noting that it has been variously examined in terms of wealth, income, and other factors.

Cubbin et al. (2010) addressed the importance of incorporating "feasible measures of wealth in health research," noting that wealth can protect individuals "from the impact of temporary low income (e.g., in the event of illness or unemployment) and it reflects power and influence over others to a greater extent than income." According to Pollack, Chideya, Cubbin, Williams, and Braveman (2007), the "failure to measure wealth may result in under-estimating the contribution of SES to health, such as when studying the etiology of racial/ethnic disparities" (p. 250).

Because African Americans "are overrepresented among socioeconomically disadvantaged groups," some theorists have used race as a "proxy for class." Kawachi, Daniels, and Robinson (2005) criticized this "common but unwarranted practice." Using risk for heart disease as an example, they showed that "low-income black Americans have more in common ... with low-income white Americans than with middle-class or affluent black Americans" They also cautioned against the practice of controlling racial differences in health for socioeconomic status because "it is race that influences class position in U.S. society, not the other way around."

Richard Wilkinson, Kate Pickett, and others have identified income inequality as a key determinant of population health. According to Wilkinson and Pickett (2009), income inequality reflects the degree of hierarchy and stratification within a society. Chronic stress and anxiety arising from these social divisions can get "under our skin" and result in a wide range of physical, emotional, and other difficulties. After reviewing 168 studies of the "relationship between inequality and population health," Wilkinson and Pickett (2007) found that "a large majority ... reported that more egalitarian societies tend to be healthier" (p. 1967).

Although this is not widely recognized, PPACA does take steps to address income disparities. Leonhardt (2010) described the bill as "the centerpiece" of President Obama's "deliberate effort to end what historians have called the age of Reagan." PPACA is funded in part by an increase in the Medicare payroll tax rate for individuals making over $200,000 (and for "married fliers" making over $250,000); moreover, the new rate will be applied to "unearned income these affluent households receive such as income from capital gains, dividends, and royalties" (Marr, 2010). At the same time, as noted, the legislation provides subsidies to individuals and families earning below 400 percent of the poverty line.

Expanding health insurance will itself reduce inequality. Burtless and Svaton (2010) noted that the consumption of health care plays an increasingly critical role in the lives of individuals and families. However, due to the expansion of insurance, both private and public, relatively few families finance "the full cost of" coverage "out of their cash incomes." For this reason, they argued, focusing on measures of "gross money income" alone underestimates "the resources available to finance household purchases" and exaggerates the degree of inequality in the country. By this logic, extending health insurance to the bulk of the population, as PPACA does, will further narrow income inequalities.

IMPLICATIONS FOR SOCIAL WORK

Although the role of social work practice and research in PPACA has not been defined, it is not difficult to imagine how the profession could contribute to the success of PPACA's mission of addressing differences in access to health care and promoting prevention. Many features of health social work distinguish it from other health professions and are congruent with the Obama administration's plans for implementing PPACA.

Awareness is growing among policymakers that eliminating disparities depends on our ability to produce culturally appropriate interventions and policies and to apply them sensitively. Translational research, which has become a prime focus of federal efforts in the past few years, attempts to expand the boundaries of research from T1, or research from the "laboratory" to clinical applications, to T4, or research that determines the impact on the health of the population (Khoury et al., 2008). More recently, comparative effectiveness research (CER) has been championed to ensure that research findings apply to disparity populations. The American Recovery and Reinvestment Act of 2009 (RL. 111-5) created a mechanism for coordinating CER across the federal government, with an allotment of $400 million.

Both translational research and CER are congruent with the approach of health social work. In the first place, health social work contextualizes health within a nexus of social and environmental variables, which is essential for translating research into real-world settings and for developing and testing culturally tailored interventions. Second, health social work has always focused on the social impediments to health (Gehlert, 2006).

Clearly there is a place for health social work in PPACA. Establishing this place must be done proactively, however. Many professions are wing for position in PPACA, and no one will come knocking at social work's door. It is important for health social workers to continue to build their skill sets to prepare themselves to play a major part in furthering the mission of PPACA. This can be done in the classroom, in field education, and at meetings of the major social work professional associations. It also is imperative that health social workers advocate for themselves in the continuing process of health care reform.

CONCLUSION

As debate continues over the relative contributions of race, ethnicity, and class to health disparities, access to coverage remains an important issue. However, although critical, coverage alone will not reduce health disparities. In addition to efforts at the individual level, we must also make changes at the neighborhood level and beyond. PPACA may provide more opportunities for disadvantaged communities through expanded funding of community health centers. These centers may allow health professionals and community members greater access to health resources, health education, and local space for collaborating. The inclusion of local perspectives, transparency, and open communication are essential for improving health prevention and outcomes. The benefits of PPACA are not one-sided--it will not only give provide greater access to health care for racial, ethnic, and socioeconomically disadvantaged minorities, but also provide health professionals greater access to those communities, which will likely help ameliorate health disparities.

IN THIS ISSUE

We are pleased to have edited this special issue on health inequalities, the first time that Health & Social Work has devoted an issue to this critical topic. Inequality increasingly exists in health care and health status for disadvantaged populations, such as racial and ethnic minorities, homeless veterans, residents of rural areas, women, families with low incomes, and others. In addition, particular health disparities (for example, HIV infection) have reached pandemic proportions among racial and ethnic minority communities.

Health inequalities also seem to affect middle-and even upper-income people. Marmot (2004) noted that "where you stand in the social hierarchy is intimately related to your chances of getting ill, and your length of life" (p. 1). In the United States and other industrialized countries, the "higher" an individual's "status in the pecking order, the healthier they are likely to be" (p. 1). According to Marmot, "for people above a threshold of material well-being. ... Autonomy--how much control you have over your life" is "crucial for health, well-being, and longevity" (p. 2).

These and related facts have motivated health professions to consider health inequality a major priority. Consistent with social work's historical context and mission, it is critical for our profession to play a leading role in disseminating knowledge to not only improve social work practice, but also effect change in the systems and structures that perpetuate health inequalities.

The authors in this issue examine inequality from a range of perspectives. Ashcroft discusses the social determinants of health and political economy perspectives and considers their implications for social work theory and practice. Kahng examines the impact of racial differences in body weights and socioeconomic status (SES) on racial disparities in chronic health conditions (CHCs). He found that over time, white people enjoyed a significantly more positive CHC trajectory than African Americans, a disparity linked with the lower SES of African Americans. He concluded that to address disparities in CHCs, social workers must also address inequalities in SES.

Pandey and Kagotho examine differences ill health insurance among recent legal immigrants. They found that although many recent immigrants were in the labor force, almost two-thirds lacked insurance; after controlling for a range of factors, they found that "diversity immigrants" were most likely to go without insurance. The authors conclude with a discussion of strategies for expanding health care coverage among legal immigrants.

Ward, Nichols, and Freedman address health care inequalities among adults with intellectual and developmental disabilities. They found that individuals with these disabilities face health care inequities in terms of access, knowledge, communication, and quality.

Hernandez, Montana, and Clarke focus on health inequality among children. Noting the impact of early life experiences on adult health outcomes, they urge social workers to work with other disciplines to develop approaches to address poverty, neighborhood conditions, and other contributors to child health inequality. They also discuss implications for social work practice, policy, and research.

Gehlert and Coleman focus on interventions to ameliorate health disparities. They stress the importance of tailoring interventions to the specific needs and cultures of diverse communities and engaging the community. They discuss their work addressing breast cancer in an African American community.

In a Viewpoint column, Moniz discusses the background of the social determinants of health perspective and considers its implications for social work. In addition, Pine reviews The Spirit Level: Why More Equal Societies Almost Always Do Better, by Wilkinson and Pickett. This work has been the focus of much discussion in Europe.

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Stephen H. Gorin, PhD, MSW, is professor, Social Work Department, Plymouth State University, Plymouth, NH, and executive director, NASW New Hampshire Chapter. Sarah J. Gehlert, PhD, is E. Desmond Lee Professor of Racial and Ethnic Diversity, George Warren Brown School of Social Work, Washington University in St. Louis. Thomas Alex Washington, PhD, MS W, is associate professor, School of Social Work, California State University, Long Beach, and senior research fellow, National Center for Health Behavioral Change, Baltimore. Address correspondence to Stephen H. Gorin, 4 Abby Drive, Canterbury, Nil 03224; e-mail: s.gorin@comcast.net.
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