How Social Workers, and all Americans, can work together to ensure the Affordable Care Act Succeeds
In his Dec. 31 New York Times op-ed piece “The Obamacare We Deserve” filmmaker Michael Moore concluded by saying, “…Obamacare can’t be fixed by its namesake. It’s up to us to make it happen.”
Moore wasn’t kidding. His words ring true as we face the challenge of addressing the enormous hurdles in implementing the Affordable Care Act (ACA). The ACA, or Obamacare as it is often called, is really a revolution in health care. It promises to incrementally increase access to high quality care for all Americans. And that’s a tall order as many of us have struggled for decades with a woefully inadequate system. The ACA changes guarantees health coverage to the poor, the situationally unemployed, and those struck by unpredictable tragic illness.
In essence, it protects all of us. Once fully implemented, it should correct many gaps in our current healthcare system.
Of course, there are a few problems. A big, looming one exists in the cost of the program, the main issue that Michael Moore addressed in his op-ed piece. The reality is that there is little consideration in the ACA for the cost side of the healthcare equation. It speaks to access, which will grow our healthcare industry, but little about how to pay for all those new customers.
In fact, as a country, it’s pretty clear that we can’t afford what we’ve committed to buy. Bloomberg Businessweek predicts that by 2022, ACA implementation will result in reducing the uninsured by 30 million people (a good thing); however, also as a result of ACA implementation, health expenditures will grow to 19.9 per cent of GDP by that same year (a most worrisome thing). So what do we need to do? If we accept that the ACA is here to stay (and we should), then it seems clear that two fundamental changes are needed.
First, as the American people, we must come to terms with the reality that there are limits to our healthcare dollar and correct the mistaken belief that healthcare resources in our country are plentiful and unlimited. They are not. In fact, in order to make the ACA work, we must accept into our national healthcare system the revolutionary notion that cost should, rather than should not, be a factor in health care decisions. In the land of plenty, this is a difficult pill to swallow.
Many Americans jump to the conclusion that managing the cost of care is bad. It seems like rationing care, a decidedly unpalatable notion. Rationing also conjures up memories of politicized scare tactics, including the term “death panels,” and visions of refusing treatment to frail elders and sick family members. We believe that managing cost rather than rationing care is a big part of the answer to the ACA funding challenge. As social workers who grew up in a profession famous for liberal thinking and a mindset that often equated good treatment with more treatment, we believe that managing cost is actually an issue of social justice. For social workers, social justice thinking is a hallmark of our professional training and deeply ingrained in the thinking and practice of the 130,000 members of the National Association of Social Workers.
We further believe that better management of health care resources can significantly reduce the cost of health care, a point shared with Dr. Don Berwick, former administrator of the Centers for Medicare and Medicaid. In a recent op-ed piece in The Boston Globe, Dr. Berwick outlines some creative experiments that incorporate what we see as the social justice perspective in health care. Access is increased and at the same time cost is decreased.
It is our belief that the social work profession will take the lead in fostering the many complex and important conversations that need to begin now if we are to experience the ACA as a humane, yet fiscally responsible, health care system that benefits ALL Americans.
Berwick argues that health care quality and clinical outcomes are a critical part of this cost management equation, and he offers creative and hopeful ideas. These include giving power and voice to citizens who shape how care can be more effectively provided by centering much of care in the community rather than hospital (e.g. the “medical home” model of care), making better use of behavioral health care professionals in health care delivery system, and a fascinating example of a successful community-based care model by Alaskan natives (the “Nuka” system of care) which has resulted in a dramatic decrease in the use of expensive inpatient care in the communities served.
In addition to challenging how the American public thinks of managing health care costs, we must also identify and implement cost containment practices among the nation’s cadre of highly trained health care providers in all disciplines. Each health care profession must challenge themselves in their own “best practices” and find how services can be delivered with full attention paid to decreasing costs. We believe that opportunities for saving exist in the service delivery approaches of all health care professions and that professional social workers have an important contribution to make in these conversations.
Second, we believe that innovative care strategies must be developed to manage the health care experience of the group of high-cost individual who fail to engage in the health care system in a conventional way. These persons, many of whom are funded through the governmental health care programs in Medicaid and Medicare, represent some of the most complex and costly health care utilizers in our system.
While small in number, (they constitute just 20 percent of all covered patients), they consume a whopping 50 percent of total healthcare dollars. It is perhaps even more alarming that, despite staggering expenditures, health care outcomes among these persons are often less than optimal. This special population presents major challenges for health care providers. Many are tri-diagnosed, meaning they often struggle with a chronic medical condition, a major mental illness, and in many cases, a substance use disorder. Perhaps most difficult is that they don’t engage the health care system proactively, entering a system of care at times of extreme medical or psychiatric crisis. Once stable after what is usually high intensity (and costly!) treatment, they have limited success following through on aftercare plans.
Social workers know these clients well and we have learned that the best chance of successful treatment occurs through innovative case management models. Successful case management occurs through a trusting relationship, often developed over time, and knowledgeable navigation of the health care system. Social workers can act as a conduit for the client into the myriad of providers of care in a patient’s treatment system. As systems thinkers, social workers are uniquely positioned to manage these complex treatment delivery systems, including transitioning individuals across levels of care and ensuring that an identified patient is compliant with treatment. Not only is this good health care practice from a health outcomes perspective, it is also fiscally responsible care.
Today is an exciting yet complex time in health care. Michael Moore’s challenge extends to all to all health care professionals and indeed to all Americans. We know that it is imperative to address the expense side of the health care equation, and failure to do so will bankrupt the system.
As citizens, it is essential that we begin to think of health care as a limited resource with a real price attached to each service. And as health care professionals, we must recognize our obligation to utilize our discipline-specific leadership to find ways to deliver health care more humanely and more efficiently. Unless we all work together, we risk losing an historic opportunity. It is our belief that the social work profession will take the lead in fostering the many complex and important conversations that need to begin now if we are to experience the ACA as a humane, yet fiscally responsible, health care system that benefits ALL America