Social Work in Public Health

ISSN: 1937-1918 (Print) 1937-190X (Online) Journal homepage: http://www.tandfonline.com/loi/whsp20

How Policy Improves Health Colita Nichols Fairfax & Marvin D. Feit To cite this article: Colita Nichols Fairfax & Marvin D. Feit (2015) How Policy Improves Health, Social Work in Public Health, 30:5, 410-422, DOI: 10.1080/19371918.2015.1034002 To link to this article: http://dx.doi.org/10.1080/19371918.2015.1034002

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Date: 05 November 2015, At: 15:37

Social Work in Public Health, 30:410–422, 2015 Copyright q Taylor & Francis Group, LLC ISSN: 1937-1918 print/1937-190X online DOI: 10.1080/19371918.2015.1034002

How Policy Improves Health Colita Nichols Fairfax and Marvin D. Feit

Social Work in Public Health 2015.30:410-422.

Ethelyn R. Strong School of Social Work, Norfolk State University, Norfolk, Virginia, USA

A discussion of health equity should be intricately examined in policy and practice discourse about the healthcare industry. This article addresses health equity with strategies to institutionalize it through policy implementation. This discourse is relevant to social work because social workers are charged with elucidating conditions that are maniacal and disadvantageous to racial groups, undocumented workers, immigrants and women. Social workers engaged in policy practice should consider how these stakeholders are excluded from health equity, because of the lack of transformative policy implementation that addresses industry practices that encourage disparity and maintain equity. This article hopes to provide a helpful view of health equity. Keywords: Policy implementation, health equity, health disparity, social justice

INTRODUCTION This examination is about the implementation of health policy affecting health outcomes for all people intergenerationally, with a specific emphasis on achieving societal health equity; “the absence of unfair and unavoidable or remediable differences in health among social groups” (Chapman, 2011, p. 133). What is obvious from the literature is the omnipresence of overwhelming inequity, correlating with poverty, race, educational status, income, and residence. Social workers have documented the disastrous impact of health disparity in a person’s life and throughout the trajectory of the lived experiences. Health disparity not only exacerbates poverty, it also devastates the person’s potentiality in areas of societal contributions, family advancement, professional and work fulfillment, cultural and spiritual needs, and status. Social workers are charged with elucidating conditions that are maniacal and deliberately disadvantaged to racial groups, undocumented populations, immigrants, and women. Social workers should create relevant and meaningful approaches to eliminating disparities to address equitable health services and outcomes. Applying a social justice concept requires an inherent personal and professional belief in human equality, rights and privileges, and advocacy that “individuals should not be denied of economic, socio-cultural, political, civil, or human rights based on the perception of their inferiority by those with more power or influence” (Dilworth-Anderson, Pierre, & Hilliard, 2012, p. 26). Social workers have to engage in a societal socialization process to move the dialogue and systems along toward health equity. This requires advocacy measures in addressing governmental role for ensuring systemic relationships with all people to ensure health outcomes, to prevent health catastrophes. To address equity, inequity of specific disparities within communities, and involvement groups of people affected by inequity must be addressed. Therefore, policy implementation begs the involvement of community agencies and the people who are affected by an abusive system. Address correspondence to Colita Nichols Fairfax, PhD, The Ethelyn R. Strong School of Social Work, Norfolk State University, 700 Park Avenue, James A. Bowser Building, Suite 121G, Norfolk, VA 23504, USA. E-mail: [email protected]

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Involving constituents in the community mean developing the change mechanism for those who have been abused, by inviting their narratives and their experiences within the analysis. The concrete evidence that is offered is used to locate the pressure points of health inequity and the areas of change that are vital to transform an abusive system. This article addresses health equity with strategies to institutionalize it through policy implementation. For purposes of this article, policy is defined as a formal course of action, predicated upon a particular set of values and ideology, to organize society. Social welfare policy is a subset of social policy, referring to government intervention of policies and programs to meet the needs of persons who cannot access private industry. Policy can either improve health or adversely affect health. This analysis employs a racism-centered perspective, utilized to explore how American social welfare policies (in this instance health care policy implementation), have regulated the lives of people of color, which have often been resisted by said populations (Schiele, 2011). To capture how people of color have been affected by health care policy, this perspective provides the reader with an examination of the interplay and dynamics of racism as a critical factor of how the health care industry operates. This analysis also employs a critical perspective, which identifies problems and solutions, based upon the interaction between people and social change practice (Longres, 1990). Social workers should become as familiar with a critical perspective that focuses on strategies linking people and social change, as they are with generalist practice or feminist approaches. This analysis is couched in a racism-centered perspective, with a critical approach requiring people to engage in policy implementation as a social change mechanism. It is suggested that there be an expansion in the social work curriculum about equity and equality. The National Association of Social Workers (NASW) Code of Ethics (2008) articulates a clear definition about equality, where we believe all people should be treated equal, with respect to self-determination. Yet an articulation about equity requires that the field makes a distinction between equality and equity, which this article explores. For purposes of this discussion, equity is the economic shared value of the health care system, with regards to ownership and inclusion of decision making and power. Equity then requires that all entities, such as stakeholders (consumers), medical social workers, nurses, physicians, and insurance companies have an equal role in ownership, and inclusion of decision making and power. In addition to equality, social workers should advocate for equity. Equity is an important aspect of health care, because consumers are treated based upon their economic worth and value. One’s economic worth and value is based in racism, even with the passage of America’s seminal public welfare policy. “From its start, the economics of the marketplace, . . . and racism combined to limit the scope and the effectiveness of [the Social Security Act of 1935]” (Axinn & Stern, 2005, p. 199).

THE ROLE OF GOVERNMENT Health care is an industry that, unfortunately, is inherently racist. It is a wealthy system based upon the preponderance of sick poor people who are politically and economically vulnerable. It promulgates health, while maintaining barriers to equalizing experiences, treatment, prevention, and relationships. If we lived in a society that was fair and equitable, then there may little discussion about the role of government. Given that we live in a society where poverty, racism, and sexism are enduring historical elements with damaging consequences that undermine the social contract, there must be an entity that seeks to adjudicate social well-being. Implementing the Affordable Care Act, Medicaid, and Medicare are the tasks of government. Does government have a role? It certainly does. The federal government plays a number of different roles in the American health care arena, including regulator; purchaser of care; provider of health care services; and sponsor of applied research,

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demonstrations, and education and training programs for health care professionals. (National Research Council, 2002, p. 57)

There have been major governmental policies passed that allocated health programs, that is, The Special Supplemental Nutrition Program for Women, Infants and Children (WIC), Supplemental Nutrition Assistance Program (SNAP, formerly referred to as food stamps), the State Children’s Health Insurance Program (SCHIP), the Department of Defense TRICARE, Veterans Health Administration (VHA), and Indian Health Service (HIS). These programs have had different outcomes upon different populations, because of existing inequality and unintended consequences. The intended and unintended consequences of policy implementation are based upon inflexible protocols, procedures, administrative bias, and accessibility that are afforded due to social status. Save Veterans and active military, persons who are forced to use these programs are systemically discriminated against and have interfaced with recalcitrant social institutions such as public education, the economic system in areas of employment, entrepreneurship and housing, and are marginalized by social services, corrections, and public health departments. By applying Schiele’s (2011) racism-centered perspective, one observes that equity is a systemic and ideological issue that is not isolated in health care, but supported by how the health care industry responds to the economic and political institutions that maintain racial disparity and other forms of inequality. “Inequities in health systemically put groups of people who are already socially disadvantaged . . . at further disadvantage with respect to their health; health is essential to wellbeing and to overcoming other effects of social disadvantage” (Braveman & Gruskin, 2003, p. 254). To begin true change, an entirely new method of policy implementation must include all stakeholders equally. Social workers should engage stakeholders to participate in programmatic strategies that will reduce unintended consequences and disparity to advance health equity. Furthermore, equity speaks to America’s tolerance of poverty, racism, sexism, and other forms of systemic injustices that we observe for in health outcomes. “The concept of health equity focuses attention on the distribution of resources and other processes that drive a particular kind of health inequality-that is, a systemic inequality in health between more and less advantaged social groups” (Braveman & Gruskin, 2003, p. 255). To work toward health equity requires social workers to address recalcitrant barriers to all people experiencing prosperity, selfdetermination, and equality. Health equity speaks to the public embarrassment about social well-being in America. The absence of equitable health treatment, intervention and affordable medication, has threatened the growth and advancement of particular people of color, with devastating marriage and family, economic, child-development, and aging outcomes. The health care industry has tolerated and accepted unequal systemic behaviors toward groups of people and has made human suffering a natural part of American society. Therefore, the target of a 21st-century analysis should be the implementation of health policy. Health equity is defined as imperatively the inclusion of all forms of sincere systemic sponsorship where the well-being of people is evidenced by dignified medical treatment, shared health governance with community constituents and resources. It means honoring and valuing people equally and honestly addressing the racial systemic reasons for inequity. Amartya (2002) agreed: Health equity cannot be concerned only with health, seen in isolation. Rather it must come to grips with the larger issue of fairness and justice in social arrangements, including economic allocations, paying appropriate attention to the role of health in human life and freedom. (p. 659)

Addressing health equity means addressing disparities in quality of life issue that is a never-ending task. It is frustrating to address because factors implicating health equity lack a comprehensive response from all systems, thus equity is systemically encouraged. So though health disparities exist between and among populations defined by race or ethnicity, social class, education, employment and underemployment, gender and gender identification (Schild & Sable, 2006, p. 77), disparity is

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confounded by the systemic response to the health needs of particular populations, because health care has been a system that has maintained inequity. “Social inequalities in health is to understand social determinants of health, and, increasingly, to explain the mechanisms or pathways that lead to the observed social differences in health outcomes” (Peter, 2001, p. 159). Conversely, disparity is influenced by systemic imbalances and poor uncoordinated service delivery, and the kind of service that is allowable. When people make a decision about how to treat their bodies, how to engage against maladaptive behavioral practices, in order to survive, we observe for disparity and high levels of health inequity. Compounding these everyday scenarios with race adds a complexity to any analysis of policy implementation. The most serious disparity occurs between Whites and African Americans, with great consequences that are recalcitrant to change (even though Native Americans have the highest rates of alcoholism). Even when disparities are confronted by communities reasonably, outcomes do not change disparity. Disparity can materialize in any system, in schools, in retail, in commerce, in corrections, because every system is a microcosm of disparity in American society. Disparity should not be truncated to one area of life’s vicissitudes. However, disparities remain that involve how people are diagnosed, how they receive treatment and how they respond to treatment, in all spectrums of health care: dental, psychiatric, public clinics, and so on. Policy can improve health or neglect health. Despite whom the people are, their race, ethnicity, social class, if the health care system comprehensively honored ethical codes of medical treatment, equity would be much more discernable. In other words, there has to be much more focus and pressure to change how health care is administered and to create policy where procedures are used for every case scenario, regardless of who the client/patient is. Several examples within the 20th century have shown that involving a variety of constituents to implement societal change to eliminate poor public health practices have proven effective. The tobacco and sugar industries are examples of this kind of policy implementation. An example of implementing meaningful analysis of disparity is in the current national discussion about the harmful effects of tobacco and sugar. Both of these multi-billion-dollar global industries have origins in the enslavement era, where Africans were forced to plant, harvest, and grow these substances in the Americas and Caribbean Islands (Ayala, 1999; Breen, 1985; Mintz, 1985). Historically, tobacco and sugar have occupied a source of pain for some racial groups, and pleasure for others. We continue to see remnants of this pain, as these substances wreak havoc in the lives of those powerless groups in these industries. Tobacco and sugar became habitual commodities in American markets, meals, and households. Some entities of the sugar industry are now indicating (admitting) that sugar can cause heart disease. The next step would be to determine where and what types of items contain the amount of sugar leading to heart disease. The questions may be how much sugar is purchased by families, how much is ingested, and what are other variables influencing the potency of sugar (types of foods, affordability of foods, exercise, risk behaviors, etc.). A social policy task force would seek out where these items are located and what will be done to correct this problem, with feedback from the community. What has to be determined is the extent of the problem, that is, the distribution of sugary items in the community. Once this data is collected, it needs to be shared with all constituents, all partners, to determine what needs to be done and how this issue is addressed. The tobacco industry is an example of meaningful policy implementation to curb tobacco usage. Initially, tobacco companies denied the harmful effect of smoking and chewing tobacco (Brownell & Warner, 2009). Yet activists, medical specialists, consumers, and other constituents engaged in years of lobbying against the industry. Social policy implementation of where one can and cannot smoke environmentally, age-appropriate purchases of tobacco products, information dissemination, advertisements appealing to “uncool” aspects of smoking has improved health behaviors. Smoking has decreased significantly among pregnant women and teens, and smoking is depicted less on television and the silver screen. A parallel observation has

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been made of the sugar industry. Sugar is now omnipresent in daily beverages and entrees. Sugar has been targeted as a variable in obesity and chronic illnesses. Sugar, or high fructose corn syrup, is cited to induce a host of toxicity, as a growing number of public health scientists are calling for reduced fructose (Lustig, Schmidt, & Brindis, 2012). Alcohol, tobacco, and sugar are distributed, consumed, and regulated due to aggressive policy implementation changes by stakeholders. So, for example, alcohol and tobacco are not sold to persons younger than age 18. Regardless of race and gender, if potential customers are younger than age 18, they are treated the same way at a legitimate store. Yet in the health care arena, all stakeholders who are African American, Latino American, Asian, or Native American are not treated in the same manner. Therefore, government has a role in health care.

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HISTORICAL REVIEW OF HEALTH EQUITY The history of health care is essentially a history of inequity. Social workers must be socialized to correlate policy and history to ascertain the impact of inequity upon social well-being. There cannot be a discourse or analysis about policy implementation that is outside of historical factual data. If one considers how policy is developed, one may conclude that, due to historical and social forces, certain procedures and protocols maintain ideological status quo in the health industry. Thus health care has never been equal in America. Although Native people had their systems and rituals of health care, and African people’s kidnapped migration transplanted indigenous health care practices, these groups were so heavily regulated and maligned that these practices were not respected and allowed to flourish. Day and Schiele (2013) documented that “the first general hospital, for both the mentally and physically ill, was begun in 1755” (p. 166), “and the first colonywide mental hospital built in 1769 in Virginia” (p. 168). Typically throughout the early centuries of America, medical treatment was provided for in homes, and within communities, free and enslaved. “Poorhouses became teaching hospitals, where treatment was a combination of old remedies, guesses, and experimental treatment or surgery, where vulnerable populations were experimented on did not receive care and reliable intervention” (Day & Schiele, 2013, p. 166). The health care industry mimicked segregated, malevolent racial practices (Washington, 2006), and human neglect, behaving as an ideological player. Although there was some type of health care coverage for military personnel, industrialization buttressed the development of employer-provided health insurance. Aetna Life Insurance Company, Travelers Insurance Company, London Guarantee and Accident Company in New York, Blue Cross and Blue Shield, Metropolitan Life Insurance and Prudential Insurance, Liberty Mutual Insurance Company, and Kaiser Permanente are among the first health insurance companies providing on-the-job medical care and accidental bodily injury policies (Scofea, 1994). So White workers connected with unions and categorized as skilled labor were potentially insured. Although people of color who occupied unskilled work, agricultural and domestic jobs, and were barred from union membership due to race, were unable to receive private insurance. Furthermore, in the absence of federal Veteran pensions, many African Americans experienced decades of inadequate or nonexistent health care, which worsened by the refusal of hospitals and availability of medical personnel to provide health care to people of color (Washington, 2006). It is significant to highlight that there were hospitals in the African American community, founded by Black doctors to serve that particular community, in the advent of segregation. Provident Medical Center in Chicago (founded as Provident Hospital and Training School) was the first, opening its doors in 1891 through the efforts of Dr. Daniel Hale Williams, the open heart surgery pioneer. The next oldest black hospital was the Frederick Douglass Memorial Hospital in Philadelphia, founded by Dr. Nathan Mossell and three other black physicians in 1907. By 1900, there were 40 Black hospitals and 11 Black medical schools in the nation (Hubbard Hospital was

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founded in Nashville in 1911 whereas Tuskegee Institute Hospital was founded in 1913). In 1932, there was only one Black hospital for every 100,000 blacks (or one hospital bed for every 1,000 Black patients). For Whites, it was 1 to 19,000 ratio (or one hospital bed for every 110 White patients). Most Black hospitals were located in the South where services for Blacks were at a minimum. Additionally, widespread segregation and inequity in hospital care, as administered by the state-wide boards, resulted in the high mortality rate of African Americans nationwide, with Howard University Medical School being the first) (Gamble 1995). Given that the health care industry was supporting private insurance for workers, hospitals were moving toward only treating those with insurance and those who were White. With donations from numerous private individuals and philanthropic organizations, White and Black, efforts were made from the early 1900s through the 1930s to build hospitals. The largest White contributor was the Julius Rosenwald Fund, but their gifts were given primarily to a handful of Black hospitals mostly in the North (Gamble, 1995). The Social Security Act of 1935 did not provide government insurance for occupations that African, Hispanic, and Asian Americans. The passage of this act allowed for the creation of a permanent mechanism to distribute programs and assistance related to health concerns of certain beneficiaries. Funds were provided by the Federal Emergency Relief Administration, the Civilian Conservation Corps, the Civil Works Administration, the Federal Emergency Relief Administration, the Federal Housing Administration, and the Works Progress Administration. For example, it was in 1915 that what would later be called Norfolk Community Hospital was founded. However, not until the Public Works Administration funded its facilities did it actually open for business in 1939. Even with PWA funding, the Black Masons, Black churches, the Universal Negro Improvement Association, the Black Elks, and numerous private individuals subsidized Norfolk Community Hospitals with private donations (Gamble, 1995). The advent of integration in the 1960s has forced the closing of many Black hospitals, especially those identified as the traditional Black hospitals. In 1984, only 32 Black hospitals were still in existence (a decrease from 40 in 1983). Between 1961 and 1988, 71 Black hospitals were closed, merged, consolidated, or converted (Gamble, 1995). Although equity in the White community continued to grow, equity in the African American community decreased, and those groups and persons who routinely supported these institutions were not able to continue to sustain the growth of the industry, with new technologies, medical protocols, and cost of medicine. Coupled with disgusting examples of egregious forms of medical abuse, such as the gynecological and Tuskegee syphilis experiments performed on Black enslaved women, public and private health care treatment and research have been discriminatory and dehumanizing. Between 1845 and 1849, Dr. J. Marion Sims, regarded as the father of surgical gynecology, president of the American Medical Association, and slave owner, performed experiments on African enslaved women, who were not anesthetized, to investigate vesicovaginal fistula, which is an obstruction created during labor (Washington, 2006). For 40 years between 1932 and 1972, the U.S. Public Health Service (PHS) conducted an experiment on 399 Black men in the late stages of syphilis (Washington, 2006). These men and their families were uneducated sharecroppers from one of the poorest counties in Alabama and were never told what disease they were suffering. Treating physicians had no intention of curing them of syphilis at all. The data for the experiment was to be collected from autopsies of the men, and they were thus deliberately left to degenerate under the ravages of tertiary syphilis— which can include tumors, heart disease, paralysis, blindness, insanity, and death. Their deaths were the goals, as autopsies were used for research (Washington, 2006). A contemporary example is found in the 1990s, where African American youths in New York were injected with Fenfluramine, the discontinued weight loss drug, by Columbia researchers investigating a hypothesis about the genetic origins of violence (Washington, 2006). Not only are people of color ill benefitting from competent medical attention, they are victims of predatory behavior from a system that has wealth, power, authority, lawlessness, upon people who are not protected by laws, and are economically

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and politically vulnerable, as there isn’t enough group equity to combat this heinous behavior that accompanies the development of American society. Even with the health laws and amendments of the 1960s, expanding the Social Security Act did not change health equity. The Community Mental Health Act of 1963, to provide funds and set up community mental health centers, the Food Stamp Act of 1964 to help meet the nutritional needs of the poor, Medicare (Title XVIII) and Medicaid (Title XIX) of 1965, which provided health insurance to the elderly and the medically indigent provided insurance (Axinn & Stern, 2005), have not altered health consequences for those living in poverty and social isolation. With the development of managed care plans, we do not observe for any change in how people of color experience health treatment. Managed care plans emerged in the 1970s, to integrate health insurance plans and preferred provider organizations in the financing and delivery of healthcare services to covered people with common elements such as selected providers to furnish comprehensive set of services, explicit standards for the selection of providers, quality assurance and utilization review and significant financial incentives for members to use providers and procedures covered by the plans. (Scofea, 1994, p. 7)

The Indian Health Care Improvement Act of 1976 was passed to address deplorable conditions in Native communities, and appropriate health care delivery methods. Social workers have been unwilling participants in how managed plans have operated, because the industry powerbrokers are unchanged. Insurance companies, hospitals, medical schools, and wealthy physicians maintain power and control in the midst of health policies that are passed. The passage of The Patient Protection and Affordable Care Act of 2010 (ACA) has not changed the health care landscape, because “the patterns of health and ill-health are shaped by discrimination, poverty, and exclusion that both biological and sociocultural factors play a significant role” (Chapman, 2011, p. 138). Social workers in Congress have a long history advocating for health care, and contemporarily, were principal advocates for ACA. Congresswomen Barbara Lee (CA), Allyson Y. Schwartz (PA), Susan A. Davis (CA), Carol Shea-Porter (NY), Niki Tsongas (MA), Congressmen Edolphus Towns (NY), Luis V. Gutierez, Ciro Rodriquiz (TX), Senators Barbara Mikulski (MD) and Debbie Stabenow (MI), have included health care on their platforms, based upon their practice experience in the field. Maintaining their membership with professional social work organizations kept them connected to the pulse of professional and practice concerns. While lobbying for the ACA, these social workers collectively lobbied for the passage of the Dorothy I. Height and Whitney M. Young Social Work Reinvestment Act in 2008. Given the need for more social workers in the fields of gerontology, mental health, and substance abuse, the Social Work Reinvestment Act of 2008 was a precursor to the passage of the ACA (Gorin, 2010). Social workers have been instrumental in culling data about essential health benefits, distributing consumer information, demystifying state health insurance exchanges, informing women of health and well-being issues, and identifying accountable care organizations.

UNIVERSAL HEALTH CARE: THE PATIENT PROTECTION AND AFFORDABLE CARE ACT The ACA is the country’s latest policy attempt to overhaul the health care industry. There are 10 titles in the Act to address reform: (a) Articulating quality, affordable health care for all Americans, (b) improving and coordinating the role of public programs, (c) improving the quality and efficiency of health care, (d) preventing chronic disease and improving public health, (e) increasing a health care workforce, (f) increasing transparency and program integrity, (g) improving access to innovative medical therapies, (h) expanding community living assistance services and supports, (i) aligning revenue provisions, and (j) reauthorizing the Indian Health Care Improvement Act

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(Shelton, 2004). As the only major industrialized country without a universal health care plan, there has been a growing movement for this citizenry entitlement. From as early as the presidencies of Theodore Roosevelt, Lyndon B. Johnson, and William J. Clinton, to the mantle passing to Barack H. Obama, to get such a bill passed through both chambers of Congress. Social workers have been advocating for universal health care policy since the 1955 inception of the National Association of Social Workers (NASW). Under William J. Clinton, NASW had its own Congressional bill that included a comprehensive health plan and cost –benefit analysis. The politics surrounding proposed universal health care included arguments about personal choices, government burdened with another program with regards to cost, maintenance, and taxes. Questions about government plans competing with private insurance plans pitted political groups against each other, whereas lobbyists poured millions of dollars to sway legislators from supporting any bill for universal care. Additional issues included whether government should go this far with providing care to wider population of people that is based in the rights of citizenship. These issues were intricately vetted during national campaigns of President Obama. In fact, using the term Obamacare has been used negatively, to assign the face of the first African American president with an “entitlement” program for those who were essentially accused of betraying the social contract of American society. Given the nation’s presidential voting trend toward Democrats (Fairfax, 2013), of those who favored the Act, other means to subvert implementing the law were used. Many Republican governors refused to have the program implemented. The Supreme Court voted not to punish governors for refusing the policy in their states: By a 7-2 vote, the Supreme Court held that the federal government couldn’t punish the states if they choose to not expand their Medicaid rolls. Obamacare can’t work unless they do so. More than half of the uninsured targeted for coverage under Obamacare are supposed to receive that coverage via Medicaid, thus getting the states to shoulder much of the cost. But states are struggling to balance their budgets with their current Medicaid burden. It makes no sense for them to expand their Medicaid rolls even further. By choosing to not expand their Medicaid rolls, they place a huge obstacle in the path of implementing Obamacare. The population originally planned for placement into Medicaid will have to seek coverage via the Obamacare exchanges (Skinner, 2012).

Given that there were many Republican governors who refused to implement the law, society witnessed a divided, visible union. The statute was ignored and was not enforced. What was unfortunately memorable about the implementation of the ACA of 2010 was the disastrous Internetbased enrollment process at healthcare.gov. Instead of establishing call centers manned with trained experienced personnel, the decision to totally rely on the Internet to register people in state-based exchanges were utilized. It was reported that the Internal Revenue Service and private nonprofit groups had planned to hire thousands of staffers and volunteers, with the goal of enrolling 2.7 million people for state exchanges to fulfill the individual mandate. The Department of Health and Human Services sent staffers to conduct informational sessions about the law and its mandate (Reuters, 2013). Employer-based mandates were delayed until 2015, sparing business owners the additional responsibility to provide health insurance. Yet the employee mandate was to offset the economic burden of the program. The individual mandate is when a health plan is purchased through one’s employer, a provider, obtained through the expanded Medicare or Medicaid program, or the health insurance exchange pool. Persons without insurance after a determined date would pay a fee for not enrolling. The controversy that threatened the viability of the ACA was the unsustainable online traffic to the government website. For weeks, accessing the website was arduous. Finally, telephone staffers were utilized more, yet they used the same website that proved to be user unfriendly. Sadly, this policy, unlike its health policy predecessors did not carry bipartisan support, although close to eight million people have enrolled in the program. Social workers should advocate for stakeholders (consumers) to have an equal role with insurance companies and state government administrators in how health care is allocated and administered, and be regarded as groups with power to influence protocols and processes. This is a beginning of addressing health equity.

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SUCCESSFUL POLICY IMPLEMENTATION TO ENHANCE HEALTH EQUITY: LESSONS LEARNED If we were to discuss health equality, then the discourse would only address equal treatment for all people regardless of race, gender, income, disability, and so on. Although equality is an important aspect of implementation and service delivery, to achieve health outcomes, equity speaks to “the exercise of countervailing power through empowering people, particularly disadvantaged groups to take increased collective control over the factors that shape their health” (Chapman, 2011, p. 142). We have witnessed health policies that have leveled equality, in the form of Medicaid and Medicare for citizens who means test for those programs. Yet we observe for continued social indicators that do not allow for health: poverty, low educational status, food deserts, racism, sexism, institutional discrimination, and so on. A successful health policy that has assisted with achieving health equity is the Family and Medical Leave Act (FMLA) of 1993. FMLA entitles covered employees to take unpaid job-protected leave for specified family and medical reasons with continuation of group health insurance coverage under the same terms and conditions as if the employee had not taken leave. Provisions include 12 workweeks of leave in a one-year period for maternity leave, spousal, child, or parental care, and a serious health condition that interferes with work functions (Asher & Lenhoff, 2007). Employees may also take up to 26 workweeks of leave to care for a family member who is an injured military member (Asher & Lenhoff, 2007). FMLA allows families to maintain their employment, insurance, and incomes, without losing items that achieve equity, such as homes, savings, credit scores, and Individual Retirement Accounts (IRAs). Also, the FMLA maintains a person’s health insurance policy, which allows one to continue a relationship with his or her primary physician, specialists, and other ancillary services. The implementation of FMLA allows for persons to maintain their resources and other indicators of upward mobility. This is a successful policy that has been implemented where greater health equity can be maintained. However, it isn’t a “universal” policy, as federal employees, some states, and some corporations utilize this policy. Earlier health policies passed have not ushered in health equity, and given the administrative nature of those policies, coupled with social indicators described, they will not achieve health equity. Groups that can influence policy implementation include stakeholders, as constituents with vested interest in the affairs and actions of an organization (Rakich & Feit, 2001). Health equity shall not be achieved if the industry structure is the same, with the same decision makers. To address equity means to also address social determinants of less advantaged racial groups with regards to resources and processes in receiving the appropriate treatment (Braveman & Gruskin, 2003). All constituents engaged in the health care industry, whether they are providers or consumers, should be equally regarded and included in the process. Quaid (2002) suggested that “key players associated with any policy ‘good idea’ are politicians, policy-makers, administrators, the target group (consumers), evaluators and the public to include lobby groups, the media and the general public” (p. 194), and insurance companies. More importantly, consumers are multifaceted players, which are hardly addressed in policy implementation. Upper-class and progressively educated groups will organize around these nutritional causes and corral an abundance of resources to infiltrate the media (and now social media) with messages about harmful substances and health care treatment. Yet poor groups remain observers and are often uninvited to the table. Poor groups such as unmarried women with children, poor men, intellectually and physically challenged persons, and newly immigrant persons are seldom consulted and included as legitimate consumers. The first strategy to engage policy implementation should be to intentionally widen the table to all consumers. If the system is to be fair, then conventional notions that medical providers are favored as mandatory experts maintain the industry status quo. As recommended before, “policy development should be placed more in the hands of those who receive and pay for healthcare than only under the control of physicians and politicians” (Congdon, 1995, p. 183). Those who receive services are valued experts, for they are

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able to speak to nuances of treatment and prevention experiences, and remain oblivious and untouched, thus encouraging health inequity and disparity. Secondly, the pain points of health care delivery must be identified, from triage courtesy, length of time with and quality of physician interaction, quality of specialist interface, screens and tests that are ordered, diagnosis and examination of test outcomes equally (i.e., X-rays, psychological, psychiatric, magnetic resource imaging [MRIs], computed tornography [CT] Scans, etc.), precautions, monitoring, injections, availability of therapy and follow-up. To eliminate these pain points, the same procedures should be followed for every patient. Congdon (1995) agreed that, “there is a general discrepancy between diagnosis and corresponding treatment in the medical profession” (p. 182). Such discrepancy occurs because of systems’ failure to ensure the same procedures for each case. However, bias and discrimination, judgments about patients’ ability to fulfill copay, unregulated medical delivery, disregard for family-involved consultation, and length of time tests are ordered are some of the pain points that can be targeted in delivery if policy persisted in universalizing procedures for all patients. When applying Schiele’s (2011) racismcentered perspective, we find that overwhelming people of color are affected by uneven and disjointed procedures that affect health delivery. Next, people of color must be included as stakeholders when addressing utilization. To sensitize the industry to equally serving all people, people of color must be at the table discussing direct care implementation. African Americans and other people of color are experts about the care that they receive. The barriers are not only inaccessible quality medical personnel, by virtue or segregated neighborhoods, but the lack of providers who represent and respect them. Coupled with a critical perspective that shows that utilization is not uniform. What if every medical personnel ordered the same test for each case? What if every chart was read by the same medical personnel with the same years of experience and expertise? Where is the policy that dictates that every case received an early diagnosis, invasive examination, courtesy of consultation, anesthesia, screening, therapy? What if every patient received the same follow-up call and was prescribed the same medication? Is there a uniform case management care plan? Utilization isn’t just the presence of a public health clinic or hospital, but that the medical staff is representable of the city or county racial population, and that there are procedures followed for every case, for every family regardless of race. The lack of these voices in setting health care policy may explain why attention to routine experiences lag (Congdon, 1995). Conversely, utilization should consider that given the historical and contemporary abuse that groups of color experience, there should be much more intensive analysis of diagnosis, with regards to cancers, high blood pressure, diabetes, kidney disease, HIV/AIDS rates, child asthma, obesity, and other medical issues that are over-represented among people of color. As people live longer, these issues will not melt away but exacerbate chronic sickly existences. This form of utilization reflects the need for comprehensive response to the complexity of health care that continues to threaten the lives of people of color. The implementation of direct care is vital to societal wellbeing, therefore people of color should be engaged in setting procedures to meet those medical needs that are devastating to marriages and communities and child well-being. This example of health “equity would tend to remove confounding effects of status bias in making sound review decisions” (Congdon, 1995, p. 190). So though people are asking to make lifestyles choices, as First Lady Michelle Obama’s Let’s Move campaign promulgates, people of color should be also asked to participate equally in health processes and procedures regarding industry behavior. The groups of people uniquely suffering from conditions and diseases should engage aggressive utilization with more exhaustive and comprehensive interventions. Next, policy implementation that is stakeholder based must engage the demands for a discriminatory system. Applying a critical perspective means addressing ethically and sincerely the prejudicial treatment in health delivery. Discrimination practices appear in the perpetuation of maltreatment. Amartya (2002) explained that the overall allocation of resources, or the rationing of healthcare, and social arrangements either deprives or provides different outcomes. The social

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arrangement implies that Whites are healthier, deserve better treatment because of who they are, and are important, valued, “‘employed,” moral, favored. Blacks and other people of color of weak, unhealthy, slovenly, dependent, immoral, caricatured, tolerated. Physicians who do not hire qualified African Americans and other people of color in hospitals, offices, and public clinics are maintaining a discriminatory system. Physicians who do not hire social workers to mediate povertyrelated issues that exacerbates health ignore the inherent aspect of racism. Medical clinics and hospitals who do not employ multilanguage interpreters are maintaining a discriminatory system that violates public health laws or intervention and treatment. Psychiatrists who involuntarily commit African American and Hispanic American males at higher rates are maintaining a discriminatory system that regulates the livelihood of these men, their families, and communities (Davis, Lewis, Zhang, & Thompkins, 2011). Social workers should be educated about the differences between equality and equity. We have learned that the notion of equal opportunities to be healthy is fundamental to the concept of equity as it reflects inherently in discrimination and marginalization (Braveman & Gruskin, 2003; Chapman, 2011). Although “achieving health equity may be challenging to tackle because it requires fundamental changes in underlying social and economic structure” (Braveman & Gruskin, 2003, p. 255), consumers should be included as stakeholders to change how structures operate. Social workers should evaluate the ACA’s disastrous implementation of 2012 to 2013. This significant and necessary legislation is the beginning of policy improving health. Yet when applying a critical approach, it seems to be riddled more than capitalism than socialism. The structure of health care has remained. Although more Americans will have access, decision making remains in the hands of the same entities: insurance companies, businesses, and corporations. We observe a structure that remains hierarchical, patriarchal, and wealthy. Despite well-intentioned evaluations of staff performance, quality improvement, client satisfaction and accessibility, we continue to observe racist interactions, expensive copays, lack of circularity, and a continued disempowered consumer base. Even though the Department of Health and Human Services headed the website roll out and implementation, social work organizations were not consulted in service delivery (Andrews, Darnell, McBridge, & Gehlert, 2013). The National Association of Social Workers, National Association of Black Social Workers, National Association of Puerto Rican and Hispanic Social Workers, Council for Social Work Education, The Society for Social Work Leadership in Healthcare, and National Alliance on Mental Illness offer a vast network of social work practitioners with tentacles in all communities that could have been utilized as valuable stakeholders in decision making and service delivery aspects of the implementation of this Act.

IMPLICATIONS FOR SOCIAL WORK There are a plethora of research confirming the existence of health inequality in policy implementation, administrative bias, service delivery, and outcomes. As the ACA continues to evolve, there is an opportunity for social workers to practice health equity. For example, practicing to ensure that consumers and social workers are present on advisory and hospital patient advocacy boards, and in other decision-making outlets that have the attention of those in the industry, are initial steps, because increasing transparency and program supports is a goal of the ACA. Social workers can engage critical thinking skills to create empowerment zones for consumer participation, “empowerment rests on an expanding notion of the requirements of human dignity and the affirmation of the principles of consultation, participation, transparency, and accountability” (Chapman, 2011, p. 143). These mezzo approaches are critical to combatting oppressive institutional behavior that has been recalcitrant and harmful to those most vulnerable. Social work research should investigate barriers to consumer input and involvement in areas where their experiences would yield more insight. Empirical research should investigate (a) why

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consumers absent in decision making factors of health equity? (b) Where is the lack of inclusion in areas of lobbying? (c) What are the economic interactions between local governments and grocery chains? (d) What are the economic possibilities for localities to collaborate with Native people to build and fund hospitals/clinics where indigenous practices are also utilized? (e) What are the best ways to teach poor families to change their nutritional habits, when they reside and work in food deserts? Research should focus more on the best approaches to build health equity by leveling social advantage, instead of rehypothesizing questions about the existence of health disparities. Social work education should consider expanding its curriculum of social well-being, human rights, social justice, and equality to include equity. Given that there is a distinct difference between equality and equity, social workers should be trained to conceptualize and measure equity in relationship to opportunity, resources, and process in ways that can address health and mental health outcomes in policy, practice, and research. “Awareness of the need for greater clarity about the definition of health equity” (Braveman & Gruskin, 2003, p. 257) would provide social workers with more knowledge about the impact of structural discrimination, racism, and sexism. Social work education should socialize students to focus more on changing outcomes than on the causes of social illnesses that maintains the lack of equity that undermines vulnerable people.

CONCLUSIONS In this age of the ACA, social workers are completely important in its implementation to create more health equity for all people. Policy affects health. Policy affects the delivery of health care. Policy implementation that is transformative will only occur if there is large-scale social, cultural, and value shifts in the thinking and behavior of those in power, with influence over how the health care industry operates. This article addresses ideas of how to effectively change the hierarchical structure of health care to include consumers, social workers, and other health care practitioners. In other words, health equity cannot be achieved if the structure is maintained. The structure must be changed to include other stakeholders as power brokers in decision making, redefining delivery designs and variations of health interventions. Furthermore, the necessity to include professional social work organizations is vital to shifting industry behavior. “Understanding the effects the basic structure has on people’s prospects of health may help us decide whether or not these institutions ensure the social bases for self-respect for everybody” (Peter, 2001, p. 167). Self-respect may be the beginning, but the issue of health equity is truly a life-or-death situation for millions of Americans. Using Schiele’s (2011) racism-centered perspective and Longres’ (1990) critical thinking approach revealed how entrenched racism is a part of the function of health care delivery, and social workers have the collective power to uncover practices and interactions that maintain bias, unhealthiness, and inequity. It is incumbent upon the field to corral its organizational resources to prioritize overhauling an industry with years of abusive and maniacal practices that are inhumane and wreak of injustice. Policy implementation that is transformative must address not only disparity, but also elimination of industry practices that maintain disparity. Through a well-coordinated strategy, stakeholders are empowered to offer their expertise as consumers and receivers of care in delivery reform that will seal the deal allowing policy to positively affect health.

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