What Will Obamacare Mean to Social Work?

January 8, 2013
by Eric Lindberg

Health care in the United States is undergoing a dramatic transformation.

The re-election of President Barack Obama has solidified the likelihood that his landmark health care reform legislation known to many as Obamacare will endure, with lasting implications for those in the field of social work.

Although the new law, officially titled the Patient Protection and Affordable Care Act, is still being rolled out, and its effects on the health care industry and related professions remain relatively murky, one thing is clear—more people than ever are going to have access to health care.

An estimated 19 million people will become newly eligible for Medicaid, including many low-income residents who face a multitude of physical and mental health challenges.

“In theory, there is a greatly expanded role for social workers given this large influx of patients into the health care system, both in roles that help patients coordinate and navigate multiple systems, and in direct service such as case management and counseling,” said Marilyn Flynn, dean of the USC School of Social Work.

In addition to expanding access to federal health care programs, the act bans insurers from denying coverage to people with preexisting conditions, lets children remain on their parents’ insurance plans until age 26, and mandates that companies with more than 50 employees offer health insurance to their workers. It also creates state-based marketplaces that offer health insurance and provide assistance with insurance premiums to low-income populations.

Flynn noted that a hallmark of the Affordable Care Act is its emphasis on cost savings, efficiency and effectiveness, and preventive care. Although social work practitioners and researchers have been strongly engaged in those issues for decades, she said social work leaders will need to highlight their expertise if they want to guide the health care industry into a new model of sustainability.

“How quickly we get to the table, how quickly we establish the roles we can play, and how quickly we actually demonstrate cost savings in these new systems will probably determine the extent to which this has a revolutionary impact on us or whether we simply fall back and fade back and are overtaken by other professions,” she said.

Regardless of national politics and whether the new health care legislation survives in its current form, it is clear that the nation’s health care system is not structured in a sustainable way, said Marv Southard, director of the Los Angeles County Department of Mental Health.

“In the next decade, there will be a massive and systemic change,” he said. “We don’t know the details of how that will come about, but for social work it represents an enormous opportunity.”

Southard, who holds a doctorate in social work, believes the profession’s increasingly holistic focus on clients in the context of their families and communities, rather than simply in terms of their specific physical or mental ailments, is a major advantage for social work.

In fact, a more integrated approach to care is a key component of the path forward, he said, particularly for those with co-occurring health, mental health, and substance abuse problems. Systems of care for those issues currently operate on relatively separate tracks, Southard said, and will need to begin shifting to an integrated model if health care providers hope to achieve successful outcomes and contain costs.

“It’s been my hope that social work is the profession that provides the intellectual and historic resources to complete that integration,” he said. “I’m just worried that we aren’t going to move fast enough.”

In outlining several main strategies he views as critical for the profession to take a leading role in health care reform, Southard said social work scholars need to be more assertive in conducting research and publishing results on the social determinants of health outcomes—how an individual’s social environment and interaction affects their treatment and recovery.

In the mental health field, new approaches such as the use of peer navigators, or those who have experienced mental illness themselves, to help their fellow clients access care and adhere to treatment is an example of how social work can capitalize on its focus on the recovery model, he said.

“USC is moving very much in the right direction,” Southard said. “Dr. [John] Brekke’s work on the use of people with lived experience as care coordinators is an absolute perfect step for our profession.”

Another area of emphasis for the profession should be what Southard termed “unsponsored” illnesses that don’t seem to fit into any specific field of health, such as dementia and traumatic brain injury.

“Those with dementia aren’t considered part of the mental health system, and the physical health system can’t do much for them. For those with Alzheimer’s, it’s pretty much custodial care,” he said. “We can take leadership and imagine how to provide care for these orphaned ailments.”

On the education front, Southard said social work students interested in health care need to be aware of ongoing developments in the field and develop some basic integration skills, such as knowledge of various screening and assessment tools for substance abuse and mental illness.

He expects to see an increasing demand for those well versed in the latest technologies, a view shared by Kathleen Ell, the Ernest P. Larson Professor of Health, Ethnicity, and Poverty at the USC School of Social Work.

As a researcher who has bridged the gap between social work and health care since her groundbreaking studies on the link between depression and mortality among heart disease patients during the 1960s, Ell said the need to revolutionize the health care industry with new approaches and cost-effective technology is critical.

“There is gigantic literature out there on health policy that says we’re going to destroy Medicare and Medicaid if we don’t do something,” she said. “From a medical perspective, there are too many expensive tests. There’s so much duplication right now if you have co-morbid illnesses.”

Improving coordination across providers is a big focus of her current research agenda. For example, although a primary care physician may be viewed by many as the point person for someone fighting cancer, it’s likely that patient will also visit an oncologist, a surgeon, a chemotherapy specialist and a radiologist.

With recent breakthroughs that have increased cancer survival rates, Ell said there is a lack of follow-up care to ensure patients who receive successful cancer treatment return to their primary care physician for regular checkups and to address other medical problems. And when patients begin experiencing depression or other mental health issues as a result of their health situation, it is unclear who is responsible for coordinating that care.

“Doctors are so busy, so how is information going to be transferred back and forth?” she said. “There is no commander of the ship.”

Ell sees social workers as strong candidates for the role of care coordinator, but said they must develop knowledge of new health technologies and information systems if they want to compete for that position. She is pursuing several research projects focused on technology that is designed to improve quality of care while reducing costs.

One project involves automated phone calls to discharged patients to track their symptoms, monitor their progress and ensure they are taking the correct medication. If a patient describes worsening symptoms or indicates they might be experiencing depression, for example, an alert is issued to health professionals involved in that patient’s care, including nurses, physicians and social workers.

“In the not-too-distant past, social workers were all over the place in hospitals and clinics, and used to write notes in medical charts or talk directly with the doctor or nurse,” Ell said. “Now that’s gone. We can’t afford that kind of practice anymore, so we need to have all these new technological applications, including for patients.”

Although she understands many people prefer in-person interaction with their health care providers, telehealth is becoming increasingly prevalent and cost effective, particularly in rural areas. A key to its successful expansion is revised training for baccalaureate and master’s degree students in social work, Ell said, to acquaint them with the process of providing virtual care.

In terms of research, she said more social work scholars will need to partner with scholars in different disciplines, such as engineering and economics, to gain an edge as advances are made in health care technology. She recently began working with a specialist in industrial and systems engineering, as well as a health economist who focuses on the expense side of her research initiatives.

“Things that aren’t cost effective are just going to go away,” Ell said. “That’s the reality.”

USC School of Social Work leaders have encouraged interdisciplinary collaboration, particularly with those in the medical field. The school’s behavioral health research cluster has emphasized collaborative research, as well as a focus on person-centered health care that integrates health, mental health and substance abuse services.

“It gives us a starting point for innovation that other places don’t have,” Flynn said. “We also have a very strong connection with our medical school. This is a big advantage for us, and hopefully we’ll be able to build new roles for our internships and for our researchers, simply here in our own institution.”

Julie Cederbaum, an assistant professor who specializes in health and social welfare, noted the school’s health concentration and its joint degree program in social work and public health also give it an edge over other universities.

“That is absolutely a sign that we recognize the importance of having this kind of multidisciplinary approach,” she said. “We are specifically training people in health and integrated health care, and that gives our graduates more specialized training that their peers in other schools might not get.”

However, Cederbaum stressed the need to view health care beyond the hospital setting, particularly given the Affordable Care Act’s focus on preventive care. Under the legislation, hospitals can be sanctioned if their patients return too quickly after being released, she said.

That places additional pressure on social workers and other health practitioners to develop community-based preventive care programs. Cederbaum also sees a role for social work practitioners as community care coordinators, checking up on clients when they leave the hospital to make sure they adjust to life at home and manage their medication appropriately.

“We need to move out of the hospitals and into the community,” she said. “We need to emphasize community-based work and utilize our skills of empowerment and advocacy to make this a community-driven initiative rather than a top-down initiative.”

As the landscape of health care continues to evolve during the coming years, Flynn said new opportunities for inquiry and exploration will emerge. Faculty members will need to show leadership and the ability to adapt their teaching and research skills in a fluid and rapid manner if they want to successfully compete in the new paradigm.

“There is a very broad reorientation that is taking place,” she said. “There is no person who fails to see this as fundamentally important for the profession of social work, but people are still struggling to understand how we will be impacted and how we can best respond and organize ourselves.”