A Social Work Approach to Policy: Implications for Population Health

摘要

The substantial disparities in health and poorer outcomes in the United States relative to peer nations suggest the need to refocus health policy. Through direct contact with the most vulnerable segments of the population, social workers have developed an approach to policy that recognizes the importance of the social environment, the value of social relationships, and the significance of value-driven policymaking. This approach could be used to reorient health, health care, and social policies. Accordingly, social workers can be allies to public health professionals in efforts to eliminate disparities and improve population health. Despite spending the most on health care, the United States lags behind a majority of its peer countries in life expectancy and other major health indicators across the life course. US infant mortality rates are more than triple those of the Organisation for Economic Co-operation and Development countries with the lowest rates (Iceland and Finland), 1 and later in life levels of obesity and cardiovascular disease far exceed those of other countries. 2 Given the many similarities between the United States and England, comparisons of risk factor biomarkers and objective indicators of health between residents of the 2 countries are particularly instructive: US residents fare worse on nearly every health indicator, and this situation persists even after differences in individual risk behaviors (e.g., smoking and alcohol consumption) and insurance coverage have been taken into account. 2,3 Coupled with consistent evidence on the sizable socioeconomic, racial/ethnic, and geographic disparities in morbidity and mortality within the United States, 4 these comparisons suggest that higher levels of health care spending, the continued narrow focus on individual behaviors, and expansion of insurance, although likely important, are not sufficient to significantly improve health in the United States. There is a growing consensus that policies can respond to these important disparities. The American Public Health Association has adopted a health in all policies mantra, developing a series of recommendations for state and local governments to “incorporat[e] health considerations into decision-making across sectors and policy areas.” 5 The US Patient Protection and Affordable Care Act (ACA; Pub L No. 111-148) has created a number of opportunities for innovative care provision, many of which acknowledge the particular needs of the poor and the medically underserved, including expanded opportunities for community health centers, community health workers, and patient-centered medical homes. 5,6 Consonant with an emphasis by key federal entities on the importance of social factors, 7 researchers have begun to investigate whether a focus on the social determinants of health can reduce hospital readmissions and improve patient outcomes. 8 Also, attention has turned to the use of innovative payment mechanisms such as federal waivers that allow Medicaid reimbursement for nonmedical services (e.g., housing). 5 However, the predominant focus of the ACA has been the expansion of insurance coverage. Although insurance increases access to and use of various health services, 9 and coverage expansions under the ACA have been linked to better self-reported well-being and health, the extent to which expanded health care coverage can substantially improve population health remains unclear. 9 Furthermore, many of the innovations noted here focus exclusively on clinical interactions, limiting their potential to effect meaningful changes in population health. This concentrated policy focus on insurance and the health care delivery system is uniquely American, and despite the number of innovations in recent years that endorse a broader view of health policy, the continued predominant focus on insurance (to the exclusion of other policies) has important effects on health. Indeed, social policy differences between the United States and peer countries probably contribute to both the “American health disadvantage” internationally and the within-country health disparities just noted. 10 For instance, UK antipoverty policies are more expansive than comparable US policies, 1 with Britain’s package of social policies representing a far greater commitment to poverty reduction and social redistribution of wealth. 11 Although both countries spend roughly 8% of their gross domestic product (GDP) on public health care, UK family policy expenditures, directed toward family allowance, parental leave, early childhood education, and child care, exceed US expenditures nearly 6-fold (4.0% vs 0.7% of GDP). 1 These comparisons highlight the urgent need for US policymaking to more actively target the social determinants of health, including the “upstream” social structures that activate and maintain health disparities. Reflective of a number of core principles that will be familiar to many in the public health audience, a social work app