Advance care planning (ACP) is the process of determining and documenting desired wishes for the end of one’s life. Referred to by such terms as end-of-life planning, advance (health) directives, and living wills, ACP is a relatively new concept within our society, having emerged as a social, political, and ethical issue in the United States only since the 1960s. Researchers and legislators have been challenged in their efforts to examine healthcare decision-making and design appropriate policy to guide practice. This article will define ACP, provide an overview of the history and evolution of the process and the associated legal and ethical issues, and describe the process with three specific populations. In addition, it examines the role of the social work profession in working with individuals and families on planning for the end of one’s life.
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Advance Care Planning
Meredith Stensland, Sara Sanders, and Marla Berg-Weger
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Affordable Care Act
Stephen H. Gorin, Julie S. Darnell, and Heidi L. Allen
This entry describes the development and key provisions of the Patient Protection and Affordable Care Act (ACA), which instituted a major overhaul of the U.S. health system, much of which took effect in 2014. The key provisions of the ACA included an individual mandate to purchase insurance, an employer mandate to offer coverage to most workers, an expansion of Medicaid to all persons below 138 percent of the federal poverty level (FPL), minimum benefit standards, elimination of preexisting condition exclusions, and reforms to improve health-care quality and lower costs. This historic legislation has deep roots in U.S. history and represents the culmination of a century-long effort to expand health care and mental health coverage to all citizens.
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Aging: Public Policy
Jeanette C. Takamura
Public policy advances in the field of aging in the United States have lagged compared to the growth of the older adult population. Policy adjustments have been driven by ideological perspectives and have been largely incremental. In recent years, conservative policy makers have sought through various legislative vehicles to eliminate or curb entitlement programs, proposing private sector solutions and touting the importance of an “ownership society” in which individual citizens assume personal responsibility for their economic and health security. The election of a Democratic majority in the U.S. House and the slim margin of votes held by Democrats in the U.S. Senate may mean a shift in aging policy directions that strengthens Social Security, Medicare, and Medicaid, if the newly elected members are able to maintain their seats over time. The results of the 2008 presidential election will also determine how the social, economic, and other policy concerns will be addressed as the baby boomers join the ranks of older Americans.
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Food (In)Security
Maryah Stella Fram
This entry provides an overview of current knowledge and thinking about the nature, causes, and consequences of food insecurity as well as information about the major policies and programs aimed at alleviating food insecurity in the United States. Food insecurity is considered at the nexus of person and environment, with discussion focusing on the biological, psychological, social, and economic factors that are interwoven with people’s access to and utilization of food. The diversity of experiences of food insecurity is addressed, with attention to issues of age, gender, culture, and community context. Finally, implications for social work professionals are suggested.
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Global Health
Jessica Euna Lee
Within its 150-year history, public health has grown from a focus on local communities to include countrywide, then international, and now global perspectives. Drawing upon the United Nations Sustainable Development Goals, this article provides an overview of global public health within the broadest possible context of the world and all of its peoples. Also provided are the global burden of disease as measured in disability-adjusted life years, global health statistics, current health priorities, and recommendations for action by social workers and other health professionals.
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Health Care Reform
Cynthia Moniz, Stephen H. Gorin, and Terry Mizrahi
National health care reform in the United States, from its introduction into the public policy agenda at the turn of the 20th century through policy debates and legislative proposals more than a century later, has achieved limited success with universal coverage for health and mental health services. Opposition to government-sponsored health care has always been present. The extent of the opposition has depended on the type of reform proposed and the era in which it occurred. Medicare and Medicaid reform in the 1960s greatly expanded access and coverage for older adults and low income individuals and families. But, the first true effort to reach universal coverage occurred with the passage of the Affordable Care Act in 2010.
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Health Disparities and Inequities
Sandra Wexler and Valire Carr Copeland
Despite technological advances and changes in healthcare delivery, some groups in the United States continue to have better health-related outcomes than others. This article discusses health disparities and inequities—differences in health status and healthcare utilization that are influenced by complex social, structural, economic, and cultural factors. It begins by exploring the “problem” with health disparities—what makes them problematic and for whom they are problematic. Factors contributing to health inequities, commonly referred to as social determinants, are then reviewed. Finally, the article considers early 21st-century policy and programmatic responses as well as future directions, including social workers’ role as macro practitioners.
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HIV/AIDS and People of Color
Michele Rountree and Courtney McElhaney Peebles
Communities of color are disproportionately burdened by the prevalence of HIV/AIDS. Research has shown that race and ethnicity in the United States are population characteristics that correlate with other fundamental determinants of health outcomes. This entry will chronicle the history of the epidemic, report the disparate impact of the disease affecting communities of color, and acknowledge the social determinants of health that contribute to the vulnerability of risk. A call to address the imbalance of health inequities, with a complement of individual-level interventions and new approaches that address the interpersonal, network, community, and societal influences of disease transmission, is discussed.
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Indigenous and Tribal Communities
Megan G. Sage
Indigenous populations have experienced hundreds of years of historical trauma, systemic racism, and oppression since colonization began in the Americas, Australia, and New Zealand. Settler colonialism has created and continues to perpetuate historical and ongoing trauma and systemic racism in Indigenous populations. Despite considerable diversity and resilience among Indigenous populations globally, there is a clear pattern of significant disparities and disproportionate burden of disease compared to other non-Indigenous populations, including higher rates of poverty, mortality, substance use, mental health and health issues, suicide, and lower life expectancy at birth. Substantial gaps related to access to healthcare and service utilization exist, particularly in low-income Indigenous communities. Implementation and sustainment of White dominant-culture frameworks of care in Indigenous communities perpetuate these systems of oppression. Development and implementation of culturally informed services that address historical trauma and oppression, and systematically integrate concepts of resiliency, empowerment, and self-determination into care, are issues of policy as well as practice in social work. The co-creation and subsequent implementation, monitoring, and sustainment of effective systems of care with Indigenous populations are essential in addressing health disparities and improving outcomes among Indigenous populations globally.
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Institutional Racism and Effects on Health and Well-Being
Valire Carr Copeland, Betty Braxter, and Sandra Wexler
Racial inequality negatively influences the lives of people of color in the United States. Although race refers to differential concentrations of specific genes, the impacts are confined to physical characteristics such as skin color, hair type, and eye color. Rather than designating meaningful biological categories, race is a social construct. Yet, where there are inevitable intersections with institutional structures and interpersonal health relationships, race and racism produce inequities.
Racism occurs within and permeates the overarching political, social, cultural, and economic systems of American society. It can take several forms: structural, institutional, interpersonal, and internalized. Institutional racism in the healthcare system yields adverse effects on the physical and mental health and well-being of racialized individuals and communities. These inequities are well documented.
Recommendations are offered for creating a fairer and more just healthcare system in America. Equality and equity in the country’s healthcare system will be achieved only if racism is challenged in all its forms.
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Managed Care
Vikki L. Vandiver
Since the mid-1980s, managed care has been one approach used to address the economic crisis in the American health-care system. This entry overviews managed care from the perspective of policy, procedure, practice, and system. Specifically, emphasis is given to understanding the emergence and history of managed care, multiple definitions, how it works, and examples of managed care plans, key legislation, existing research, its future, and implications for social-work practitioners.
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Medicaid and Medicare
Victoria M. Rizzo, Sojeong Lee, and Rebekah Kukowski
In 1965, Titles XVIII and XIX of the Social Security Act were passed, creating Medicare and Medicaid and laying the foundation for U.S. healthcare policy. Originally, Medicare was created to meet the specific medical needs of adults aged 65 and older. In 2022, individuals with end-stage renal disease, amyotrophic lateral sclerosis (ALS), and other disabilities may also receive Medicare, regardless of age. Medicaid was established to provide a basic level of medical care to specific categories of people who are poor, including pregnant women, children, and the aged. As of 2010 as part of the Affordable Care Act (ACA), states are provided with the opportunity to expand Medicaid to close the coverage gap for public health insurance. This entry provides explanations of Medicaid and Medicare and associated social healthcare programs in the United States. An overview of significant programming developments and trends, future directions, challenges, and controversies as of 2021 are also provided.
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Military Social Work
Kelli Godfrey and David Albright
Although there are many definitions of military social work, this article primarily focuses on social work by uniformed personnel within the United States military. Social work with military and veteran-connected populations is also done by civilian professionals.
The history of military social work in the United States is rooted in the civilian professional social work community and is a microcosm of that sector. Military social work has a rich history of providing services to military men and women and their families during periods of peace, conflict, and national crises. Military social workers have been involved in humanitarian operations and have participated in multinational peace-keeping operations. Social work in the Army, Navy, and Air Force is tailored to the mission of their particular service. However, joint operations between the services are becoming more frequent. Military social workers adhere to the National Association of Social Workers (NASW) code of ethics while providing service to an institution with its own unique culture, standards, and values. The role of military social workers has expanded since the Global War on Terrorism began, in 2001.
Military social work encompasses a wide variety of skills, performed by social workers who are both civilian and military, ranging from crisis to working with families. Military social work is unique and often faces ethical dilemmas even though military social workers still follow the National Association of Social Workers’ Code of Ethics. The history of military social work dates back to the early 1940s, but has evolved with the needs of military members and their families. The Army, Air Force, and Navy all have social workers, both civilian and those who wear the uniform. Due to the number of veterans and military families living throughout the United States, and seeking care in community settings, recommendations to establish competencies for social workers working with military and veteran-connected populations is underway.
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Outcome Measures in Human Services
Bruce Friedman and Rosario Olivera
The field of social work transformed over time from providing relief to less fortunate individuals to a sophisticated profession that looks at evidence-based measures to deliver change. This has been possible by looking at accountability aspects to demonstrate improvement by addressing performance outcomes resulting from interventions. Outcomes operate on all levels from micro to mezzo to macro, and the skills needed include identifying who is being served and the specific goals to be achieved. This article introduces the use of a logic model as a way to explain interventions and outcomes on a short-term, intermediate term, and long-term basis. The section also describes current measures being used to demonstrate how outcomes are used to justify the practice.
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Psychosocial Support in Emergency Settings
Maryanne Loughry
The integration of psychosocial support into emergency responses is a recent development. In the 1990s, the need to address the mental health and psychosocial well-being of individuals and communities affected by emergencies became clear following the breakup of the former Yugoslavia (1991–1992) and the Rwandan genocide (1994). Prior to this, mental health in emergencies was primarily addressed in clinical settings. However, the humanitarian field was divided between the medical sector, which asserted that psychiatric clinical intervention was best, and many nonmedical actors, who preferred a person-in-environment approach. The need for consensus resulted in the Inter-Agency Standing Committee (IASC) working group’s establishment of the framework of Mental Health and Psychosocial Support (MHPSS), which combined both approaches. The IASC Guidelines on MHPSS in Emergency Settings, published in 2007, are widely recognized as explaining how best to administer psychosocial support in emergencies. This ended decades of tension between mental health and psychosocial experts in emergency and humanitarian settings.
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Reproductive Health
Marjorie R. Sable and Patricia J. Kelly
Reproductive health includes family planning, prenatal care, and the broader scope of primary care. Because a woman's health status at conception is as important as prenatal care, genetic screening and 20th century medical technology, reproductive health includes “the preconceptual and interconceptual periods and the menopause, and finally, not only reproductive tract problems but the wide range of risk factors that influence a woman's health in general.” Quantitative indicators of reproductive outcomes are useful for summarizing progress in reproductive health. Important indicators are discussed and reveal significant racial disparities.
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Social Capital
Katrina Balovlenkov
Social capital is a social science concept used within macro social work practice to describe the role of human relationships, connectivity, and networks in the planned change process. Social capital has been used to examine how marginalized populations and resource-limited communities mobilize and act to improve social conditions relying on human relationships, connectivity, and networks. Social capital, particularly as it relates to social support and collective efficacy, is linked to preventing and treating disease and addressing socioeconomic conditions that create community-level barriers to well-being. Cultivating social capital has influenced social movements in the United States to produce positive change, such as efforts to create green spaces, challenge discriminatory laws, expand access to healthy food in food deserts, preserve native lands, and enact healthcare reforms. While the definition and measurement of social capital has evolved over the years, in the broadest sense it informs macro social work by improving our understanding of how collective advocacy built on interconnectedness, reciprocity, and trust in both the quality and quantity of social relationships results in real change.
