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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Affordable Care Act
Stephen H. Gorin, Julie S. Darnell, and Heidi L. Allen
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Deinstitutionalization in Macro Practice
Steven P. Segal
The deinstitutionalization policy sought to replace institutional care for populations in need of care and control with prosocial community-based alternatives. U.S. institutional populations, however, have increased since the policy’s inception by 205%. As implemented, with the assistance of advocacy and cost-cutting factions, it has succeeded only in enabling the divestiture of state responsibility for target groups. It sought to prevent unnecessary admission and retention in institutions. As implemented, deinstitutionalization initiated a process that involved a societal shift in the type of institutions and institutional alternatives used to house its target groups, often referred to as trans-institutionalization. For many in need of institutional placements, it has succeeded in preventing all admissions, expanding admissions for others. In seeking to develop community alternatives for housing, treating, and habilitating or rehabilitating its target groups, it has succeeded in establishing a variety of alternative living arrangements and showcase and model programs illustrating what can be done; yet, it has failed to deliver on investments in such programs to serve the majority of its target groups. It has resulted in the abandonment of substantial numbers to homelessness. It has been documented, from political, economic, legal, and social perspectives, how this policy has affected the care and control of populations such as older adults, children, people with mental illness or developmental disabilities, people under correctional-system supervision, and, more recently, individuals without a home. Suggestions for a truer implementation of deinstitutionalization’s initial aspirations are available.
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Health Care Financing
Candyce S. Berger
The U.S. health care system is a pluralistic, market-based approach that incorporates various public and private payers and providers. Passage of Medicare and Medicaid, combined with rapid advances in technology and an aging population, has contributed to rising health care costs that typically increase faster than general inflation. This entry will review health care financing, exploring where the money is spent, who pays for health care, what the reimbursement mechanisms for providers are, and some issues central to the discussion of reform of health care financing. To effectively advocate health care reform, social workers must understand health care financing.
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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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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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Pandemics and Social Work
Sangeun Lee
A pandemic contains three key components: extensiveness, novelty, and severity. For the past century, humankind experienced the Spanish flu in 1918 and COVID-19 in 2020 as major pandemics. The global impact has been extensive in terms of their origin, international transmission, and mortality rates. Public health measures to slow and stop pandemics have been implemented. During the COVID-19 pandemic, disparate impacts on health in different populations have been witnessed due to existing social inequalities, detriments of health, and structured racism. The interests of social workers have been adversely impacted in those pandemic times. Spanish flu bolstered social work with a professional presence. COVID-19 has confirmed the need for community engagement and community development to follow large-scale social policy reforms as a response to the disproportionate impact on diverse marginalized communities, which is the core of macro social work practice and would be more strongly called on to prepare for future pandemics.
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Public Health Social Work
Sarah Gehlert, Julie A. Cederbaum, and Betty J. Ruth
Public health social work is a substantive area within the discipline of social work that applies social work and public health theories, frameworks, research, and collaborative practices to address contemporary health issues through a transdisciplinary lens. It is epidemiologically informed and characterized by prevention, health promotion, and other integrative practices. With its strong focus on health impact and population health, public health social work is central to the profession’s viability and success for tackling pervasive 21st-century challenges, such as health inequity, behavioral health integration, chronic disease, health reform implementation, and global health.
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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.
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Suicide and Public Policy
Janelle Stanley and Sarah Strole
The historical context of suicidal behavior and public policies addressing suicide arose simultaneously within the United States, and both reflect a culture of discrimination and economic disenfranchisement. Systems of oppression including anti-Black racism, restrictive immigration policy, displacement of American Indigenous communities, religious moralism, and the capitalist economic structure perpetuate high-risk categories of suicidality. Suicidal behavior, protective factors, and risk factors, including firearms, are examined in the context of twentieth and early twenty first century public policy. Recommendations for public policy will be discussed with consideration for policies that impact communities disproportionately and social work ethics, such as right to die laws and inconsistent standards of care.
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Women: Overview
Ruth A. Brandwein
This overview article introduces the topic of women, beginning with general demographic information. The section on poverty and inequality, which follows, describes the gender differences and delineates some reasons why women are poor and unequal. Issues of child care, welfare, and education are explored. Interpersonal violence and sexual trafficking are discussed, followed by a discussion of health and mental health issues affecting women, including access to health care. The role of women as well as women social workers in politics is briefly explored. Throughout, attention is paid to intersectionality. The article concludes with a discussion of current trends and challenges, with a brief examination of changes in policies affecting women from the Obama presidency to the end of the Trump administration in 2020, including implications for social justice, as well as implications for social work.