Article updated. Final sections and bibliography changed to reflect and discuss enactment of Affordable Care Act.
Health Care Reform
Abstract and Keywords
This entry presents an overview of 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. Specifically, it concentrates on the programs and strategies to obtain universal coverage for health and mental-health services for all Americans at the national level, with limited success. It ends with a discussion of the Affordable Care Act (ACA). Special emphasis is laid on the roles of social workers and their professional organizations during this period.
Proposals for a national health-care program to ensure universal coverage for all Americans have been on the public agenda in one form or another since the beginning of the 20th century. Various policy debates and the social-work roles since the inception are presented here, with an emphasis on the current policies and programs since President Clinton’s comprehensive proposal was defeated in 1994 through the passage of the Affordable Care Act proposed by President Obama in 2010. This is described in more detail in the 19th edition (Mizrahi, 1995, 1997).
Health-Care Reform: 1900–1935
The key organizational advocates for medical insurance in the early years of the 20th century were the National Civic Federation, an organization comprising major business corporations, and the American Association for Labor Legislation (AALL). The AALL organized the social insurance movement, holding its first conference in 1907. By 1912 it proposed a model bill to institute health coverage for workers and attempted to mobilize constituencies toward a compulsory, government-sponsored system of health insurance for the United States adapted from those programs developed in Germany and England (Lubove, 1968).
Opposition to government-sponsored health-care was always present. The strength, pervasiveness, and diversity of the opponents depended on the type of reform that was proposed and the era in which it was presented. Organized physician groups have always opposed a universal compulsory plan, although they supported coverage for medical disabilities and illness in the early years of the 20th century (Anderson, 1968). Additionally, the American Federation of Labor opposed government-sponsored compulsory health insurance, believing that it would weaken the union’s role in securing social benefits for its members. Private insurance companies were among the strongest opponents of national health-care reform, and they, along with big business, mainstream unions, and organized medicine, defeated all attempts at national legislation.
Throughout the 1920s, there was little publicly visible activity for comprehensive programs to cover the financing and delivery of personal health-care. Those groups that were vocal supported the development of private, voluntary health programs (Hirshfield, 1970), but even those proposals were not acted upon by Congress.
The reformers from the AALL shifted their goals and strategies by calling for the expansion of health facilities and increased expenditures for health-care for specific populations. One of the first pieces of federal legislation passed in 1921 was the Sheppard–Towner Act. It provided state health departments with funds for maternal and child health programs and was the only health-related program included in the Social Security Act of 1935 (Anderson, 1968).
The major privately funded policy initiative in the 1920s was the Committee on the Costs of Medical Care. Formed in 1927, it was composed of a voluntary, diverse group of people including social workers and others who were closely aligned with social work. However, the committee split over the ways to achieve universal, comprehensive health-care. The majority of the committee members proposed voluntary health insurance (Moore, 1933), whereas a minority of them condemned all health insurance recommendations (Anderson, 1968; Falk, 1973).
During the Great Depression, some individual hospitals and the American Hospital Association (AHA) began to expand private health insurance. Ultimately, Blue Cross was formed to ensure hospital reimbursement for patient services, which staved off government-sponsored compulsory health insurance (Anderson, 1968; Law, 1976). Eventually, the American Medical Association (AMA) supported the concept of voluntary hospital insurance, as well as voluntary insurance for physicians’ services in hospitals known as Blue Shield.
The emerging social-work profession in the early 20th century participated in critical debates on social insurance. Social workers began to write and speak about health reform as early as 1888. Discussions and debates appeared in the proceedings of the National Conference of Charities and Correction (NCCC). Rabinow’s (1916) Standards of Health Insurance served as a model for all progressive discussions in public and private forums for several decades. However, as in the general society, there were ideological divisions within the profession about the methods of health-care financing and delivery.
The NCCC, whose name was changed in 1919 to the National Conference of Social Work, attempted to reach a middle ground by educating the public on the health-care needs of the citizenry while remaining loyal to political leaders. In the 1920s, as social work sought to institutionalize itself as a profession, it invested itself in the less controversial areas of public health and the protection of women and children (Chambers, 1963).
Health-Care Reform: 1935–1960
The rise of private for-profit and nonprofit (voluntary) health insurance and, to a lesser degree, the development of alternative medical group practices in some parts of the country (known as “prepaid cooperative practices” or “capitation” models) diverted the movement for government-funded, universal health insurance. President Franklin Delano Roosevelt established the Committee on Economic Security in 1933, headed by Secretary of Education Frances Perkins, a social worker. However, no health-care proposals were submitted to Congress for inclusion in the Social Security Act of 1935 because of political opposition (Falk, 1973).
The final Social Security legislation did include several health care–related programs including Title V—maternal and child health and welfare and the crippled children’s program; Title VI—the first permanent authorization for public health grants to states and for intramural research in the public health service; and Title VII—an authorization to continue a national study on medical care. This kept a federal foot in the door for public financing and development of health-care programs in the future.
The first major bill for a national health-care program was introduced in Congress in 1939 by the Senator Robert Wagner. Physician and hospital groups waged a heavily financed campaign, which led to its defeat. Another important bill that was first introduced in Congress in 1943 served as the foundation for national health debates for the next 50 years. That bill, which became known as the Wagner–Murray–Dingell bill, was strongly supported by President Harry S. Truman in his National Health Program messages of 1945, 1947, and 1949.
A revised bill that Senator Wagner introduced in 1947 advocated a national compulsory health program covering all employed people and their dependents with comprehensive benefits and various reimbursement mechanisms to providers. The bill’s main features were later adopted in the Medicare and Medicaid legislation in 1966. It had the active support of social-work organizations, consumer groups, unions, and some physician groups.
In 1952, President Truman established the Commission on the Health Needs of the Nation. With 58% of Americans covered by some type of private health insurance at that time, the majority on the commission believed that the source of financing for health-care should be voluntary. However, a minority on the Commission believed that the recommendations did not go far enough (Anderson, 1968).
In addition, during this era, the Republican Senator Robert Taft produced his own bill to provide federal support to states for medical and hospital care for needy persons and related public-health programs (Clark & Clark, 1947). Although the Taft bill did not pass, the 1950 amendments to the Social Security Act permitted federal funds to be used by state public-assistance agencies for the direct payment of physicians and others who rendered care to the poor. During the Eisenhower administration of the 1950s, there was little presidential leadership for comprehensive health-insurance legislation (Falk, 1973).
As the Kennedy–Johnson era began in 1961, the Medical Assistance Act, also known as the Kerr–Mills bill, was passed. With the support of the AMA, it was the first time that the federal government recognized the poor by expanding the public-assistance section of the Social Security Act for those aged 65 and over (Anderson, 1968).
The leaders of the social-work profession remained divided on how pervasive and radical social reform should be with respect to income redistribution, universality, equity, individual responsibility, linkage with work, and governmental contributions. In the 1930s, the Social Security Act became the predominant model for health-care reform, and this approach was supported by most social workers and their organizations, including the American Association of Social Workers. Some social-work organizations supported a publicly financed health-insurance program. However, social workers and social reformers in the White House, including Harry Hopkins and Frances Perkins, rejected social health insurance as too controversial.
Throughout the 1940s and 1950s, social workers continued to be part of the national movement toward comprehensive health insurance. In 1955, the American Association of Social Workers and six other separate social-work groups merged to form the National Association of Social Workers (NASW). Although this consolidation gave a more powerful voice to the profession, the NASW had to mediate disparate philosophies of various groups and strategies for achieving health-care reform. This mediator role was evident in the debates held in 1956 at the NASW’s first Delegate Assembly, a meeting of elected member representatives who set the national organization’s policy. They called for a national health program to ensure full health care to all individuals using an incremental approach (NASW, 1959).
Health-Care Reform: 1961–1992
During the Kennedy and Johnson administrations, a non-means-tested set of benefits for older Americans under the Old Age and Survivor Disability Insurance (Social Security) gained favor. The King–Anderson–Javits bill was introduced in 1961. The first White House Conference on Aging held earlier that year was unequivocal in its support for such legislation. The opponents of the King–Anderson–Javits bill were the AHA, the AMA, business groups, and the Health Insurance Association of America (HIAA). However, there were splits in the opposition’s ranks that eventually paved the way for politically acceptable compromises.
In July 1965, after years of intense campaigning and negotiating, President Johnson signed into law the Health Insurance for the Aged Act. This act created Medicare (Title XVIII) of the Social Security Act, which provided health benefits for the aged. Medicaid (Title XIX) was also passed, which provided separate means-tested medical care for poor and medically indigent people channeled through the states.
There were victories and disappointments for both sides. From the perspective of those who were seeking a universal comprehensive health plan, Medicare established the principle of non-means-tested universal coverage for a population with uniform benefits. Its supporters assumed Medicare would open the door to a similar approach for the rest of the population in the future. For the first time, Medicare and Medicaid also provided for greater involvement by the federal government in the regulation of hospital, physician, and nursing-home policies and practices.
On the other hand, Medicare and Medicaid also stemmed the tide that was moving toward universal national health coverage. Medicare preserved the current system of private insurance patterns and provided relief for insurance companies’ difficult and expensive insurance obligations. No providers were required to accept Medicaid or Medicare patients, and physicians were able to charge additional fees to Medicare recipients.
In 1971, in the face of dramatically rising costs, President Richard M. Nixon presented his version of national health insurance, as well as proposals for health maintenance organizations and health manpower. After his reelection in 1972, Nixon introduced the Comprehensive Health Insurance Program (CHIP). It included three components: one for working Americans, one for poor and unemployed people, and one for continuation of Medicare. It can only be speculated how much the resignation of President Nixon in 1974 played a role in the demise of almost all major health insurance measures. The one exception was the passage of the Nixon-supported Health Maintenance Organization Act of 1973. This law helped change the direction of the private health-care delivery system to one based on what became known years later as “managed care.”
During the Ford and Carter administrations, little was done on health reform. With the election of President Reagan in 1980, a conservative social agenda reversed the trend toward expanded entitlements and citizen rights. It called for cutbacks in social programs, and it promoted an ideology of individualism and personal responsibility, the elimination of many entitlements, and privatization of health-care insurance.
Beginning with the 41st President G. H. W. Bush in the late 1980s, the public national health-care debate resurfaced (Families USA Foundation, 1991). A variety of approaches to health-care reform were published in prestigious medical journals (Enthoven, Kronick, & Writing Committee of the Working Group on Program Design, 1989; Himmelstein & Woolhandler, 1989). The Canadian health-care plan began attracting serious attention based on its principles of universality, portability, comprehensiveness, public, nonprofit administration, and freedom of choice of providers (Mizrahi, Fasano, & Dooha, 1993).
In the late 1980s, Massachusetts became the first state to pass a referendum declaring health care a right, and several candidates for public office made health care a major issue.
Beginning in the 1960s, social workers, and the NASW in particular, became extremely active in health-care reform in the political arena. They were part of the major health reform coalitions, including the Health Security Action Council. By 1975, the NASW Delegate Assembly passed a policy statement on national health. It called for a universal comprehensive national health-care system. In 1979, the NASW Delegate Assembly passed a more elaborate version of a policy statement on national health.
A small group of social workers and other progressive groups supported a bill known as the U.S. Health Service Act, introduced by Congressman Ron Dellums, a social worker, in 1981 and reintroduced every year since, most recently by Congresswoman Barbara Lee, the successor to Representative Dellums (Lee, 2006). Under this plan modeled after the British health-care system, the government would establish a full range of facilities and services administered directly by elected officials and community health boards and indirectly by district, regional, and national health boards. This radical reform bill kept the debate on national health care alive.
Health-Care Reform: 1992–1996
With the election of President Clinton in 1992, hundreds of health-related bills were introduced in the 102nd Congress, and almost every interest group became involved in the health-care issue (Families USA Foundation, 1993; Mizrahi, 1992). President Clinton made health care his highest domestic priority. During his first two years in office, Clinton appointed his wife, Hillary Rodham Clinton, to head a national health-care task force, which produced a complex plan for health-care reform. In contrast to both the single-payer approach and the private insurance and physician plans, Clinton’s Health Security Act built on what was known as “managed competition” (The President’s Health Security Plan, 1993).
There were reasons to be cautiously optimistic about the prospects for passage of comprehensive health-care reform in 1994. First, because of divisions among physicians, the AMA no longer wielded the power it once did. Second, consumers openly expressed dissatisfaction with the American health-care system, and active grassroots and professional reform efforts were underway (Priest, 1994). Third, there was major presidential support.
However, as in previous decades, opposition to universal health-care surfaced (Moniz & Gorin, 2007). The HIAA, the AMA, and the pharmaceutical, high-technology health equipment, and health-care service industries all supported plans that maintained their power and financial position (Skocpol, 1996). Small business groups also opposed fundamental reform.
President Clinton’s Health Security Act (H.R. 3600) faced opposition from both the Right and the Left. Many conservatives feared that, if enacted, the Act would resurrect the Democrats’ image as advocates for the middle class. Interest groups spent more than $10 million to influence the outcome of that public policy issue in the early 1990s (Moniz & Gorin, 2007, p. 52; Podhorzer, 1995).
Liberal groups commended the Clinton proposal for its support of universal coverage and extensive health and mental health benefits and for allowing states to create their own plans, including single-payer systems. However, they criticized it for preserving the employment-based system and maintaining a role for private insurers. Social workers criticized the proposal for not including language to ensure a comprehensive role for social workers in the delivery of health and mental-health care (Johnson & Broder, 1996).
Although the Democrats controlled Congress, the Clinton plan failed without coming to a vote. With the election of the conservative Republican majority to the 104th Congress in 1996, reform took on a different meaning and direction. This meant lowering expectations about the government’s responsibility to meet human needs and increasing personal responsibility. With that conservative leadership, corporate-dominated, for-profit managed care burgeoned after 1994 (Salmon, 1995).
In the late 1980s, the NASW invested its resources and expertise to develop a comprehensive national health plan, together with a complete cost analysis. This plan was placed in the Congressional Record on May 22, 1990, by Senator Daniel K. Inouye, who also introduced the NASW’s bill, the National Health Care Act, in the House in 1992 and in the Senate in 1993. In addition to proposing its own bill, the NASW provided leadership to several coalitions that supported a single-payer model. The NASW also participated in some broader and more diverse coalitions, including the Health Care Reform Project, whose goals were compatible with the NASW’s plan. The NASW also expressed support for the Health Security Act and worked with the Clinton administration to promote universal coverage.
The 1990 and 1993 NASW Delegate Assemblies made the passage of health-care reform one of their highest policy priorities. They passed a revised policy statement on national health care to reflect the proposed NASW health-care plan (NASW, 1994).
Health-Care Reform: 1996–2007
After the failure of President Clinton’s health proposal, there was no major credible movement for a national program of universal health coverage until President Obama. Nevertheless, in the remainder of his administration, President Clinton supported expanding health coverage legislation for children and Medicare coverage. Under President G. W. Bush’s administration, prescription drug coverage was added to Medicare, and Bush proposed cuts in Medicaid and encouraged private marketplace solutions such as Health Savings Accounts (HSAs). Some of the smaller but significant health-care reform legislation and regulation included: portability, HSAs, mental-health parity, and the State Children’s Health Insurance Program.
At the end of the 104th Congress in 1996, a modest bipartisan health insurance proposal, the Health Insurance Reform Act (Pub. L. No. 104–191) was sponsored by Senators Edward Kennedy of Massachusetts, a liberal Democrat and longtime proponent of universal federal health insurance, and Nancy Landon Kassebaum of Kansas, a moderate Republican. The proposal allowed workers to maintain health insurance coverage if they changed or lost their jobs (known as “portability”), and it barred insurance companies from denying coverage to people who had preexisting medical conditions. It also made it easier for self-employed workers to afford their own insurance by increasing the share they could deduct from their income tax.
However, in the view of social workers and others interested in more comprehensive reform, this law was limited and deficient in many areas. It did not prescribe a standard benefits package, nor did it require employers to offer health insurance coverage. Moreover, because the act did not set price limits on how much such insurance would cost, insurance continued to be inaccessible to many consumers because of prohibitive costs. As part of the compromise that ensured passage, the bill also included the introduction of “medical savings accounts,” which allowed people working for small businesses or who are self-employed to set aside their own funds, before taxes, for routine or long-term care. This opened the door for a privatized insurance model, HSAs, for healthy and well-off people, leaving sick and poor people in the traditional insurance pool—with presumably higher premiums.
Health Savings Accounts
Bush administration conservatives continued to promote HSAs as a way of making health care “more accessible and affordable” (U.S. Department of Treasury, 2007). Like their “precursor” medical savings accounts, HSAs are rooted in the assumption that “third-party” payers, which give individuals relatively unlimited access to health care, have played a key role in driving up health-care costs (Fuchs & James, 2005).
The HSAs appealed to relatively young, healthy individuals, as well as upper-income people seeking to take advantage of the investment and tax benefits associated with these accounts (Moniz & Gorin, 2007).
Supporters of HSAs and other forms of “consumer-directed” health care believed that by forcing individuals to become careful shoppers, high-deductible plans would lower costs and expand coverage (Moniz & Gorin). However, because 78% of all expenditures (both individual and family) were over the deductible, this seemed unlikely (Blumberg & Burman, 2004). It also seemed unlikely that HSAs would reduce the uninsured population (Fronstin & Collins, 2006).
The HSAs are in opposition to traditional, comprehensive employer-based coverage. As healthier people would buy HSAs, then those left behind would on average be older and sicker, driving up costs in the employer-based system (Greenstein & Park, 2003). According to critics, HSAs help weaken society’s sense of collective responsibility for its most vulnerable members and bring us closer to a privatized health-care system (Robinson, 2005).
In September 1996, Congress enacted Pub. L. No. 104–204, a step to mental-health parity. The law prevented group health plans from imposing financial limits on mental-health benefits that are not also imposed on other types of benefits. Despite its limitations, Pub. L. No. 104–204 raised parity as an issue and helped push states to enact “more-comprehensive parity provisions” (Gitterman, Sturm, & Scheffler, 2001). [Unfortunately, however, these efforts have been limited by the federal Employment Retirement Income Security Act, which prevents states from regulating plans financed by employers.]
As a further step toward full parity, a bill was proposed for the late Senator Wellstone known as the Paul Wellstone Equitable Mental Health Treatment Act (S. 486), and a version of this bill (H.R. 1402) was also later introduced in the House. Although President Bush identified lack of parity as one of “three obstacles preventing Americans with mental illnesses from getting … care they deserve,” the legislation was never enacted (President’s New Freedom Commission on Mental Health, 2002).
State Children’s Health Insurance Program
In 1996, as part of the Balanced Budget Act of 1997, Congress also created the State Children’s Health Insurance Program, a federal–state program, administered by the states, that provides assistance to states to cover uninsured children. The program insured 6 million children and, along with Medicaid, helped reduce the percentage of children without coverage by a third. Despite this, in 2004, more than 9 million children remained without coverage. The program was never supported by President Bush (Park & Broaddus, 2007).
Medicare Prescription Drugs
Spending on medication grew rapidly, especially for older adults, and price increases for prescription drugs exceeded the rate of inflation (Families USA, 2004). At the end of 2003, after contentious debate and controversy, the Medicare Prescription Drug, Improvement and Modernization Act (Pub. L. No. 108–173) was signed into law. It created a Medicare Part D to provide drug coverage to Medicare recipients (Moniz & Gorin, 2007).
Critics, including the NASW, raised several concerns about this legislation (NASW, 2003). First, the Medicare Prescription Drug, Improvement, and Modernization Act did nothing to restrain the growth of costs. In fact, it specifically prohibited Medicare from negotiating with pharmaceutical companies for lower prices. Second, the Act created an unusual gap in coverage known as the “doughnut hole,” which could expose consumers to excessive financial risk (Rosenthal, 2004).
The Affordable Care Act: 2009–
By the turn of the 21st century, discussion of and efforts for universal coverage had reemerged. Between 2001 and 2004, the prestigious Institute of Medicine published a series of studies examining the scope and “consequences of uninsurance” (Institute of Medicine, 2007). In its final report, the Institute noted that uninsurance resulted in around 18,000 unnecessary deaths a year and called for the introduction of a system of high-quality, universal, and affordable coverage by 2010.
The Great Recession of 2007–2009 and the election of President Barack Obama gave new impetus to efforts for health-care reform. After two years of intense controversy and debate, in March 2010 Congress enacted the Patient Protection and Affordable Care Act (ACA; Pub. L. No. 111-148) (Gruber & Newquist, 2011; McDonough, 2011). It passed despite harsh and relentless attacks by conservatives, who demeaned the bill by calling it “Obamacare” and erroneously claimed, among other things, that it would explode the deficit, undermine Medicare and create government-run “death panels.” This misinformation has proved extraordinarily difficult to refute (Nyhan, Reifler, & Ubel, 2013).
For the NASW, the passage of the ACA was a “bittersweet” moment. The legislation was not a single-payer plan, which the NASW had long advocated, and did not include a public option, which the NASW had supported during the debate over reform. Despite this, the ACA marked a critical step forward in the almost century-long effort for health-care reform. The NASW rightly called the legislation “a monumental legislative achievement of our time” and “a significant step toward a comprehensive and universal health-care system for our nation” (as cited in Gorin, 2010).
The ACA has several key components. It has introduced a Patient’s Bill of Rights, which, among other things, ends lifetime limits on most benefits and preexisting condition exclusions for individuals under age 19 (in 2014, this will be extended to the entire population) (http://www.healthcare.gov/law/features/rights/childrens-pre-existing-conditions/index.html). The legislation also addresses the needs of older adults by introducing free preventive benefits for Medicare beneficiaries and by beginning to close the notorious Medicare Part D “doughnut hole.” The act also requires insurers to spend 80–85% of their revenue on patient benefits, as opposed to “overhead” and “marketing costs” (https://www.healthcare.gov/how-does-the-health-care-law-protect-me).
Beginning in 2014, individuals and small businesses (up to 100 employees) will become eligible to buy insurance in the so-called Health Insurance Marketplace, or health exchanges, which will operate in each state. Insurers with “excessive or unjustified premium” increases may be barred from participating in the exchanges (http://www.healthcare.gov/law/timeline/full.html#2014). In its original version, the ACA required states to extend Medicaid coverage to individuals who earn below 138% of the Federal Poverty Line (FPL), or around $30,000 for a family of four (Gorin & Moniz, 2012). The federal government would finance the bulk of this extension. In 2012, the Supreme Court found this provision unconstitutional, leaving it to the states to extend Medicaid coverage or not. Because many low-income people earn too much to be eligible for Medicaid and individuals earning below 100% of the FPL will not be eligible for assistance in buying coverage on the exchanges, Medicaid and the CHIP will cover “about 6 million fewer people than previously estimated, about 3 million more people will be enrolled in exchanges, and about 3 million more people will be uninsured. (U.S. Congressional Budget Office [CBO], 2012). In 2022, 8% of the population will lack coverage (U.S. CBO).
The ACA also takes steps to reduce health-care inflation. Gruber (an architect of Massachusetts’ pioneering health-care plan and a key player in the development of the ACA) and Newquist (2011) noted that the Obama administration incorporated several widely discussed approaches in the legislation: a tax on overly generous, or so-called “Cadillac,” health plans; health exchanges to encourage price competition among participating insurers; the creation of an Independent Payment Advisory Board to advise Congress on ways of improving quality and efficiency in Medicare; the creation of an agency to engage in comparative effectiveness research to determine which treatments are effective and which are not; and the development of Accountable Care Organizations, which will move beyond our current, largely fee-for-service system of reimbursement to a system in which patient care is provided under “one global reimbursement amount” (Gruber & Newquist, 2011, p. 116) and providers are rewarded for positive clinical outcomes (for example, the Medicare shared savings model)
The U.S. CBO (2012) has estimated that between 2013 and 2022, the ACA would reduce the federal budget deficit by $109 billion. In recent years, health-care inflation has moderated. According to the U.S. CBO (2013), “health care spending has grown much more slowly both nationally and for federal programs than historical rates would have indicated.” Although the precise reasons for this are not completely understood, it seems clear that providers have made efforts to moderate cost growth in anticipation of the full implementation of the ACA (Mahar, 2011). Despite this, in the long run, the ACA in its current form may prove insufficient to bring health-care costs under control, and additional measures may be necessary, including all-payer rate setting and, perhaps eventually, a single-payer system (Berenson, Ginsburg, & Kemper, 2010; Reinhardt, 2012; Stremikis, Davis, & Guterman, 2010).
Since the 1990s, the NASW has supported incremental efforts to increase health-care coverage and benefits such as children’s health insurance, mental-health parity, and prescription drugs, while opposing conservative, market-driven proposals such as HSAs. At the national Social Work Congress in 2005, the NASW and other social work organizations voted on 12 imperatives for the profession during the next 10 years. Two of these were as follows: “Take the lead in advocating for quality universal health care” and “Elevate the public’s awareness of the efficacy and cost effectiveness of social work practice in health care.” The NASW and many individual social workers participated in Health Care for America Now, the broadly based coalition that sought to mobilize grass-roots support for universal coverage and a public option, which would compete with private insurers (Kirsch, 2011). As noted above, the NASW also expressed strong support for the ACA.
Whatever its limitations, the ACA offers our best hope for achieving universal coverage and controlling the growth of health-care costs. We cannot afford to be complacent, however. Despite President Obama’s reelection, the public remains ambivalent about the legislation, and the Congressional Republicans continue to try to repeal it (http://kff.org/health-reform/poll-finding/kaiser-health-tracking-poll-april-2013/; Peters & Weisman, 2013). Social workers can play an important role in opposing these efforts. Social workers must also be involved in the ACA’s implementation and regulatory process. Andrews, Darnell, McBride, and Gehlert (2013) argued that our profession is “uniquely suited” to promote several of the ACA’s “objectives and goals.” According to Andrews et al., social workers must “develop a well-coordinated strategy” to disseminate “evidence demonstrating” our ability to advance “ACA aims” and “build the infrastructure for further research on how we can contribute to implementation of this historical legislation” (p. 71). This will not only enable us to play a leading role in reforming our health-care system but also increase the visibility and enhance the value of our profession.
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