A Social Work Approach to Policy: Implications for Population Health

Daniel P. Miller, Christopher P. Salas-Wright, and Katherine Crevi are with the School of Social Work, Boston University, Boston, MA. Angela R. Bazzi and David L. Rosenbloom are with the School of Public Health, Boston University. Heidi L. Allen is with the School of Social Work, Columbia University, New York, NY. Melissa L. Martinson is with the School of Social Work, University of Washington, Seattle. Kathryn Jantz is with the Steadman Group, Denver, CO.

Correspondence should be sent to Daniel P. Miller, PhD, Boston University School of Social Work, 264 Bay State Rd, Boston, MA 02215 (e-mail: ude.ub@rellimpd). Reprints can be ordered at http://www.ajph.org by clicking the “Reprints” link.

D. P. Miller and A. R. Bazzi led the writing of the article. All of the authors helped conceptualized the article and its organization, contributed to the writing of the article, and reviewed drafts.

Abstract

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 approach to health policy could help redirect attention toward social determinants. Social work has developed a perspective on the relationship between policy and health that is driven by a primary mission of promoting human well-being. 12 This perspective is informed by social work training, which emphasizes systemic influences on behavior, health, and well-being. It is further reinforced by social work practice; social workers are often responsible for frontline implementation of health policy 13 (more than half of the 650 000 practicing social workers in the United States are employed in health settings 14 and engage in activities across the full range of the policy process), and their work frequently places them in close interaction with the most vulnerable segments of the population, 15 both of which provide natural insights into the design and effectiveness of health policies.

Consonant with an idea that has recently gained currency in social epidemiological scholarship, 16 a social work approach would suggest the need to refocus policies on “what matters.” From a social work perspective, “what matters” includes social factors that often fall beyond the traditional foci of health policymaking and are instead consistent with some of the novel approaches to public health promotion noted here. Indeed, although recent efforts to repeal and replace the ACA have created an air of uncertainty around federal health policymaking, the advent of many of these innovations has served to formalize an emphasis on the social determinants of health, creating an opportunity for the perspective we articulate in the remainder of this article.

We argue that social workers are natural allies of public health policymakers, and in the sections to follow we describe 3 themes that constitute a social work approach to health policy: the importance of the social environment, the importance of social relationships, and the importance of values. In doing so, we adopt a definition of health policy that includes a broad range of government activities spanning programs, formal policies, and regulations at the local, state, and federal levels and encompassing “traditional” health policies and programs such as the ACA, Medicare, and Medicaid, as well as “nontraditional” policies such as antipoverty programs.

We also clarify that these themes are not intended to be an exhaustive illustration of a social work approach; others, including an emphasis on strengths, a commitment to vulnerable populations, and a focus on cultural competence are also emblematic. However, the themes we discuss here have salience for health policy, particularly in light of recent developments and policy innovations. After our introduction of the themes, we discuss their implications, summarize key challenges involved in implementing our approach, and provide recommendations for health policy consistent with the themes.

THEME 1: THE IMPORTANCE OF THE SOCIAL ENVIRONMENT

Social environments are as important to health as individual-level attributes and behaviors, and should be conceptualized as critical targets for health promotion interventions and policies. Traditionally, social workers have viewed the world through the person-in-environment lens, which emphasizes how complex physical and social environments influence individual behaviors and outcomes. Public health scholars and practitioners will recognize similarities with ecological models.

However, the person-in-environment framework differs in its role as a general organizing framework for social work practice, research, and education by encouraging social workers to eschew (or regard with extreme caution) reductionist theories that ascribe health outcomes primarily to individual-level factors. It thus provides straightforward but critical insights about the relationship between policies and health: policies relating to economics, education, housing, families, and other social determinants are critically important for population health because they create, condition, and constrain the contexts in which people live. For example, whereas some health policies may appear to directly influence health outcomes (e.g., health and safety guidelines and expanded health insurance access), social policies such as social welfare benefits and access to education affect the “upstream” social and environmental conditions that shape health across the life course. Thus, a social work perspective necessarily attends to the variety of policies targeting the social environments that shape health.

Policy interventions can optimize the relationships between social environments and health. For example, research has established that first-generation immigrants have better health than the general US population. 17 However, this advantage appears to weaken over time, raising questions about whether policies (or the lack thereof) create environments that are detrimental to immigrant health. Immigrants face discrimination and other forms of social marginalization that can negatively affect their health and well-being. 18 Thus, policies designed to prohibit discrimination and foster immigrants’ inclusion in society could help protect and improve their health status over time.

Furthermore, an approach to policy informed by a person-in-environment framework would require simultaneously attending to other consequential environmental contexts. For example, although minimum and living wage requirements and occupational health protections are firmly situated within the realm of labor policy, consistent with the health in all policies perspective adopted by the Centers for Disease Control and Prevention and others, 5 they also serve as health policies that affect workers’ income, safety, and long-term health. 19 Continuing with the example of immigrant health, these policies illustrate how universal approaches targeting environments that are important to nearly all people (as opposed to those that target specific groups) can reduce disparities as well: such policies are likely to have more profound effects on undocumented immigrants in the United States who often work in low-wage jobs that elevate their risk for work-related injuries. 20

THEME 2: THE IMPORTANCE OF SOCIAL RELATIONSHIPS

A social work perspective also emphasizes the importance of social relationships in promoting and maintaining health. 12 Even when working directly with individuals, social workers keep families and other social relationships in mind. The significance of social interactions with respect to physical health has been demonstrated through decades of research, including studies linking weak social ties with elevated risk behaviors (e.g., use of unhealthy substances, physical inactivity), morbidity, and mortality and strong social support with survival and thriving. 21 The protective effects of social support extend across the life course 22 and should be harnessed to help promote engagement and retention in prevention services and treatment programs. 23

The significance of relationships carries a pair of important implications for improving health service quality and outcomes. First, understanding and acknowledging social relationships can help facilitate health outside clinic walls, where health and well-being originate. Although providers may not be able to completely address patients’ social support needs, assessing those needs, engaging family and friends in treatment plans, and intervening to bolster support networks all constitute a social work approach to health. 24

Clinical encounters involving physical complaints often include distress related to family problems, grief over recent loss, caregiving strain, and difficulties at work. Importantly, many patients presenting for health care visits provide “cues” or openings to discuss these issues with their providers. 25 In social work practice, such moments are viewed as opportunities to prevent harm and promote growth and well-being. Serious cases may be referred to behavioral health service providers, but most health care visits do not evoke a strategic response from providers regarding social relationships, and thus opportunities to improve patient and population health are potentially lost.

Second, feeling stigmatized during health care encounters is associated with greater unmet needs, poorer perceptions of health care quality, and worse overall health outcomes. 26 Thus, treating the physician–patient relationship itself as one that requires nurturing can improve the efficacy of clinical interactions within health care settings, where treatment plans are most often implemented, monitored, and maintained over time.

As population health is increasingly recognized as the product of forces that exist beyond the boundaries of traditional health care settings, the policy implications are clear: in light of a large body of literature on the importance of promoting social support and in the context of a health care delivery system that is in constant pursuit of technological advances, approaches that leverage basic social relationships could complement traditional clinical interactions in promoting health.

Unfortunately, current policies do little to foster such “high-touch, low-tech” approaches. Concurrent with expanded health insurance coverage through the ACA, increasing interest in improved quality and financial sustainability of health care services is resulting in efforts to hold health care providers accountable for patient outcomes. Although there are some reasons to applaud this move toward greater provider accountability, an important concern about this approach within the current biomedical paradigm is the enormous chasm between medical services and health outcomes. Assessing and counseling patients regarding health risk factors remains distinct from actually modifying those risk factors, many of which occur outside clinic walls.

Policy reform would be a far more effective mechanism to ensure that health care systems and providers adequately acknowledge the links between social relationships and health. Accordingly, a social work approach would suggest the need to advocate for and contribute to the development of policies that incentivize and enable health care professionals to assess and actively use social relationships to achieve better health outcomes. Such policies could identify opportunities to proactively promote or protect health, address external barriers to healing, and maximize the effectiveness of health interventions that place demands on individuals, their support systems, or their environments.

For example, the current move from fee for service toward alternative payment methodologies (e.g., bundled payments, patient-centered medical homes) offers an unprecedented opportunity to use relationships to promote health. The patient-centered medical home model specifically acknowledges the importance of involving families and communities in healing and treatment, and the value of formal linkages between the medical home and social services. 6

THEME 3: THE IMPORTANCE OF VALUES

As in some areas of public health and other allied fields, social work approaches are informed by both evidence and value-driven appraisals of the social structures that produce health and well-being. 27 Social work is a highly value-oriented “helping profession,” with social work practice, research, and education all strongly rooted in normative principles of fairness, rights, and social justice 28 that together form the basis of social workers’ code of ethics. 12

Of these 3 principles, many social workers view the commitment to social justice as the defining value of the profession. Although definitions of social justice vary, there is some consensus among practicing social workers surrounding Rawls’ concept of distributive justice, 29 which focuses on the inequitable distribution of resources and the necessity of reallocating these resources to promote an equitable and just society. Consistent with this framing, many social welfare policies are identified as critical means to promote justice. 15 These policies can also have significant effects on population health. A clear example is the package of federal income support policies that aim to redistribute income and reduce poverty, conditions linked to pronounced and long-lasting effects on health. For example, the aim of the US earned income tax credit is to use the federal tax system to redistribute wealth by subsidizing the earnings of low-income adults. A social work perspective would argue for the need to expand such redistributive policies in light of their benefits and the relatively small US social welfare state.

More generally, the values orientation of social work encourages promoting and developing policies that protect and promote equal rights and improved opportunities (while simultaneously dismantling policies that uphold systems of oppression). In addition to supporting equality through the social redistribution of income and wealth, such policies can provide more universal benefits than targeted programs, which run the risk of stigmatizing recipients through income tests or other mechanisms.

A focus on values carries a number of important implications. With respect to practice in public health, social work, community psychology, and other allied disciplines, a values orientation suggests the importance of policy advocacy with and on behalf of clients and vulnerable groups. An essential element of such activities is the understanding that the experiences, ideas, and knowledge of these groups must be central to the development of policy. Thus, health professionals must allow these viewpoints to be central to the policymaking process. Although there is skepticism among the research community about explicitly identifying values as the impetus for investigation, a values-driven approach to research would imply renewed attention to the causes and consequences of poverty and social marginalization as well as the effectiveness of policies in targeting these and other social determinants of health.

POLICY IMPLICATIONS

Collectively, the 3 themes detailed here carry a number of specific implications for the development of effective health promotion policies, as summarized in Table 1 . First, reflecting on the importance of the social environment for health, policymakers and advocates should attend to the ways in which all policies affect health. By extension, policymakers must look beyond health care toward policies targeting the multiple social environments that are known to affect health (e.g., households, communities, workplaces, and neighborhoods).

TABLE 1—

Key Elements of a Social Work Approach to Policy

Second, policies that encourage a focus on relationships as a central element of health and health care could be effective and efficient mechanisms to promote health. As health is influenced by numerous factors outside health care settings, efforts to hold providers accountable for health outcomes might fail unless we improve our ability to join with patients in addressing the multiple environmental determinants that affect health and well-being.

Third, the centrality of values means that attending to equity, fairness, and justice is essential within a social work approach to policymaking for improved population health. Expanding the reach of social policies that redistribute resources and reduce poverty may be particularly effective, especially in light of the relatively limited scope of the US social welfare state in comparison with the situation in peer countries. A values-oriented approach can inform research that illuminates the relationship between upstream factors and health and can promote client voices at all stages of the policy process to identify more effective policy solutions.

VIABILITY OF A SOCIAL WORK APPROACH TO POLICY

Although Table 1 presents a thematic road map for framing a social work approach to policy and highlights implications for policy efforts, a valid concern is whether this approach can gain traction in public health or traditional policymaking circles. This concern is driven by factors internal to the field of social work as well as perceptions of social work by other health professionals. For one, questions regarding social workers’ readiness to assume policymaking roles stem from the evolution of social work practice toward reliance on clinical therapy as a key practice modality. 30 As a consequence, not all social work clinicians may see the benefit of embracing policy practice 31 or possess the analytical and technical skills required to take advantage of policymaking opportunities. 32

An additional challenge is whether other professionals view social workers as policy experts. Perceptions that public policymaking should be a value-less process and should depend exclusively on objective assessments of evidence by policy “experts” 33 may result in exclusion of the social work perspective from the policymaking arena. Although social workers are actively engaged in all aspects of the policymaking process, it is our experience that many do not explicitly identify themselves as serving in these roles, potentially minimizing acceptance of the social work perspective.

RECOMMENDATIONS FOR SHIFTING POLICY PRIORITIES

To provide specific recommendations regarding how social workers should be mobilized to insert their unique perspectives into policy problems and solutions, we draw on Kingdon’s model, which counters the notion that policymaking is a wholly rational process based on value-free evaluations of evidence regarding available solutions. 34 This model describes 3 process streams that proceed through time: problems, policy solutions, and politics or actors.

Problems, such as lack of access to health care for low-income Americans, can persist for years without gaining much attention. Generic policy solutions exist, such as using tax incentives to promote desired goals, yet new policies emerge only when events of a certain type cause the problem and solution streams to run together through a brief window of opportunity. Policy solutions that are enacted are thus blends of the ways in which problems are framed as issues (e.g., all people have a right to health care), particular solutions that can be applied to the problems (e.g., expanding existing programs for the poor such as Medicaid), and the balance of power among actors within the political stream. Therefore, framing the ways in which problems and solutions are presented is critical because political actors settle on solutions that come closest to their goals and values.

The November 2016 election ushered in an era of unprecedented uncertainty with respect to the future and scope of the ACA and other domestic social policies. For example, recent congressional budget blueprints call for massive cuts to Medicaid and the Supplemental Nutrition Assistance Program, and recent revisions to the Senate tax bill have included an employer tax credit that would defray a portion of the wages paid to employees taking paid family leave as well as a repeal of the ACA’s individual mandate. A reasonable view of this political climate might hold that any efforts to implement a social work vision will be realized only in the long term; however, we stress that the Kingdon framework 34 emphasizes the importance of continued efforts to frame both problems and solutions to influence policymaking.

Advancing a health policy agenda that is reflective of the themes articulated here and in Table 1 will thus require social workers and public health professionals to continue to frame problems and develop policy solutions that are reflective of these values and to work to develop a political climate that is in turn favorable to these solutions. We argue that, in the midst of uncertainty, like-minded professionals must align themselves around a shared vision for health policy and that a social work approach is an underused avenue to create appreciable and consequential changes in population health.

For evidence of the potential for a social work approach to take hold, we note the long-standing (but perhaps underrecognized) importance of moral arguments to health and social policy. 35 A recent example was the immediate objection to proposed cuts to some of the federal programs that support the Meals on Wheels program (which provides food assistance to home-bound older Americans) 36 by some of the more conservative members of the president’s own party. Whether they are sufficient to protect funding for the program, such objections are the product of clear values with respect to the deserving nature of poor older adults, implying that careful messaging around other value-driven statements might be effective. Furthermore, it seems unlikely that all of the new payment models and other innovations promulgated by the ACA and supported by the growing consensus among policymakers regarding the social determinants of health will fully disappear, and thus there will be opportunities for continued improvements to our system of care delivery.

Accordingly, we provide a series of policy recommendations that are described in the box on the next page. 5,35,37–40 The first recommendation is a general one that calls for social work perspectives to be included more consistently in all elements of policymaking and for social work programs to bolster training in policy. The remaining recommendations are related to the specific themes identified here, tying them to the steps of the policymaking process.

RECOMMENDATIONS FOR POLICY

For example, we argue that policymakers should more fully adopt a health in all policies strategy informed by attention to values and the importance of social environments. We also emphasize the need for research in public health, social work, and other fields to more explicitly identify and explicate the nature of social structures and environments that promote ill health and health disparities. This step is necessary to translate a focus on values (which anchors the social work approach to health policy) into actionable evidence that can be used to develop and evaluate policies. With respect to health care delivery, we recommend using policies to modify clinical encounters so that they include attention to relationships and the psychosocial and material supports and stressors that may affect healing. Such changes are consonant with recent attention to the role of social factors in health and health care 7,8 and could be specifically targeted by local, state, and federal policies.

Finally, we emphasize the importance of incorporating client and patient perspectives into all steps of the health policymaking process. This recommendation is premised on the straightforward idea that clients should be involved in identifying problems, developing policy solutions, and evaluating the effectiveness of policies. This is a natural outgrowth of the themes articulated here insomuch as it underscores the importance of having clients and patients identify the values, relationships, and environments that are essential to their health.

CONCLUSIONS

The social work approach to policy exemplified by the 3 themes discussed here could provide a path toward policymaking that better addresses the social determinants of health and reduces disparities both within the Unites States and between the United States and peer countries. Despite some of the challenges in applying this approach, we believe that there are important opportunities for public health professionals, social workers, and those from other like-minded professions to work together to implement policies at multiple levels that will ultimately improve population health.

ACKNOWLEDGMENTS

Support for this work was provided by the Boston University Peter T. Paul Career Development Professorship.

HUMAN PARTICIPANT PROTECTION

No protocol approval was needed for this project because no human participants were involved.

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